Prognostic Acceptance and the Well-Being of Patients
Receiving Palliative Care for Cancer
Genevieve N. Thompson, Harvey M. Chochinov, Keith G. Wilson, Christine J. McPherson, Srini Chary,
Fiona M. O’Shea, David R. Kuhl, Robin L. Fainsinger, Pierre R. Gagnon, and Karen A. Macmillan
From the Department of Psychiatry;
Manitoba Palliative Care Research Unit,
CancerCare Manitoba and Faculty of
Nursing, University of Manitoba,
Winnipeg, MB; Department of Medi-
cine (Division of Physical Medicine and
Rehabilitation) and School of Psychol-
ogy; Faculty of Health Sciences,
University of Ottawa, Ottawa, ON;
Department of Oncology, University of
Calgary, Calgary; Palliative Care Medi-
cine, Department of Oncology, Univer-
sity of Alberta; Grey Nuns Community
Hospital, Covenant Health, Edmonton,
AB; Dr. H. Bliss Murphy Cancer Centre,
St. John’s, NL; Department of Family
and Community Medicine, University of
British Columbia, Vancouver, BC,
Canada; and Faculty of Pharmacy,
Universite ´ Laval, Centre de recherche
de l’Ho ˆ tel-Dieu de Que ´ bec, Maison
Michel-Sarrazin, and Centre de recher-
che Universite ´ Laval Robert-Giffard,
Paris, France.
Submitted March 19, 2009; accepted
June 18, 2009; published online ahead
of print at www.jco.org on October 13,
2009.
Supported by a grant from the Cana-
dian Institutes of Health Research
(CIHR) and by a New Emerging Team
grant from the Institute of Aging.
H.M.C. is supported by a Tier I Canada
Research Chair in Palliative Care from
the CIHR.
Authors’ disclosures of potential con-
flicts of interest and author contribu-
tions are found at the end of this
article.
Corresponding author: Harvey
Chochinov, MD, PhD, Department of
Psychiatry, University of Manitoba and
Manitoba Palliative Care Research Unit,
3017-675 McDermot Ave, Winnipeg,
MB, R3E 0V9 Canada; e-mail: Harvey
.chochinov@cancercare.mb.ca.
© 2009 by American Society of Clinical
Oncology
0732-183X/09/2799-1/$20.00
DOI: 10.1200/JCO.2009.22.9799
A B S T R A C T
Purpose
To identify the impact of prognostic acceptance/nonacceptance on the physical, psychological, and
existential well-being of patients with advanced cancer.
Patients and Methods
A Canadian multicenter prospective national survey was conducted of patients diagnosed with
advanced cancer with an estimated survival duration of 6 months or less (n = 381) receiving
palliative care services.
Results
Of the total number of participants, 74% reported accepting their situation and 8.6% reported
accepting with “moderate” to “extreme” difficulty. More participants with acceptance difficulties
than without acceptance difficulties met diagnostic criteria for a depressive or anxiety disorder (
2
=
8.67; P .01). Nonacceptors were younger (t = 4.13; P .000), had more than high school
education (
2
= 4.69; P .05), and had smaller social networks (t = 2.53; P .05) than Acceptors.
Of the Nonacceptors, 42% described their experience as one of “moderate” to “extreme”
suffering compared with 24.1% of Acceptors (
2
= 5.28; P .05). More than one third (37.5%)
of Nonacceptors reported feeling hopeless compared with 8.6% who had no difficulty accepting
(
2
= 24.76; P .000). Qualitatively, participants described active and passive coping strategies
that helped them accept what was happening to them, as well as barriers that made it difficult to
come to terms with their current situation.
Conclusion
The challenge of coming to terms with a terminal prognosis is a complex interplay between one’s
basic personality, the availability of social support, and one’s spiritual and existential views on life.
Nonacceptance appears to be highly associated with feelings of hopelessness, a sense of
suffering, depression, and anxiety, along with difficulties in terms of social–relational concerns.
J Clin Oncol 27. © 2009 by American Society of Clinical Oncology
INTRODUCTION
How much patients know and how much they
ought to know about a terminal prognosis remains a
matter of contention. Some would argue that an
awareness of dying is integral to achieving a good
death,
1,2
their argument being that in order for
death to be meaningful and to plan accordingly, it is
critical for patients to be aware of and accepting of
their approaching death.
3-8
Several studies have
highlighted the role that prognostic acceptance plays
in facilitating the completion of advance directives,
do-not-resuscitate orders, and delineating goals of
care.
9,10
However, little research has explored the
impact of prognostic acceptance on terminally ill
patients’ well-being. The purpose of this study was
to explore the issue of prognostic acceptance on the
physical, psychological, and existential well-being of
patients with advanced cancer and the factors that
may contribute to this process.
PATIENTS AND METHODS
Participants
This project was a component of the Canadian Na-
tional Palliative Care Survey (NPCS), a multicenter study
that examined the experiences of patients with end-stage
cancer. Details of the study have been reported previous-
ly.
11
Briefly, consecutive patients at eight sites across Can-
ada were recruited through inpatient palliative care units
or hospices, consultation services to general hospitals, or
home care between May 2001 and March 2003. The fol-
lowing were inclusion criteria: (1) patient was diagnosed
with cancer; (2) patient was informed that the cancer was
not curable; (3) clinician estimated survival duration of 6
months or less; (4) patient was deemed to be cognitively
JOURNAL OF CLINICAL ONCOLOGY
O R I G I N A L R E P O R T
© 2009 by American Society of Clinical Oncology 1
http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2009.22.9799 The latest version is at
Published Ahead of Print on October 13, 2009 as 10.1200/JCO.2009.22.9799
Copyright 2009 by American Society of Clinical Oncology
Copyright © 2009 by the American Society of Clinical Oncology. All rights reserved.
204.187.34.100.
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