Vol. - No. - - 2013 Journal of Pain and Symptom Management 1

Brief Methodological Report

Assessment of Patients’ Dignity in CancerCare: Preliminary Psychometrics of theGerman Version of the Patient DignityInventory (PDI-G)Leon P. Sautier, MSc, Sigrun Vehling, MSc, and Anja Mehnert, PhDDepartment of Medical Psychology (L.P.S., S.V., A.M.), University Medical Center Hamburg-

Eppendorf, Hamburg; and Division of Psychosocial Oncology (A.M.), Department of Medical

Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany

Abstract

Context. The Patient Dignity Inventory (PDI) is a valid and reliable instrument

designed to measure different sources of dignity-related distress in cancer patientsreceiving palliative care.

Objectives. We investigated item characteristics, factor structure, reliability, andconcurrent validity of the German version of the PDI (PDI-G) among patients withcancer.

Methods. PDI was translated into the German language following state-of-the-art criteria. In a sample of 112 inpatients with mixed tumor types, principalcomponent analysis, reliability analysis (Cronbach’s coefficient alpha), andcorrelation analysis were performed. Concurrent validity was evaluated byvalidated measures of distress, demoralization, anxiety, depression, hopelessness,quality of life, sense of meaning and purpose, and supportive care needs.

Results. Cronbach’s coefficient alpha for PDI-G was 0.96; factor analysisresulted in a four-factor solution, accounting for 71% of the overall variance,with factor loadings ranging from 0.49 to 0.86. Factor labels include Loss ofSense of Worth and Meaning, Anxiety and Uncertainty, Physical SymptomDistress and Body Image, and Loss of Autonomy, showing high internalconsistencies ranging from Cronbach’s a 0.80 to 0.95. Evidence for concurrentvalidity was established by significant associations between PDI-G scales andconcurrent measures of distress.

Conclusion. Although we were unable to replicate the five-factor structureprovided by Chochinov, this study gave strong support to an alternative four-factorsolution of PDI-G, capturing all 25 items. We conclude that PDI-G isa psychometrically sound instrument assessing a broad range of dignity-relateddistress issues in patients with cancer. J Pain Symptom Manage 2013;-:-e-.� 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Address correspondence to: Leon P. Sautier, MSc,Department of Medical Psychology, UniversityMedical Center Hamburg-Eppendorf, Martinistraße

52 - W26, 20246 Hamburg, Germany. E-mail:l.sautier@uke.de

Accepted for publication: February 18, 2013.

� 2013 U.S. Cancer Pain Relief Committee.Published by Elsevier Inc. All rights reserved.

0885-3924/$ - see front matterhttp://dx.doi.org/10.1016/j.jpainsymman.2013.02.023

2 Vol. - No. - - 2013Sautier et al.

Key Words

Dignity, distress, measurement, cancer, palliative care, Patient Dignity Inventory

IntroductionIn recent years, a growing body of research

has focused on the understanding of potentialcauses of distress in patients with advancedcancer undergoing treatment.1e6 The majorityof studies focused on physical and illness-related sources of distress as well as on psycho-logical, social, or existential dimensions ofdistress. However, the association between per-ceived distress and sense of dignity has beenaddressed to a lesser extent, although digni-fied care is an unquestionable goal of compre-hensive treatment.7e10 Chochinov et al.11

created an empirically based model of dignityin the terminally ill, which is increasingly con-sidered in health care. On the basis of semi-structured interviews, patients suffering fromincurable cancer reported how they define dig-nity and what affected their sense of dignity.The model suggests that the broad range ofdignity-related distress issues perceived by pa-tients during palliative care can be dividedinto three major categories: 1) factors causedby, or associated with, the underlying illness,2) social or externally mediated factors, and3) psychological and spiritual considerations.Chochinov et al. reframed the major themesand subthemes into specific questions, givingpatients the opportunity to indicate the extentto which these items have a possible influenceon their sense of dignity. Thus, the Patient Dig-nity Inventory (PDI) is a novel, reliable, andvalidated self-report questionnaire assessingbroad dimensions of dignity-related distressin patients who are terminally ill.12,13

