Efficacy of Short-Term Life-Review Interviews on the Spiritual Well-Being of Terminally Ill Cancer Patients

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1 Vol. 39 No. 6 June 2010 Journal of Pain and Symptom Management 993 Original Article Efficacy of Short-Term Life-Review Interviews on the Spiritual Well-Being of Terminally Ill Cancer Patients Michiyo Ando, RN, PhD, Tatsuya Morita, MD, Tatsuo Akechi, MD, PhD, and Takuya Okamoto, MD Faculty of Nursing (M.A.), St. Mary s College, Kurume City, Fukuoka; Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice (T.M.), Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka; Department of Psychiatry and Cognitive-Behavioral Medicine (T.A.), Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi; and Palliative Care Unit (T.O.), Palliative Care Unit, Toya Onsen Hospital, Abuta-Gun, Hokkaido, Japan, on behalf of the Japanese Task Force for Spiritual Care Abstract Context. There is a little information about effective psychotherapies to enhance the spiritual well-being of terminally ill cancer patients. Objectives. The primary aim of the study was to examine the efficacy of a oneweek Short-Term Life Review for the enhancement of spiritual well-being, using a randomized controlled trial. The secondary aim was to assess the effect of this therapy on anxiety and depression, suffering, and elements of a good death. Methods. The subjects were 68 terminally ill cancer patients randomly allocated to a Short-Term Life-Review interview group or a control group. The patients completed questionnaires pre- and post-treatment, including the meaning of life domain from the Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT-Sp) scale, the Hospital Anxiety and Depression Scale (HADS), a numeric scale for psychological suffering, and items from the Good Death Inventory (Hope, Burden, Life Completion, and Preparation). Results. The FACIT-Sp, Hope, Life Completion, and Preparation scores in the intervention group showed significantly greater improvement compared with those of the control group (FACIT-Sp, P < 0.001; Hope, P < 0.001; Life Completion, P < 0.001; and Preparation, P < 0.001). HADS, Burden, and Suffering scores in the intervention group also had suggested greater alleviation of suffering compared with the control group (HADS, P < 0.001; Burden, P < 0.007; Suffering, P < 0.001). Conclusion. We conclude that the Short-Term Life Review is effective in improving the spiritual well-being of terminally ill cancer patients, and alleviating psychosocial distress and promoting a good death. J Pain Symptom Manage This study was supported by the Cancer Research Program of the Ministry of Health, Labor, and Welfare of Japan. Address correspondence to: MichiyoAndo,RN,PhD,Faculty of Nursing, St. Mary s College, Tsubukuhonmachi Ó 2010 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved. 422, Kurume City, Fukuoka, Japan. andou@ st-mary.ac.jp Accepted for publication: November 6, /$esee front matter doi: /j.jpainsymman

2 994 Ando et al. Vol. 39 No. 6 June ;39:993e1002. Ó 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Psychotherapy, Short-Term Life Review, terminally ill cancer patients, spiritual well-being, randomized control trial, good death Introduction Palliation of psycho-existential suffering in terminally ill cancer patients is of great importance because it is related to quality of life, good death, depression, 1 desire for a hastened death, hopelessness, and suicidal ideation. 2 It has been reported that 17% of patients have a strong desire for a hastened death, and 16% of patients met criteria for a major depressive episode. 3 Desire for a hastened death was significantly associated with clinical depression and hopelessness. Many studies have explored effective strategies to alleviate psychoexistential suffering based on concepts such as dignity, meaning, and demoralization. 4e7 A recent single-arm preliminary trial in Canada suggested that Dignity Therapy 4,5 is promising for alleviating psycho-existential suffering of terminally ill cancer patients, but no intervention of this type has been confirmed to be effective. In Japan, a multidisciplinary professional task force has been established to develop a clinical strategy for psycho-existential suffering of terminally ill cancer patients, and this group first proposed a conceptual framework for psycho-existential suffering based on a theoretical model and a good death survey. 8 We defined psycho-existential suffering as pain caused by extinction of being and meaning of self through loss of relationships with others, loss of autonomy, or loss of a future. In this model, psycho-existential suffering has the sense of meaning as a core concept, and includes seven subdomains (relationship, control, continuity of self, burden to others, generativity, death anxiety, and hope). We tested the efficacy of reminiscence therapy for alleviation of psycho-existential suffering, initially through exploration of the feasibility and efficacy of four-week formal reminiscence therapy in terminally ill cancer patients. 9 This study demonstrated a positive effect on spiritual well-being, 10 but about 30% of the enrolled patients did not complete the study because of rapid physical deterioration. We then developed a novel psychotherapy, the Short-Term Life Review, comprising two sessions over one week, and explored its feasibility and efficacy using a pre/post study design. 