【作者】 明星；

【导师】 赵继军；

【作者基本信息】 第二军医大学 ， 护理学， 2013， 博士

【摘要】 [目的]生命意义的寻求是人一生中重要的课题,生命意义会随着一个人所处的时间、空’间不同而改变,特别是面临受苦与死亡时,更容易遭受寻求生命意义的挫折。晚期癌症患者面对疾病带来的痛苦以及因癌症已无可能治愈,感到死亡逼近时,往往会遭遇寻求生命意义的挫折。本研究在文献分析的基础上初步构建晚期癌症患者生命意义干预方案,并利用晚期癌症患者生命意义寻求的质性研究结果修订该方案,再通过专家小组会议法对方案进行认证,从而形成本土化的晚期癌症患者生命意义干预方案,然后进行干预效果评价。从而为提升国内晚期癌症患者的生命意义感、降低其焦虑抑郁情绪和心理痛苦程度,在精神层面提升其生存质量提供参考依据。[方法]1.质性研究于2012.04.01-2012.06.15间选取此期间入住上海市某三级甲等医院中医科符合纳入标准的晚期癌症患者(30名)作为研究对象,选择质性研究方法之一的“诠释学”作为研究方法了解晚期癌症患者生命意义的寻求途径及寻求挫折。根据“诠释学”的重要原则之一：在利用诠释学方法进行质性研究前必须掌握本研究主题的“前见”。本研究通过系统的文献分析将癌症患者生命意义的寻求途径归为7类：即疾病归因,失落中寻求获得,创造与行动,希望,爱,自我认同,信仰。并据此构建晚期癌症患者寻求生命意义的模型(图2-2),此为研究者所掌握的本研究主题重要的“前见”之一,并根据此模型构建质性研究的访谈提纲。2.方案构建参考“内容分析法”进行文献分析,初步构建晚期癌症患者生命意义干预方案,然后根据质性研究结果修订该方案,再选取12名专家通过小组会议法进一步修订该方案,从而形成本土化的晚期癌症患者生命意义干预方案。3.干预研究于2012.07.01～2012.12,31间选取此期间入住上海市某三级甲等医院中医科符合纳入标准的晚期癌症患者,采用随机对照试验(Randomized Control Test, RCT)的研究方法,将其随机分为干预组与对照组。干预组(18名)接受病房常规照护的同时接受本土化的生命意义干预,对照组(20名)仅接受病房的常规照护,选择合适的量表分别对两组在干预前及干预后的24小时进行干预效果评价。[结果]1.质性研究结果(1)析出与晚期癌症患者生命意义寻求途经相关的主题16个,亚主题13个。将所有主题归为癌症患者寻求生命意义途径的7个类别,类别及主题依次为：①疾病归因(自我因素,医疗服务因素,环境因素)；②失落中求获得(体味生命真谛,向下比较)；③创造与行动(为人处事,制造乐趣,了却牵挂)；④希望(信任治疗,安宁疗护)；⑤爱(爱人,被爱)；⑥自我认同(坚强,包容)；⑦信仰(宗教信仰,个人信念)。(表2-2)(2)析出与晚期癌症患者生命意义寻求挫折相关的主题6个,亚主题10个。主题及亚主题依次为：①个体因素(拖累感,担忧,恐惧,自我封闭)；②经济负担；③生活变化；④治疗相关(副反应大,沟通问题,求医困难)；⑤支持缺乏(婚姻不幸,社会关注低,信息缺乏)；⑥癌症歧视。(图2-1)2.方案构建(1)文献分析：关于癌症患者生命意干预的文献主要分布于近六年(2006-2012),经文献分析发现：干预方案的模式可概括为“一对一”式与群体式。“一对一”式的生命意义干预方案分别为生命意义干预(Meaning-making Interventions, MMi)、生命意义为中心的个体治疗(Individual Meaning-Centered Psychotherapy, IMCP)及生命回顾(Life Review, LR);群体式的生命意义干预方案为群体生命意义心理疗法(Meaning-centered Group Psychotherapy, MGP)与意义治疗法(Logotherapy)。然后对如上干预方案按照干预对象纳入标准、干预模式、干预措施、分组方法、干预者、实施步骤、评价指标、评价时间、评价效果、局限性与改进十个方面进行系统分析(表3-1)。在此基础上选择最佳的干预方案作为参考依据,再结合临床观察初步构建晚期癌症患者生命意义干预方案,再根据前期的质性研究结果对初步形成的干预方案进行修订,再通过专家小组会议法对方案进行认证后确定本土化的晚期癌症患者生命意义干预方案。(2)本土化的晚期癌症患者生命意义干预方案：①干预实施者：研究者本人；②干预措施：认识现在(Acknowledge the Present),生命回顾(Life Review),面对未来(Live the Present for the Future);③任务完成方式：依次分三次完成,每次完成一项,每项任务相隔1～2天,时间控制在6天内；④干预效果评价量表：“心理痛苦程度数字评分量表”、“医院焦虑抑郁量表”、“晚期癌症患者生命意义量表”；⑤干预效果评价时间：干预前及干预后的24小时(表3-4)。3.干预效果评价(1)t检验：①组间比较：心理痛苦程度评分、抑郁维度总分、生命的意义与满足感维度总分、苦难承受与死亡接纳维度总分差值存在统计学差异(P<0.05)。即干预组较对照组在干预后心理痛苦程度降低、抑郁水平下降、生命意义与满足感提升、苦难承受与死亡接纳能力提升(表4-3)。②自身前后比较：干预组在干预前后心理痛苦程度评分、焦虑抑郁量表总分、抑郁维度总分、生命意义量表总分、生命的意义与满足感维度总分、苦难承受维度总分与死亡接纳维度总分有统计学差异(P<0.05)。即干预组干预后较干预前心理痛苦程度与焦虑抑郁水平降低,生命意义感总体水平、生命意义与满足感、苦难承受与死亡接纳能力提升(表4-4)。对照组求意义的意志维度总分有统计学差异(P<0.05)。即对照组干预后较干预前求意义的意志高于干预前。其余指标均无统计学差异(P>0.05)(表4-5)；(2)协方差分析：两组干预前后的患者的心理痛苦程度评分、生命意义总分、苦难承受维度总分差值的修正均数比较有统计学差异(P<0.05)。即,干预组较对照组在干预后心理痛苦程度降低、生命意义感提升、苦难承受能力增强。其余指标均无统计学差异(表4-6)。[结论]1.当前,国内晚期癌症患者可通过多种途径寻求生命意义,然而在寻求生命意义的过程中会遇到诸多挫折。辨识晚期癌症患者寻求生命意义的挫折对于制定科学、有效的本土化的晚期癌症患者生命意义干预方案非常重要。2.开展国内晚期癌症患者生命意义干预可减轻晚期癌症患者心理痛苦程度程度,对改善患者的焦虑、抑郁情绪效果尚不能确定,可提升患者的生命意义感,特别能够增强其苦难承受的能力。经临床研究证实,该干预方案对于晚期癌症患者具有良好的接受性和临床应用的可行性。3.生命意义干预是国内晚期癌症患者迫切的精神需求。培养相关专业人员开展晚期癌症患者生命意义干预的研究及临床实践非常必要。更多还原

【Abstract】 [Aim]Searching for meaning is a persistent, changing and individual process through one’s life and one may encounter frustration in the process, especially when one faces suffering or death.Encountering the pain cancer brings and impossible cure for cancer, advanced cancer patients usually feel the approach of death, often encounter frustration for the meaning of life.To supply references for improving the quality of life on the spiritual level through improving the sense of meaning of life and reducing the anxiety, depression, moreover the psychological pain for advanced cancer patients, we constructed the localization meaning making intervention (MMi) by literature analysis,clinical observation,understanding the searching for meaning for domestic advanced cancer patients and panel meeting.And then evaluate the effect of the intervention.