The objectives of the present study were toevaluate thepsychometric properties of theGer-man version of PDI (PDI-G) in a mixed sampleof cancer patients undergoing treatment withboth curative and palliative intent to providea psychometrically sound German translationand facilitate future research efforts regardingthe sense of dignity.We investigated factor struc-ture item characteristics, internal consistency(Cronbach’s alpha coefficient), and concurrentvalidity through correlations with validatedmeasures of distress, anxiety, depression, de-moralization, hopelessness, quality of life, sense

ofmeaning andpurpose, and unmet supportivecare needs. Although previous evaluations ofPDI were performed in palliative care patientsamples solely, themixed sample was supportedby recent evidence showing comparableamounts of existential distress in both patientsreceiving curative care and palliative carepatients.14

MethodsSetting and ParticipantsThis analysis used data collected as part of

a multicenter, epidemiological, cross-sectionalstudy aiming to investigate the prevalence ofmental disorders, psychosocial stress, andneed for psychosocial support in cancerpatients. The study protocol was publishedseparately.15 The analysis of psychometric prop-erties of PDI-G is based on a subsample of 112cancer patients with mixed tumor types (re-ceiving both curative und palliative treatment),who completed questionnaires during their in-patient care at the University Cancer CenterHamburg (response rate 63%). The study pro-tocol was approved by the ethics committee ofthe local chamber of physicians. All patientsprovided written informed consent beforestudy participation.

Study MeasuresParticipants completed PDI-G. The question-

naire was translated forward and backward intoGerman following state-of-the-art criteria.16

The original PDI contains 25 items comprisingfive factors: Symptom Distress, Existential Dis-tress, Dependency, Peace of Mind, and SocialSupport. The five-point response scale rangesfrom ‘‘not a problem’’ to ‘‘an overwhelmingproblem,’’ with higher scores indicating higherperceived dignity-related distress. PDI totalscore shows excellent internal consistency(a ¼ 0.93). Additionally, Chochinov et al.12 re-port a highly consistent test-retest-reliability(r ¼ 0.85). However, some of its subscales ap-pear to be less reliable (e.g., Peace of Mind:a ¼ 0.63). Concurrent validity of PDI is con-firmed by various significant correlations

Vol. - No. - - 2013 3German Version of PDI

between the individual subscales of PDI andconcurrent measures assessing aspects of dis-tress identified within the Model of Dignity inthe Terminally Ill.11

In addition, we also used the German versionsof the following self-report questionnaires: theNational Comprehensive Cancer Network Dis-tress Thermometer (a brief screening toolconsisting of a scale from 0 to 10 assessing over-all perceived psychosocial distress17), PatientHealth Questionnaire 9 and the GeneralizedAnxiety Disorder seven-item scale18 (used toassess depression and anxiety), the Demor-alization Scale (measures existential distressreferring to the demoralization syndrome19),and the Beck Hopelessness Scale (measurespessimistic cognitions). Quality of life was as-sessed using the European Organisation for Re-search and Treatment of Cancer Quality of LifeQuestionnaire-Core 30 (EORTC QLQ-C30),which incorporates five subscales about func-tional aspects (physical, role, cognitive, emo-tional, and social), a broad range of symptomscales, and a global health and quality-of-lifescale.20 The Life Attitude Profile-Revised (LAP-R) was used to measure meaning and purposein life.21Finally, weused theShort FormSupport-ive Care Needs Survey (SCNS-SF34-G) to takeinto account unmet supportive care needs.22

Statistical AnalysisA principal component analysis (PCA) was

conducted on the 25 Items of PDI-G with or-thogonal varimax rotation. The selection of fac-tors for rotation, consistent with the proceedingof Chochinov et al., was based on dual criteria:Kaiser’s criterion (eigenvalues greater thanone) and the analysis of a scree plot. Becauseof the limited sample size, PCA was controlledfor sampling adequacy. Item analysis includedmean, SD, discrimination power, skewness,and kurtosis. Internal consistency was estimatedby calculating Cronbach’s coefficient alpha foreach scale. Concurrent validity was analyzed us-ing Pearson’s correlation coefficient.

ResultsParticipants

Table 1 presents the participants’ demo-graphic and treatment-related characteristics.The mean � SD age of the 112 participants

was 56 � 14 years; 48 were female (43%). All112 participants were inpatients with advanceddisease; 62% were receiving active cancer treat-ment and 38% palliative care. Primary tumorsites included hematologic 36%, gastrointesti-nal 16%, prostate 11%, respiratory and intra-thoracic 11%, female genital organs 10%,breast 6%, and other solid tumors 10%.