11 The results were promising: the completion rate was 83%, and there was a significant increase in the sense of meaning, as measured by the Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT-Sp) scale. 12 In the current randomized controlled trial, our goal was to confirm the efficacy of the Short-Term Life Review to enhance the sense of meaning in terminally ill cancer patients. The secondary aim was to investigate the effects of the Short-Term Life Review on anxiety and depression and on elements of a good death (Hope, Burden, Life Completion, and Preparation). Patients and Methods Participants The participants were cancer patients from the palliative care units (PCUs) of two general hospitals in Western Japan. The same kind of care was delivered in these two hospitals, with a multidisciplinary team including a pastoral care worker. The inclusion criteria were as follows: 1) incurable cancer, undergoing treatment in the PCU (the duration in the PCU was between two and four weeks), 2) ability to communicate, and 3) age >20 years old. The exclusion criteria were as follows: 1) severe pain or physical symptoms diagnosed by the primary doctor, 2) cognitive impairment such as dementia or consciousness disturbance, and 3) difficult family problems, such as problems with regard to inheritance of property, conflicts about the patient funeral among family members, and the reconciliation of past troubles between the patients and their

3 Vol. 39 No. 6 June 2010 Spiritual Well-Being of Terminally Ill Cancer Patients 995 family members. Palliative care specialists determined whether each patient had cognitive impairment. Regarding selection of participants, first doctors and nurses in the two hospitals introduced the research to patients who met inclusion and exclusion criteria, and the therapist explained the research in detail after patients expressed interest in participating in the research. The study was approved by the Ethics Committee of St. Mary s Hospital and St. Mary s College. Outcome Measures Following the model of our group, 8 we chose the sense of meaning measured by the FACIT-Sp scale as the primary end point. The validity and reliability of the Japanese version of the FACIT-Sp is well established. 13 The FACIT-Sp consists of two domains, meaning of life and religious issues, but only the meaning of life domain was used because an effect of the Short-Term Life Review on religious issues in one week was unlikely. The meaning of life domain includes eight items and is scored on a 5-point scale (range 0e4). The total range of the FACIT-Sp is 0e32, and high scores indicate an elevated sense of meaning of life or a peaceful state of mind. The reliability coefficient of the eight items was Anxiety and depression and some domains of the Good Death Inventory were chosen as secondary end points. The Japanese version of the Hospital Anxiety and Depression Scale (HADS) 14,15 was used to measure levels of anxiety and depression. The HADS score ranges from 0 to 42. To explore the effects of the Short-Term Life Review on patient-perceived good death, we used several items from the Good Death Inventory. 16 This is a 28-item questionnaire with 10 core domains, of which we used four (Hope, Burden, Life Completion, and Preparation for death) domains to relieve each patient from answering questions for all the domains. The Hope domain reflects maintenance of hope and pleasure, Burden reflects the feeling of being a burden to others, Life Completion reflects the feeling of life completion, and Preparation for death reflects the patient s feeling that he or she has said what they wanted to say to the important people in their life. Hope is measured using a 7- point numeric rating scale (NRS) for the statement, I have some pleasure in daily life, with a high score indicating an elevated sense of hope (range 1e7). Burden is evaluated using a seven-point NRS for the statement, I am distressed that I am being a burden to family members, with a high score indicating an elevated feeling of being burdensome (range 1e7). Life Completion includes three items I feel that my life is complete, I feel that my life has been fulfilling, and I worry about something that I have yet to complete. The reliability coefficient of these three items postintervention was 0.71 in this study. A high score indicates an elevated sense of life completion (range 1e7). Preparation for death is assessed based on the statement, I have said what I want to say to the important people in my life, with a high score indicating an elevated sense of preparedness for death (range 1e7). In addition, to compare the results with a previous study, 4 we investigated the intensity of psychological suffering using a 7-point numeric scale (from 0, no distress to 6, extreme distress). We also monitored the intensity of pain and physical symptoms other than pain, such as dyspnea and weariness, using a single-item measure on an 11-point NRS (0e10), but we did not expect to achieve palliation of pain or symptoms by the intervention. The same therapist administered the questionnaire for patients in the intervention and control groups. Performance status was measured by the Eastern Cooperative Oncology Group Performance Status Rating (ECOG-PSR), 17 which is a singleitem rating of five activity levels from 0 (fully active) to 4 (completely disabled). Randomization This study was conducted from April 2007 to March A co-author prepared sequentially numbered, sealed, opaque envelopes that contained placements for the participants. A patient was allocated into the intervention or control group by opening the envelope. The identities of the patient and the interview were kept anonymous, and the patients were randomly assigned to the intervention or control group. Interventions The Short-Term Life Review and general support were used as interventions. In the

