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. 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. Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: Professional boundaries, competency, and ethics. Ann Intern Med 2000;132:578-583. For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work 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]

Sartre J-P. Being and nothingness: An essay on phenomenological ontology. Barnes H, translator. New York: Washington Square Press; 1992. p. 680-698. 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 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 International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created theAn alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, Kierkegaard S. Søren Kierkegaard’s journals and papers. Hong HV, Hong EH, editors and translators. Bloomington: Indiana University Press; 1967. p. 22-26, 56.

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 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

All three levels work perfectly as gentle night lights, and the warm coloured light has been designed to help you fall asleep more easily. Breitbart W, Poppito S. Meaning-centered group psychotherapy for patients with advanced cancer: A treatment manual. New York: Oxford University Press; 2014. 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. Boston P, Bruce A, Schreiber R. Existential suffering in the palliative care setting: An integrated literature review. J Pain Symptom Manage 2011;41:604-618. 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.

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Gemes K, Richardson J. The Oxford handbook of Nietzsche. New York: Oxford University Press; 2013. p. 675-700. 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 in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as 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.