Factor Structure of PDI-GThe Kaiser-Meyer-Olkin measure (0.91) veri-

fied the sampling adequacy for PCA. Barlett’stest of sphericity, c2 (300) ¼ 2164.12, P <0.001, indicated that correlations betweenitems were sufficiently large for PCA. The ini-tial analysis resulted in four components hav-ing eigenvalues over Kaiser’s criterion of one.The scree plot was marginally ambiguous andresulted in inflexions that would justify re-taining both components 2 and 4. Given theconvergence of the scree plot and Kaiser’s cri-terion on four components, this is the numberof components we retained in the final anal-ysis. Table 2 shows the sums of squared load-ings after rotation. In combination, thesefour components explore a total of 70.65%of the variance. Factor loadings after rotationare represented in Table 3. All 25 items ofPDI-G could be allocated to one of the fourfactors. The items that cluster on the samecomponents suggest that the four componentsbe labeled: Loss of Sense of Worth and Mean-ing, Anxiety and Uncertainty, Physical Symp-tom Distress and Body Image, and Loss ofAutonomy.

Item AnalysisTable 3 also contains the item characteristics

of PDI-G. Discriminatory power ranges fromri(t-i) ¼ 0.42 (Item 1) to ri(t-i) ¼ 0.86 (Item19). Hence, all 25 items show adequate dis-criminatory power. Items 5, 9, 11e14, 17e20,22, and 24 show the highest coefficients ofri(t-i)> 0.70.

Internal ConsistencyCronbach’s alpha coefficient for PDI-G was

calculated to be a ¼ 0.96, the mean inter-item correlation accounts to r¼ 0.48. Further-more, the dimensions emerging throughPCA (Table 3) show following internal consis-tencies (calculated by Cronbach’s alpha):Loss of Sense of Worth and Meaning ¼ 0.95,

Table 1Patient Demographic and Treatment-Related

Characteristics

Sample Characteristics

Total Sample(N ¼ 112)

n %

Mean age in years (SD, range) 56.3 (13.9; 19e75)Gender

Male 64 57.1Female 48 42.9

MarriedYes 70 62.5No 42 37.5

EducationLess than elementary school 2 1.8Elementary school (8e9 years) 30 26.8Junior high school (10 years) 43 38.4High school (13 years) 37 33.0

Vocational educationWithout vocational education 7 6.3Vocational training 54 48.2Technical college 17 15.2Advanced technical college/university of applied sciences

24 21.4

Employment statusEmployed 39 34.9Unemployed 11 9.8Retired 50 44.6Housewife/househusband 5 4.5

Monthly household net income (V)Less than 500 15 13.4500 to less than 1000 8 7.11000 to less than 2000 41 36.62000 to less than 3000 20 17.94000 and above 9 8.1

Cancer typeHematological malignancies 40 35.7Gastrointestinal cancer 18 16.1Prostate cancer 12 10.7Respiratory/intrathoracic cancer 12 10.7Gynecologic cancer 11 9.8Breast cancer 7 6.3Other solid tumors 11 9.8

Mean months since currentdiagnosis (SD; range)

6.1 (9.8; 0e51)

Clinical characteristicsFirst primary tumor 82 73.2Second primary tumor 14 12.5Recurrence 12 10.7

MetastasisYes 18 16.1No 78 69.6

Treatment phaseCurative treatment intent 69 61.6Palliative treatment intent 43 38.4

Mean Karnofsky Index (SD; range) 83.2 (19.0; 20e100)

Table 2Rotated Factor Loading for PDI-G

Component

Rotation Sums of Squared Loadings

Total % of Variance Cumulative %

1 6.798 27.193 27.1932 4.585 18.341 45.5343 3.559 14.236 59.7704 2.720 10.881 70.651

PDI-G¼German version of the Patient Dignity Inventory.

4 Vol. - No. - - 2013Sautier et al.

Anxiety and Uncertainty ¼ 0.90, PhysicalSymptom Distress and Body Image ¼ 0.83,and Loss of Autonomy ¼ 0.81.

