of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally Formalized interventions include meaning-centred psychotherapy, an intervention developed at Memorial Sloan Kettering Cancer Center and aimed at helping patients with advanced cancer reconnect with experiential, creative, attitudinal, and historical sources of meaning;[ 9, 10] Dignity therapy, created by Harvey Chochinov and colleagues in Winnipeg;[ 25] and Managing Cancer and Living Meaningfully (CALM) psychotherapy, developed by Gary Rodin and colleagues in Toronto.[ 26, 27] LeMay and Wilson present a review of other manualized therapies for existential distress.[ 20] Helping patients find a silver lining Aase M, Nordrehaug JE, Malterud K. “If you cannot tolerate that risk, you should never become a physician”: A qualitative study about existential experiences among physicians. J Med Ethics 2008;34:767-771. Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med 2000;3:129-137.

International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Holland JC, Romano SJ, Heiligenstein JH, et al. A controlled trial of fluoxetine and desipramine in depressed women with advanced cancer. Psychooncology 1998;7:291-300. Lo C, Hales S, Jung J, et al. Managing Cancer And Living Meaningfully (CALM): Phase 2 trial of a brief individual psychotherapy for patients with advanced cancer. Palliat Med 2014;28:234-242.

Family members experience distress and require support as well. We all internalize aspects of our parents, and when a parent is dying both young and adult children may feel a core part of themselves or their life is dying. Related to children feeling that their purpose or worth is in “becoming” something to please encouraging adults, children may feel a loss of identity or purpose with a parent’s death. Similarly, family members often grieve not only the loss of their loved one, but also the loss of their caregiving role, especially if the person has been ill for a long time. Educating family members about how common these feelings are and letting them know that these feelings will generally become less painful over time can reduce distress. In expressing condolences to family members, we commonly say something like “I’m sorry for your loss” or “This must be very difficult” to convey empathy. Following up such statements by asking “Who’s supporting you right now?” communicates a greater impression that you care about how they are going to cope with their grief. Adjusting boundaries

Looking at social, psychological, and spiritual suffering, spiritual distress is likely to be viewed as the most remote from a physician’s core training. Many equate spirituality with religion and, understandably, physicians are reluctant to discuss religions they may know little about. Physicians are about half as likely as patients to hold a particular spiritual belief.[ 14] Even if a physician follows a religion, he or she might be concerned about being intrusive,[ 15] and some guidelines for communicating with patients about spiritual issues caution against discussing your own religious beliefs, stating they are generally not relevant.[ 16] However, it is possible to bring wisdom from the world’s major religions into therapeutic discussions about illness and death without intrusively promoting a particular faith. It is always helpful to know what a patient’s spiritual beliefs are, and questions based on the FICA spiritual history tool[ 17, 18] can help you do this (see the Table). Søren Kierkegaard is widely regarded as the father of existential philosophy.[ 1] His work often focused on personal choice and commitment, and how everyone lives as a “single individual.”[ 2] Kierkegaard also explored the emotions of people making significant life decisions, and certainly there can be often a number of these to make at the end of life in a modern medical system.

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Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA 2000;284:2907-2911. Martin Heidegger extended Kierkegaard’s idea of living as a single individual to dying as a single individual, proposing that death is an entirely personal experience that must be taken on alone.[ 3] Patients do sometimes experience a new and distressing sense of aloneness at the end of life, knowing that nobody is going to share this specific experience with them. The feeling of being the only one who can make choices about how to live out final days can be overwhelming. Kierkegaard S. Søren Kierkegaard’s journals and papers. Hong HV, Hong EH, editors and translators. Bloomington: Indiana University Press; 1967. p. 22-26, 56. Although one could argue it is a religious leader’s role, and not a physician’s, to discuss spiritual or religious matters with a patient at the end of life, an equally strong argument could be made in support of a role for the physician by posing questions about training: What exactly is the training religious leaders receive to provide this kind of care? Is their training accredited in some way or based on evidence of effectiveness? Do religious leaders know more than palliative care specialists? These questions are posed here not to diminish the important role of religious leaders (some of whom do have specialized training in working with dying patients) in caring for patients at the end of life, but rather to suggest that physicians’ knowledge and training should make them confident that they, too, have something to offer. In Boston and colleagues’[ 12] summary of how existential suffering is defined in the literature, many of the definitions focus on meaning and purpose, and these are concepts for which modern evidence-based medical interventions have been developed.[ 9, 10]