[Methods]1. The Qualitative studyWe selected "Hermeneutics" as our research methodology which is one of the qualitative methods in order to understand the searching for meaning pathways for advanced cancer patients (30) who were selected according to Inclusion criteria in a traditional Chinese medicine department general ward from a three level of first-class hospital in Shanghai from April1,2012to June15,2012. We constructed the model for searching for meaning for cancer patients thourgh literature analysis as one of the important of the principle of "Hermeneutics". The model includes seven categories which are "cancer attribution, construing benefits from loss, creation and action, hope, love, spiritual belief or faith and self-identity" for searching for meaning pathways. And then we formulated the interview outline according to that.2. The construction of interventionThe localized meaning making intervention final draft for advanced cancer patients was formed by constructing the first draft of the intervention using literature "content analysis" combined with the clinical observation, revising that according to the results of qualitative study further and taking panel meeting method to revise that lastly.3. The intervention study Randomized Control Test was used in the intervention study part. We selected the eligible advanced cancer patients who were in a traditional Chinese medicine department general ward from a three level of first-class hospital in Shanghai from July1,2012to December31,2012firstly, and then they were randomized divided into intervention group (18) and Control group (20). The intervention group patients accepted ordinary care and at the same time the localized meaning making intervention and the control group patients accepted ordinary care only. The effects were evaluated by many scales before the intervention and24hours after the completion of the intervention for the intervention and control group.[Findings]1. The findings for qualitative study(1) Sixteen themes and thirteen sub-themes relating to searching for meaning pathways emerged. We classify those themes to seven categories for searching for meaning pathways wich are cancer attribution(self factors, the medical service factors and environmental factors), construing benefits from loss (appreciate the true meaning of the life and downward comparison), creation and action (way of doing things, making fun and settleling care), hope (treatmen trust and hospice care), love (love and to be loved), self-identity (be strong and tolerance) and spiritual belief or faith (religious belief and personal faith)(table2-2)(2) Six themes and ten sub-themes relating to frustrations in the process of searching for meaning for them emerged. The themes and sub-themes include self factors (burden, worry, fear and self sealing), economic burden, changes of life, treatment related(great side effects, communication problems and difficult seeking of medical treatment), lack of support (unfortunate marriage, low attention from society and the lack of information) and cancer discrimination (figure2-1)2. The literature analysis and the intervention formed(1) The literature analysis:The literatures about meaning intervention mainly distributed about the past six years (2006-2012).The interventions can be summarized as two types which are"one-to-one"model and group model. The interventions of one-to-one"model include Meaning-making Interventions, individual Meaning-Centered Psychotherapy and life review. The interventions of group model include Meaning-centered Group Psychotherapy and logotherapy. We analysed the above interventions systematicly according to the inclusion criteria of the intervention objects, the intervention meatures, intervenor, implementation steps, evaluation indexs, evaluation time, intervention effects and the advantages and limitations for the intervention. The sysmetic analysis of that and clinical observation are the basis of the construction of the localized meaning making intervention.