4 996 Ando et al. Vol. 39 No. 6 June 2010 Short-Term Life Review, we used two interview sessions because our previous study 11 suggested that three or four sessions were too many and that patients could not complete the therapy. In the first session, the patient reviewed his or her life with an interviewer who was trained to conduct the therapy. Each interview session lasted from 30 to 60 minutes, with a one-week interval between the first and second sessions. The following questions were prepared with reference to autobiography life-review therapy, in which clients review their lives, along with themes in life, and Dignity Therapy, because these are useful for patients to recall and integrate events in their lives. In the first session, the patients were asked 1) What is the most important thing in your life and why? 2) What are the most vivid or impressive memories in your life? 3) In your life, what event or person affected you most? 4) What is the most important role you played in your life? 5) What is the proudest moment in your life? 6) Is there anything about you that your family needs to know? 7) Are there things you want to tell them and are there things you want them to remember? 8) What advice or words of guidance do you have for the important people in your life or for the younger generation? The patient s narratives were recorded, and the interview was transcribed verbatim. The therapist made a simple album, including key words from the answer to each question that were selected through a discussion between the patient and the therapist. Key words included both positive and negative elements of the interview. The therapist then pasted photos or drawings from books or magazines that were related to the patient s words or phrases to make the album beautiful and memory provoking. In collage psychotherapy, a client pastes photos or drawings by himself; however, this activity may be a cognitive burden to terminally ill cancer patients, and thus the therapist made the album. In the second session, the patient and therapist viewed the album together and agreed on the contents. The therapist tried to encourage the patient to feel continuity of self from the past to the present, to accept life completion, and to be satisfied with their life. After the second session, the therapist presented the album to the patient. As the therapist was not affiliated with the hospital, the patients did not maintain a relationship with the therapist and could easily say whether they received the album. There are several differences between the Short-Term Life Review and Dignity Therapy. In the Short-Term Life Review, patients review their lives for themselves and receive an album, whereas in Dignity Therapy, patients review their lives with regard to important persons and do not receive a real album. Visualization by an album may make patients feel their lives are much more impressive and valuable. In addition to the Short-Term Life Review, the intervention group received general support, in which the therapist interviewed the patient regarding physical and mental status and mood in a supportive way. The therapist spent more time discussing these issues with the patient. The interviewer responded to the patient s narrative in a personcentered manner that was nonjudgmental and supportive. Thus, the intervention group received both the Short-Term Life Review and general support. The control group received only general support in the first and second sessions. Patients in both groups received normal medical treatment but no particular psychotherapy during the present research; therefore, the only difference between the groups was the intervention with the Short-Term Life Review. Patients in both groups completed the questionnaires before the first session and after the second session with a therapist. The therapist was certified as a clinical psychologist in Japan, and had eight years of clinical experience for life-review interviews. The same therapist conducted the investigation for the intervention and control groups to prevent confounding by differences in therapists techniques. Because each patient s performance status was 3 or 4, they were unable to move freely and did not talk to each other; therefore, they were not blinded in the study. Adherence to the interview process was verified by two raters (co-authors) who reviewed 10% of the completed audiotaped sessions and audit forms. This selection of audiotapes was based on sex (male, female) and session length (short, long) to assess the extent to which the intervention was delivered according to the protocol.

