Patients suffering with chronic conditions, such as advanced cancer, must deal with the deteriorating reality of losses and grieving almost daily as their condition worsens, treatments and side effects take their toll and they struggle with a precarious future and possible death. Indeed, the challenge of living with a terminal disease likely triggers existential issues and death anxiety, yet unfortunately, research tends to focus on interventions for the bereaved---not for the patient who is staring death square in the face. One intervention that may hold promise for the dying patient is mindfulness-based stress reduction, of which a plethora of cancer studies indicates its effectiveness in significantly reducing scores on: stress levels and symptoms, anxiety and depression, cancer distress, pain levels and pain anxiety, existential well-being, and death and dying distress. Future studies as to the efficacy of mindfulness interventions for terminal disease populations are needed where loss, grief, and death concerns are common.

Keywords: Cancer and mindfulness, Death and dying, Mindfulness intervention, Grief, loss and cancer, Dying distress intervention

In 2009, the Nomenclature Committee on cell death A diagnosis of cancer elicits greater distress than any other diagnosis, regardless of prognosis, for humans fear pain and death since they are the ultimate threats to our survival and existence [1,2]. Each year, around 600000 Americans die from cancer, and breast cancer is the second most common cancer in the world, as well as the most common cancer in women [3]. Psychological anguish is common in terminally ill persons and can be a source of great suffering. The experiences of dying cancer patients may be described by what happens before, during, and after the transition from---living with and, often, being treated for advanced stages of cancer---to being cared for while dying from cancer [4]. Chronic illness and terminal disease deplete patients’ biopsychosocial and spiritual resources to cope with the forced challenges brought upon them by such conditions, for example, adapting to continual losses. Dealing with multiple losses and grief are experienced by cancer patients as they come to grips with the disease, deal with treatment side effects and struggle daily with a precarious future and possible death [5]. Loss and grieving are natural responses to chronic and terminal illness, yet frequently, research focuses on research or grief interventions for the bereaved---not the patient. Thus, there is a paucity of research and interventions in this area. Mindfulness meditation is an intervention now frequently employed to help cancer patients reduce a variety of symptoms, which has potential to aid in loss and grief issues facing patients with advanced or terminal cancer. Accordingly, a brief review follows as to mindfulness effects on thanatological issues, that is, death/dying, grief and loss factors.

THE WORRY OF DEATH

Patients with chronic illnesses, such as advanced cancer, may be aware of impending death by their worsening condition, which triggers existential issues [6]. Generally, the term, death anxiety, is used to conceptualize the worry generated by this death awareness, of which, Yalom, saw death fear as a primitive, pervasive and deeply held dread of non-existence [7,8]; and, not only are thoughts about death and loss common in palliative care patients, but so too, is suicide [9]. It has been estimated that approximately 80% percent of patients with advanced cancer are plagued with distressing thoughts about death-related issues as dying, loss and grief with associated symptoms of depression and fears of suffering [10-12].

Psycho-oncology researchers describe the difficult dichotomy of “double awareness”’ for palliative care patients, who try to balance two conflicting mindsets: remaining engaged and enjoying what remains of their life, while being aware of their near-certain physical deterioration and death [13]. Not surprisingly, death concerns negatively impact quality of life remaining [14]. In cancer, the medical team’s focus is stabilizing the patient’s physical condition and relieving symptoms (pain, nausea, vomiting, etc.). Unfortunately, patients’ common psychosocial-spiritual suffering with death-related issues likely is neglected; hence, interventions are needed to attend to such needs of the dying [15-17].

MINDFULNESS AND DEATH-RELATED FACTORS

Kabat-Zinn’s eight-week psychosocial mindfulness stress reduction and relaxation program originated at the University of Massachusetts Medical Center in the late 1970s [18]. Basically, mindfulness is cultivating awareness each present moment. It is the disciplined practice that fosters detached, nonjudgmental witnessing of thoughts, perceptions, sensations and emotions, which provides a means of self-regulating one’s arousal and awareness [18]. For example, rumination and catastrophizing are the opposite of mindfulness which exemplifies an intentional focus on the present moment where an individual accepts each moment non-judgmentally rather than worrying about the past or the future. Several mindfulness techniques are taught that include: breathe awareness, yoga, sitting meditation, mindful eating and walking meditation [18]. A plethora of cancer studies indicate that the MBSR is effective in significantly reducing scores on: stress levels and symptoms, anxiety and depression, cancer distress symptoms, insomnia, fatigue, pain anxiety and pain catastrophizing, existential well-being and mental adjustment to cancer [5,19-22]. Minimal research exists as to mindfulness effects on factors in the field of thanatology or death and dying, loss and grieving.

Specifically, only two MBSR studies have examined death-related factors in women with breast cancer. The first study of 65 women with breast cancer explored pre-post effects of a traditional eight-week mindfulness-based stress reduction intervention (MBSR) on scores for existential well-being, total self-identified losses and grief; additionally, a six-month follow-up determined intervention maintenance [5]. Data on the revealed significantly improved scores for all measures and six month follow-up revealed that 88% of the 58 respondents reported continued use of mindfulness strategies. The second study involved the use of a new measure of death anxiety known as the Death and Dying Distress Scale (DADDS) [21]. Specifically, 42 women with breast cancer participated in the traditional eight-week MBSR program, pre-post intervention design, where data were collected on death anxiety, pain anxiety, existential well-being and the death attitude of death as an escape. Results showed significant improvement for death anxiety, pain anxiety and existential well-being post the intervention, yet the scores for the death attitude of escape did not reach significance.

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