Maugans TA, Wadland WC. Religion and family medicine: A survey of physicians and patients. J Fam Pract 1991;32:210-213. to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies. Clearly, talking to patients about death is key to helping them cope with anxiety about it. By taking something as nebulous as death and discussing it in more concrete terms in regular conversation, we can make death less frightening and unpredictable for our patients. And in that same spirit, by considering some relevant contributions from a few existential philosophers and thinkers, we can feel better equipped to do this. Kierkegaard Although it may be a manifestation of depression or some other modifiable condition, existential nihilism is a concept that great minds have either supported or struggled with, and one that is not easy to dismiss out of hand. However, there are certainly alternate views that may facilitate a patient’s leap of faith to a more comfortable opinion. Sartre While some at the end of life take great comfort from their faith, others may find their unfortunate circumstance cause them to question it. Kierkegaard theorized that there is no faith without uncertainty or doubt.[ 4] He described how faith is not required to believe in something tangible like a chair, but is necessary to believe in something for which there is little or no evidence. In other words, faith is required when there is significant uncertainty or doubt, and without uncertainty or doubt there may be little role for faith. The concept of a “leap of faith” originates in Kierkegaard’s writings, although he does not use this exact phrase. One can suggest to a patient that fear centred on uncertainty surrounding death is common and that the doubt they are feeling may actually be an opportunity to strengthen their faith rather than to abandon it. While not directly related to Kierkegaard’s ideas, another potentially comforting aspect of uncertainty is that it means you have wiggle room or flexibility and that nothing is set in stone. Nietzsche

It can also automatically turn off after 30 minutes.

Are you currently going to through an existential crisis yourself? If so, please let us know in the comment section below, and don’t forget to mention what triggered it. The author wishes to thank Dr Patricia Boston and Dr Sharon Salloum for their comments on a draft manuscript and Ms Amanda Wanner from the College of Physicians and Surgeons of BC library. Competing interests Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected

Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: Professional boundaries, competency, and ethics. Ann Intern Med 2000;132:578-583. Friedrich Nietzsche is intimately associated with the concept of nihilism, which in turn is related to existential nihilism—the idea that life has no meaning or purpose. Patients at the end of life may experience a kind of existential nihilism and say that their existence has been meaningless or that there is no longer any point in being alive. Nietzsche argued that our primary driving force is not meaning or happiness, but rather the “will to power” or pursuit of high achievement and reaching the best possible position in life.[ 5] If this is our primary driving force, it is understandable that patients who have had great success in their careers or other pursuits may feel there is no longer any purpose to their existence once they are seriously ill. Viktor Frankl was an Austrian psychiatrist who spent 3 years in Nazi concentration camps. In contrast to Nietzsche’s “will to power,” Frankl maintained that “will to meaning” is the primary driving force of human behavior. His experiences in the concentration camps are described in his book Man’s Search for Meaning,[ 8] which confirms his belief that meaning can be found in any situation, even in great suffering. He theorized that finding meaning in difficult situations gives us the will to continue living through the worst of circumstances. Frankl’s ideas are now being applied in modern evidence-based psychiatric interventions for patients with advanced cancer as meaning-centred psychotherapy.[ 9, 10] Yalom Gemes K, Richardson J. The Oxford handbook of Nietzsche. New York: Oxford University Press; 2013. p. 675-700. Kierkegaard S. The essential Kierkegaard. Hong EH, Hong HV, editors and translators. Princeton, NJ: Princeton University Press; 2000. p. 216-217.Above is the information needed to cite this article in your paper or presentation. The International Committee