5 Vol. 39 No. 6 June 2010 Spiritual Well-Being of Terminally Ill Cancer Patients 997 Statistical Analysis The number of participants was determined using the criteria of the FACIT-Sp score. In a previous study for standardization of this scale in Japan, the mean score was 32, and the standard deviation (SD) was 9.2. In the present study, when we established an effect size of 20%, a power of 0.8, an alpha of 0.05, the effect size was 6.4 (0.2 32) and a standardized effect size was 0.70 (6.4/9.2). This required a sample size of 34 patients per group. To evaluate the efficacy of the Short-Term Life Review in improving spiritual well-being, we used a two-way repeated-measures analysis of variance (ANOVA) (2 [groups: intervention, control] 2 [period: pre, post]) on the FACIT-Sp score. As we needed to know the efficacy between the groups with inclusion of a time factor, we refer to the main effect and the interaction of the ANOVA. A correlationanalysis was also performed between the FACIT-Sp scores and other variables. A P-value less than 0.05 was chosen as the significance level in all the statistical analyses, and all the reported P-values are two-tailed. The main effect shows the significance of differences between groups, and the interaction shows the difference of the effects of interventions. All the statistical procedures were conducted with SPSS 15.0 (Japanese version) software for Windows (SPSS Inc., Chicago, IL, 2006). Results The protocol of the study is shown in Fig. 1. Five patients from the control group and four from the intervention group withdrew from the study because of death (n ¼ 1), physical deterioration (n ¼ 1), discharge from hospital (n ¼ 1), and patient refusal (n ¼ 1) in the intervention group; and death (n ¼ 3), physical deterioration (n ¼ 1), and refusal (n ¼ 1) in the control group. Thus, a total of 68 patients completed all of the sessions, and the response rate was 88%. There were no significant differences in background between the groups (Table 1). Primary End Point Regarding the FACIT-Sp, the main effect was significant and the score of the intervention group was significantly higher than that of the control group. The interaction was also significant, and the scores of the intervention group significantly increased after the Short- Fig. 1. Study protocol.

6 998 Ando et al. Vol. 39 No. 6 June 2010 Table 1 Comparison of Background Factors Between the Intervention and Control Groups Characteristics Intervention Control P-value a Age Gender Male Female Religion Presence 4 1 Absence Stage ECOG-PS Marital status Married Divorced 6 2 Single/widowed Primary tumor site Lung 6 6 Stomach 7 2 Breast 2 4 Liver 2 3 Pancreas 2 2 Others ECOG-PS ¼ Eastern Cooperative Oncology Group Performance Status; 2 ¼ ambulatory and able to care for self but unable to work more than half of waking hours; 3 ¼ capable of only limited self care, confined to bed or a chair; 4 ¼ completely disabled, unable to care for self, confined to bed or chair. a c 2 test. Term Life Review, whereas those of the control group significantly decreased (Table 2). The mean FACIT-Sp scores were 26 for the intervention group and 14 for the control group (SD ¼ 7.5); thus, the effect size for the FACIT-Sp was Secondary End Points For the HADS, the main effect was significant, and the score of the intervention group was significantly lower than that of the control group. The interaction was significant, and the score for the intervention group significantly decreased, whereas the score of the control group did not change. For Hope, the main effect was significant, and the score for the intervention group was significantly higher than that for the control group. The interaction was also significant, and the score for the intervention group significantly increased after the intervention, whereas the score for the control group significantly decreased. For Burden, the main effect was not significant. The interaction was significant, and the score for the intervention group significantly decreased after the intervention, whereas that for the control group did not change. For Life Completion, the main effect was significant, and the score for the intervention group was significantly higher than that for the control. The interaction was also significant, and the score for the intervention group significantly increased after the intervention, whereas that of the control group did not change. For Preparation, there was no main effect between the groups. The interaction was significant, and the score for the intervention group significantly increased, whereas that of the control group did not change. For Suffering, there was no main effect between the groups. However, the interaction was significant, and the score for the intervention group significantly decreased after the intervention, whereas that of the control group did not change significantly. Physical Pain and Physical Symptoms. The Short-Term Life Review had no significant effect on the Pain and Physical Symptoms scores. Intensity of pain ranged from 2.9 to 4.2 and intensity of symptoms ranged from 3.7 to 5.1, indicating good control of pain and symptoms, although the scores did not change positively. Correlation Analysis. We conducted a correlation analysis to explore relationships between sense of meaning and other variables (Table 3). The FACIT-Sp score was moderately correlated with Hope (r ¼ 0.36, P ¼ 0.02), Life Completion (r ¼ 0.66, P ¼ 0.001), HADS score (r ¼ 0.52, P ¼ 0.001), Suffering (r ¼ 0.60, P ¼ 0.001), and Pain (r ¼ 0.36, P ¼ 0.02). Discussion Effectiveness of the Short-Term Life Review To our knowledge, this is the first study to show a beneficial effect of a Short-Term Life- Review interview on spiritual well-being in terminally ill cancer patients. The Short-Term Life Review is effective in facilitating a sense of meaning, alleviating anxiety and depression, and promoting a good death. The most important finding is that the sense of meaning

