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Patients with terminal illness express existential suffering and spiritual distress in a number of different ways. Hearing a patient say the words above, a physician may feel paralyzed or poorly equipped to respond. What can you really say when a patient has a progressive terminal illness? There is no denying the illness, and no denying the patient’s experience of it. However, the feelings of dread, powerlessness, and loss of control that a physician may experience on hearing these words can be used to help the patient. Experiencing these emotions shows our capacity to understand or perceive some of what our suffering patients are feeling. Though initially difficult for us to experience, these feelings can become a guide to what a patient needs help with. Foundations of existentialism and existential psychotherapy The author wishes to thank Dr Patricia Boston and Dr Sharon Salloum for their comments on a draft manuscript and Ms Amanda Wanner from the College of Physicians and Surgeons of BC library. Competing interests Bodek H. Facilitating the provision of quality spiritual care in palliative care. Omega 2013;67:37-41. Although it may be a manifestation of depression or some other modifiable condition, existential nihilism is a concept that great minds have either supported or struggled with, and one that is not easy to dismiss out of hand. However, there are certainly alternate views that may facilitate a patient’s leap of faith to a more comfortable opinion. Sartre

Although one could argue it is a religious leader’s role, and not a physician’s, to discuss spiritual or religious matters with a patient at the end of life, an equally strong argument could be made in support of a role for the physician by posing questions about training: What exactly is the training religious leaders receive to provide this kind of care? Is their training accredited in some way or based on evidence of effectiveness? Do religious leaders know more than palliative care specialists? These questions are posed here not to diminish the important role of religious leaders (some of whom do have specialized training in working with dying patients) in caring for patients at the end of life, but rather to suggest that physicians’ knowledge and training should make them confident that they, too, have something to offer. In Boston and colleagues’[ 12] summary of how existential suffering is defined in the literature, many of the definitions focus on meaning and purpose, and these are concepts for which modern evidence-based medical interventions have been developed.[ 9, 10] all products ... delivered to you through the Service are (except as expressly stated by us) provided 'as is' and 'as available' for your use, without any representation, warranties or conditions of any kind, either express or implied, including all implied warranties or conditions of merchantability, merchantable quality, fitness for a particular purpose, durability" Aase M, Nordrehaug JE, Malterud K. “If you cannot tolerate that risk, you should never become a physician”: A qualitative study about existential experiences among physicians. J Med Ethics 2008;34:767-771. Viktor Frankl was an Austrian psychiatrist who spent 3 years in Nazi concentration camps. In contrast to Nietzsche’s “will to power,” Frankl maintained that “will to meaning” is the primary driving force of human behavior. His experiences in the concentration camps are described in his book Man’s Search for Meaning,[ 8] which confirms his belief that meaning can be found in any situation, even in great suffering. He theorized that finding meaning in difficult situations gives us the will to continue living through the worst of circumstances. Frankl’s ideas are now being applied in modern evidence-based psychiatric interventions for patients with advanced cancer as meaning-centred psychotherapy.[ 9, 10] Yalom

Adjusting boundaries

Breitbart W, Poppito S. Meaning-centered group psychotherapy for patients with advanced cancer: A treatment manual. New York: Oxford University Press; 2014. Kierkegaard S. The essential Kierkegaard. Hong EH, Hong HV, editors and translators. Princeton, NJ: Princeton University Press; 2000. p. 216-217. Family members experience distress and require support as well. We all internalize aspects of our parents, and when a parent is dying both young and adult children may feel a core part of themselves or their life is dying. Related to children feeling that their purpose or worth is in “becoming” something to please encouraging adults, children may feel a loss of identity or purpose with a parent’s death. Similarly, family members often grieve not only the loss of their loved one, but also the loss of their caregiving role, especially if the person has been ill for a long time. Educating family members about how common these feelings are and letting them know that these feelings will generally become less painful over time can reduce distress. In expressing condolences to family members, we commonly say something like “I’m sorry for your loss” or “This must be very difficult” to convey empathy. Following up such statements by asking “Who’s supporting you right now?” communicates a greater impression that you care about how they are going to cope with their grief. Adjusting boundaries The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, Søren Kierkegaard is widely regarded as the father of existential philosophy.[ 1] His work often focused on personal choice and commitment, and how everyone lives as a “single individual.”[ 2] Kierkegaard also explored the emotions of people making significant life decisions, and certainly there can be often a number of these to make at the end of life in a modern medical system.

Maugans TA, Wadland WC. Religion and family medicine: A survey of physicians and patients. J Fam Pract 1991;32:210-213. Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infectedNational Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous Kierkegaard S. Søren Kierkegaard’s journals and papers. Hong HV, Hong EH, editors and translators. Bloomington: Indiana University Press; 1967. p. 22-26, 56. Formalized interventions include meaning-centred psychotherapy, an intervention developed at Memorial Sloan Kettering Cancer Center and aimed at helping patients with advanced cancer reconnect with experiential, creative, attitudinal, and historical sources of meaning;[ 9, 10] Dignity therapy, created by Harvey Chochinov and colleagues in Winnipeg;[ 25] and Managing Cancer and Living Meaningfully (CALM) psychotherapy, developed by Gary Rodin and colleagues in Toronto.[ 26, 27] LeMay and Wilson present a review of other manualized therapies for existential distress.[ 20] Helping patients find a silver lining Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S.

Bates AT, Kearney JA. Understanding death with limited experience in life: Dying children’s and adolescents’ understanding of their own terminal illness and death. Curr Opin Support Palliat Care 2015;9:40-45. Heidegger M. History of the concept of time: Prolegomena. Kisiel T, translator. Bloomington: Indiana University Press; 1992. p. 313. in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Nissim R, Freeman E, Lo C, et al. Managing Cancer and Living Meaningfully (CALM): A qualitative study of a brief individual psychotherapy for individuals with advanced cancer. Palliat Med 2012;26:713-721. LeMay K, Wilson KG. Treatment of existential distress in life threatening illness: A review of manualized interventions. Clin Psychol Rev 2008;28:472-493.Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: Professional boundaries, competency, and ethics. Ann Intern Med 2000;132:578-583.