Discussion
anxiety, cancer, psychological disorders, AGS, psychological distress, depression, anticipatory grief
CANCER, BLIND, DISORDERS
In the current study, we found a significant reducing effect of family-based dignity intervention on AGS and its subscales compared with the control group. On the other hand, family-based dignity intervention could reduce anticipatory grief among caregivers of dying cancer patients. However, we found no significant effect for expressive writing intervention and combined interventions of expressive writing and family-based dignity intervention. To the best of our knowledge, this is the first study that examined the combined effects of family-based dignity intervention and expressive writing on caregivers of dying cancer patients.Since family caregivers of dying cancer patients have inadequate social support and face several problems related to their patients, they may suffer from different psychological disorders such as depression, anxiety, and psychological distress [Recently, it has been shown that some psychological interventions such as family-based dignity intervention and expressive writing have a beneficial effect on psychological disorders in dying patients [In total, our study and results from the previous studies confirmed that caregivers can benefit from family-based dignity intervention. This positive effect might be explained by that the family-based dignity intervention gives caregivers an opportunity to release pressure and express their true feelings and concerns. This approach may have a relieving effect on anxiety and depression associated with caregiving work [In the current study, expressive writing intervention had no significant effect on anticipatory grief and its subscales in caregivers of dying cancer patients. However, previous studies reported beneficial effects of expressive writing on caregivers of cancer patients. In a clinical trial, Leung et al. reported that expressive writing could enhance the ability of caregivers to overcome their difficulties in caregiving of cancer patients [The lack of significant effect of the combined intervention (family-based dignity + expressive writing) on anticipatory grief might be justified by the lack of significant effect of expressive writing. In our study, for caregivers in the combined intervention, we first hold the family-based dignity sessions, and then, caregivers were asked to do writing within a week after the dignity intervention. Therefore, the beneficial effect of family-based dignity intervention may have been attenuated by the expressive writing process. Further studies are needed to confirm our findings on the effect of expressive writing on anticipatory grief among cancer caregivers.It seems that anticipatory grief might be more affected by those interventions that participants can communicate with consultants or other participants. In the current study, in the family-based dignity intervention, the communication between interviewers (nurses) and caregivers in an interview session might help caregivers to sympathize with the interviewers and express their true feelings and concerns. Such a situation occurred in the study of Leung et al., in which caregivers in the expressive writing group could speak with each other and share their difficulties [The main strength of our study was that it did show that family-based dignity intervention had a significant impact on anticipatory grief compared to the control group. Also, this was the first controlled clinical trial that examined the effects of both family-based dignity intervention and expressive writing on anticipatory grief in family caregivers of dying cancer patients. In addition to the effects of family-based dignity intervention and expressive writing alone, the combined effect of these interventions was assessed in a separate intervention group. Also, participants were allocated to the 4 intervention groups using block randomization. It seems that the sample size of this trial was adequate and provided sufficient power to detect the efficacy of interventions. Moreover, we controlled for baseline measurements in the statistical analysis. Some limitations of our study need to be taken into account. Despite using validated questionnaires for the assessment of anticipatory grief, misclassification of caregivers in terms of this variable cannot be fully excluded. Since the interventions used in the current study were interview-based, we cannot blind the caregivers to the interventions. Although we do block randomization, we could not match the intervention groups in terms of caregivers’ age and gender.In conclusion, family-based dignity intervention presented by an experienced nurse improves anticipatory grief and its subscales in caregivers of dying cancer patients. However, we found no significant effect for expressive writing intervention and combined interventions of expressive writing and family-based dignity intervention. Since family-based dignity intervention can easily be carried out in palliative care centers, it can be taught to nurses to use in their conversations with cancer patients and caregivers. It must be kept in mind that family-based dignity intervention is not routinely conducted in cancer treatment centers in Iran.