7 Vol. 39 No. 6 June 2010 Spiritual Well-Being of Terminally Ill Cancer Patients 999 Table 2 Changes in FACIT-Sp, HADS, Life Completion, Hope, Burden, Preparation, Suffering, Pain, and Symptom Scores Time Effects Baseline After Intervention Main Effect Between Groups Interaction Between Group Time Outcome Measure Mean (SD) Mean (SD) F a P-value F a P-value FACIT-Sp Intervention < <0.00 Control HADS Intervention < <0.00 Control Life Completion Intervention < <0.00 Control Hope Intervention < <0.00 Control Burden Intervention < <0.041 Control Preparation Intervention < <0.013 Control Suffering Intervention < <0.00 Control Pain Intervention < <0.53 Control Symptom Intervention < <0.27 Control FACIT-Sp ¼ Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale; HADS ¼ Hospital Anxiety and Depression Scale. a F statistic in repeated-measures ANOVA. of terminally ill cancer patients increased. Moreover, the feasibility of the Short-Term Life Review is comparable with that of Dignity Therapy, based on withdrawal rates of 12% for the Short-Term Life Review and 22% for Dignity Therapy. The Suffering score (as used by Chochinov et al.) gave a more negative z value for the Short-Term Life Review (z ¼ 4.2, P ¼ 0.01) compared with Dignity Therapy (z ¼ 2.00, P ¼ 0.023). These results suggest that the Short-Term Life Review might have higher efficacy for alleviation of psychoexistential suffering and is at least equivalent to Dignity Therapy. Why was this intervention effective for psycho-existential suffering in terminally ill cancer patients? According to a previous study, 18 the primary existential concern of cancer patients is a struggle to maintain selfidentity, and they easily lose self-identity because of serious illness. Moreover, individuals build life stories incorporating past events into an organized sequence, giving them a personal meaning. 19 Considering these results and those in the present study, we propose a process model regarding the effects of this therapy (Fig. 2). Through remembering memories of their history, family lives, attainments, and social role, patients confirm self-identity and self-continuity, including their present state. This gives an increased feeling of life completion, resulting in elevated spiritual well-being and a peaceful mind. Secondary End Points The scores for the good death items showed a significant increase, and there was also a significant improvement in anxiety and

8 1000 Ando et al. Vol. 39 No. 6 June 2010 Table 3 Correlation Coefficients Between Variables After the Short-Term Life Review Post-review FACIT-Sp Completion Hope Preparation HADS Suffering Burden Pain Symptom FACIT-Sp 1.0 Completion 0.66 a 1.0 Hope 0.36 b Preparation b 1.0 HADS 0.52 a b Suffering 0.60 a 0.55 a Burden b 0.33 b Pain 0.36 b 0.41 a a Symptom FACIT-Sp ¼ Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale; HADS ¼ Hospital Anxiety and Depression Scale. a P < b P < depression in the group that received the Short-Term Life-Review intervention. From a previous study of good death, Hope, Not being a burden to others, Life Completion, and- Preparation for death were identified as factors for a good death in both Western and Japanese populations. 20,21 These factors are recognized as important components in a good death, but effective interventions have not been reported in empirical studies. Therefore, it is of note that the scores for these factors showed significant improvement in the present study. It has been demonstrated that a selfperceived burden is important in overall quality of life, with the sense of burden showing a low correlation with physical symptoms and higher correlations with psychological problems and existential issues. 22 Related to this study, 63% of patients who received a hastened death by physician-assisted suicide felt that they had become a significant burden to family, friends, or other caregivers, based on data from Oregon, United States, where physician-assisted suicide is legal. 23 In Japan, being a burden on others is also a major reason for desiring death and requesting a hastened death. 24 However, there has been no empirically tested evidence for an intervention that addresses this issue despite Remembering memories with family Confirm relationship with family Life completion FACIT- SP The Short Term Life Review Remembering attainment or role Self-continuity Remembering enjoyment Finding generativity Hope HADS Suffering Seeing the present state with balance Sharing memories with family Burden Fig. 2. A process model about the effects of the Short-Term Life Review among variables.