(2) The localized meaning making intervention for advanced cancer patient:The researcher herself carries that; Specific intervention contents for the intervention are three takes which are "Acknowledge the Present","Life Review" and "Live the Present for the Future" according to the completion order and will be finished by the patients with the help of the researcher; The tasks will be divided three times to complete, and each task intervals are1-2days and all the tasks will be controlled with in6days to accomplish; The three scales of "Numeric Rating Scales of Suffering, NRSS","Hospital Anxiety and Depression Scale, HADS" and "Meaning in Life Scale for Advanced Cancer Patients, MiLS" were adopted to evaluate the effect of the interventions within24hours after the interventions were finished.3. The evaluation for the intervention effectiveness(1) t-test:Parallel comparison results show that:The scores for the mental pain digital, depression dimension, the meaning of life and satisfaction dimension, suffering tolerance and death acceptation dimension between the two groups existed statistical significances (P<O.05). Namely, after the intervention, the intervention group patients’psychological pain decreased, depression level was reduced, the meaning of life and satisfaction ascended, suffering tolerance and death acceptation ability were enhanced compared with the control group patients (table4-3);Two groups of their own cross-references results show that: Before and after the intervention, the scores for mental pain digital, anxiety depression scale, depression dimension, the meaning of life scale, the meaning of life and satisfaction dimensions, suffering toleration and death acceptation dimension had statistical significances (P<0.05) for the intervention group. Namely, after the intervention, psychological pain degree and anxiety depression level was reduced and the overall level for sense of meaning, the meaning of life and satisfaction, suffering tolerance and death acceptance level increased for the intervention group (table4-4). Before and after the intervention, only the will to search for meaning dimension score had statistical significances for the control group (P<0.05). Namely, after the intervention (usual care), the will to search for meaning was higher, while the other scales all had no statistical significances before and after the intervention usual care) for the control group (P>0.05)(table4-5) (2) ANCOVA:The changes of adjusted mean for scores of the mental pain digital, the meaning of life scale and suffering toleration which is one dimension of the meaning of life scale before and after the intervention had statistical significances between control group and intervention group (P<0.05). That is the mental pain which was eased, the sense of meaning of life which was promoted and the ability of suffering toleration which was enhanced for the intervention group compared with the control after the intervention.There were no statistical significances for any of the rest scale between the two group (P>0.05)[Conclusions]1. The domestic cancer patients can search for meaning thourgh many ways and also can encounter many frustrations. It’s very important to identify the frustions to formulate the domestic meaning making intervention for advanced cancer patients.2. The domestic meaning making intervention can reduce the degree of mental pain, could not have made sure the effect for improve the anxiety and depreesion mood and can promote the sense of meaning of life and can enhance the ablity to bear suffering which is a dimension of scale for meaning of life especially. The intervention has a good acceptance and clinical feasibility for advanced cancer patients.3. The meaning making intervention is an important spiritual need for advanced cancer patients. And it is necessary to train related personnel to carry out the clinical research on meaning making intervention and conduct the clinical practice of meaning making intervention for advanced cancer patients.更多还原