Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S.

Bodek H. Facilitating the provision of quality spiritual care in palliative care. Omega 2013;67:37-41. Looking at social, psychological, and spiritual suffering, spiritual distress is likely to be viewed as the most remote from a physician’s core training. Many equate spirituality with religion and, understandably, physicians are reluctant to discuss religions they may know little about. Physicians are about half as likely as patients to hold a particular spiritual belief.[ 14] Even if a physician follows a religion, he or she might be concerned about being intrusive,[ 15] and some guidelines for communicating with patients about spiritual issues caution against discussing your own religious beliefs, stating they are generally not relevant.[ 16] However, it is possible to bring wisdom from the world’s major religions into therapeutic discussions about illness and death without intrusively promoting a particular faith. It is always helpful to know what a patient’s spiritual beliefs are, and questions based on the FICA spiritual history tool[ 17, 18] can help you do this (see the Table).

Nietzsche

Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA 2000;284:2907-2911. Sartre J-P. Being and nothingness: An essay on phenomenological ontology. Barnes H, translator. New York: Washington Square Press; 1992. p. 680-698.

National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the Lo C, Hales S, Jung J, et al. Managing Cancer And Living Meaningfully (CALM): Phase 2 trial of a brief individual psychotherapy for patients with advanced cancer. Palliat Med 2014;28:234-242. 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

Holland JC, Romano SJ, Heiligenstein JH, et al. A controlled trial of fluoxetine and desipramine in depressed women with advanced cancer. Psychooncology 1998;7:291-300. Irvin Yalom has written extensively on existential psychotherapy,[ 11] where psychiatric symptoms or inner conflicts are viewed as the result of difficulties in facing what he describes as the four “givens” of human existence: mortality, meaninglessness, isolation, and freedom. Existential psychotherapy focuses on identifying which of these existential givens patients are struggling with and helping them to respond in positive ways. Certainly, acute appreciation of one’s mortality, disconnection from meaning, feelings of isolation, and uncomfortable freedom in making difficult choices can all play a significant role in existential suffering at the end of life. What is existential suffering? Holding a patient’s hand for any length of time would be a boundary violation in many medical settings, particularly for psychiatrists who tend to avoid touching patients at all. Yet given that loss of connectedness to others is such a common theme in definitions of existential suffering, few things are more therapeutic than holding the hand of a dying patient who is otherwise alone. Similarly, placing a gentle hand on a patient’s shoulder as you arrive or as you leave the bedside can communicate a connectedness or caring that might be difficult to convey appropriately in words. Best practice is always to observe appropriate boundaries in the doctor-patient relationship, but there is good reason to shift these boundaries in some palliative care settings. Using formalized interventions Are you currently going to through an existential crisis yourself? If so, please let us know in the comment section below, and don’t forget to mention what triggered it.

Boston P, Bruce A, Schreiber R. Existential suffering in the palliative care setting: An integrated literature review. J Pain Symptom Manage 2011;41:604-618. 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. Sartre J-P. Existentialism is a humanism. Macomber C, translator. New Haven, CT: Yale University Press; 2007. p. 55. 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.

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For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work 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 in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med 2000;3:129-137. 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.

pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors. 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] of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universallyKierkegaard S. Søren Kierkegaard’s journals and papers. Hong HV, Hong EH, editors and translators. Bloomington: Indiana University Press; 1967. p. 22-26, 56. Many dying patients see their new-found realization about being alive and knowing how they want to spend their time as a silver lining to a diagnosis of terminal illness. Unfortunately, this is sometimes paired with guilt or remorse related to a sense of not having spent their time well up to that point. Some patients may also feel there is now no opportunity for anything other than dying because of the large amount of time they “wasted.” Helping patients with existential suffering realize they are still alive is often key. Some argue that hope is an act rather than a feeling. Children generally have a remarkable way of achieving hopefulness on their own. Youth in hospice generally have the same desires and interests as other young people, such as wanting to make friends and being interested in sex.[ 28] Maugans TA, Wadland WC. Religion and family medicine: A survey of physicians and patients. J Fam Pract 1991;32:210-213. Friedrich Nietzsche is intimately associated with the concept of nihilism, which in turn is related to existential nihilism—the idea that life has no meaning or purpose. Patients at the end of life may experience a kind of existential nihilism and say that their existence has been meaningless or that there is no longer any point in being alive. Nietzsche argued that our primary driving force is not meaning or happiness, but rather the “will to power” or pursuit of high achievement and reaching the best possible position in life.[ 5] If this is our primary driving force, it is understandable that patients who have had great success in their careers or other pursuits may feel there is no longer any purpose to their existence once they are seriously ill. Martin Heidegger extended Kierkegaard’s idea of living as a single individual to dying as a single individual, proposing that death is an entirely personal experience that must be taken on alone.[ 3] Patients do sometimes experience a new and distressing sense of aloneness at the end of life, knowing that nobody is going to share this specific experience with them. The feeling of being the only one who can make choices about how to live out final days can be overwhelming.