9 Vol. 39 No. 6 June 2010 Spiritual Well-Being of Terminally Ill Cancer Patients 1001 the relationship of being a burden with psycho-existential suffering. Our study suggests that the Short-Term Life Review is promising as a palliative treatment for the feeling of burden because patients review memories of bringing up children or taking care of family members, which allows them to view their present state with balance; for example, I have taken care of my children for a long time, and now my children take care of me: we are helping each other. Achievement of this view through life review tends to decrease the feeling of being a burden. The Short-Term Life Review was also effective in maintaining hope in terminally ill cancer patients. As hope is one of the factors in a good death, this improvement is important. Dignity Therapy, as reported by Chochinov et al., had no significant effect on hopelessness, indicating that as patients were moving toward death, the level of well-being and quality of life diminished slightly. In contrast, the Living with Hope Program 25 had a significant effect on hope. This program uses viewing of video film and activities for development of hope such as writing a letter or telling stories. The Short-Term Life Review also affected hope, and the different effects of the interventions may be because of the purpose of the activities. Duggleby et al. showed that patients felt that communication with other persons was important, and that working on activities and relationships through communication can improve hope. In support of this, the Short-Term Life-Review interview may improve feelings about relationships with family through a review of the patient s history and allow patients to look forward to their progeny s future growth. The Short-Term Life Review also was effective in improving anxiety and depression. Based on a cutoff point of the HADS of 10/11 41% patients in the Short-Term Life- Review group experienced anxiety and depression before the intervention, but no patients did so after the review, indicating a marked effect of the Short-Term Life Review on anxiety and depression. Integration of the above findings allows the proposal of a process model for the effects of the Short-Term Life Review among the variables in Fig. 2. However, this model was not validated in the present study and requires empirical confirmation. Patients lived about 28 days after the Short- Term Life Review. Some of the staff said that the participants seemed to be satisfied with their lives and peaceful death. Some of the family members said that the participants found meaning to their existence, such as family role, and said the words that they wanted to say. A family member said to the interviewer that the album would be a sweet memory of her mother. We did not examine the efficacy of this therapy on survival period or the family s psychology, and more research will be needed. Limitations This study has several limitations. First, the statistical significance of the outcome measures may not always indicate clinical significance. However, we believe that our intervention is clinically relevant, because most of the patients in the intervention group expressed their thanks for the albums and satisfaction with this therapy. Second, most patients in the study were in a palliative care ward or hospice home care clinic, and generalization of the findings to other situations cannot be assumed. Third, the generalizability also may be limited because the intervention was performed by one therapist and at only two institutions. Finally, the interviewer had clinical training to conduct this therapy. Thus, other interviewers should have training before implementing this therapy. However, within these limitations, we conclude that the Short-Term Life Review is effective in facilitating a sense of meaning, alleviating anxiety and depression, and promoting a good death and, therefore, may be useful for terminally ill cancer patients with psycho-existential suffering. A future multicenter, randomized, controlled trial using a trained therapist and a full-item Good Death Inventory is promising. Acknowledgments The authors would like to thank the participants and staff in this research, and Mitsunori Miyashita, PhD, for providing the Good Death Inventory.

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