Intercorrelation of the SubscalesTable 4 shows significant intercorrelations

among all PDI-G scales. Accordingly, Loss of

Sense of Worth and Meaning shared 62% ofthe variance with the subscale labeled Anxietyand Uncertainty and 40% with Physical Symp-tom Distress and Body Image. Additionally,Anxiety and Hopelessness shared 51% of vari-ance with Physical Symptom Distress andBody Image.

Concurrent ValidityTable 5 contains the correlations between

PDI-G scales and several conceptually overlap-ping measures assessing aspects identifiedwith the Model of Dignity in the TerminallyIll.7,11 Results show positively significant correla-tions betweenPDI-G total score andpsychosocialdistress (P < 0.001), depression (P < 0.001),anxiety (P < 0.001), demoralization (P <0.001), and hopelessness (P < 0.001). Further-more, higher perceived dignity-related distress(according to PDI-G total score) is negativelyassociated with global health status as well asall EORTC QLQ-C30 subscales regarding func-tional aspects of quality of life. Moreover, analy-ses show positively significant correlations withlargely all symptom scales of the EORTCQLQ-C30. PDI-G correlates significantly withthe Existential Vacuum scale of LAP-R, as wellas inversely with Personal Meaning and DeathAcceptance. Finally, significant correlationswere found forPDI-G total score andall subscalesof SCNS.

DiscussionAn appropriate measure for assessing sense

of dignity and dignity-related concerns in pa-tients with serious and/or progressive diseasessuch as cancer is crucial. There is an urgentneed to provide such a validated questionnairefor German-speaking countries. The resultsfrom the present study support the reliabilityand concurrent validity of the German

Table 3Item and Scale Characteristics (PCA, Varimax Rotated Four-Factor Solution) of PDI-G

No. Dimensions and Items

Item Characteristics

h2

Factor Loadings

M SD ri(t-i) Skewness Kurtosis F1 F2 F3 F4

Loss of Sense of Worth and Meaning: a¼ 0.95, 27.2%a

25. Not being treated with respect 1.40 0.78 0.58 2.10 3.86 0.66 0.8017. Concerns regarding spiritual life 1.36 0.82 0.76 2.70 7.54 0.77 0.7921. Not feeling supported by friends 1.28 0.75 0.59 3.00 8.95 0.67 0.7912. Not feeling worthwhile or valued 1.40 0.85 0.80 2.54 6.56 0.78 0.7615. Feeling have not made meaningful contribution 1.32 0.76 0.60 2.37 4.60 0.65 0.7522. Not feeling supported by health care providers 1.31 0.77 0.70 2.75 7.47 0.75 0.7414. Feeling life no longer has meaning or purpose 1.46 0.90 0.80 2.22 4.60 0.76 0.669. Not being able to think clearly 1.52 1.00 0.80 2.30 5.03 0.76 0.64

19. Not feeling in control 1.74 1.13 0.86 1.56 1.68 0.80 0.58 0.5618. Feeling a burden to others 2.01 1.04 0.83 0.97 0.61 0.75 0.5416. Feeling of unfinished business 1.85 1.01 0.55 1.12 0.65 0.61 0.53 0.5113. Not able to carry out important roles 1.80 1.05 0.71 1.27 0.93 0.57 0.50

Anxiety and Uncertainty: a¼ 0.90, 18.3%a

7. Feeling uncertain 2.13 1.12 0.61 0.82 �0.11 0.70 0.758. Worried about future 2.17 1.11 0.57 0.89 0.26 0.72 0.736. Feeling anxious 1.66 0.98 0.65 1.37 0.93 0.64 0.71

23. Not being able to fight the challenges of illness 1.63 1.00 0.80 1.70 2.42 0.85 0.59 0.7024. Not being able to accept the way things are 1.72 1.04 0.72 1.55 1.93 0.72 0.51 0.6620. Reduced privacy 1.96 1.12 0.77 1.12 0.56 0.67 0.585. Feeling depressed 1.63 0.94 0.72 1.35 0.66 0.58 0.49

Physical Symptom Distress and Body Image: a¼ 0.83, 14.2%a

4. Feeling how you look has changed 1.74 1.05 0.51 1.45 1.60 0.69 0.7910. Not being able to continue usual routines 1.98 1.21 0.68 1.03 0.06 0.71 0.673. Physically distressing symptoms 2.22 1.17 0.53 0.57 �0.80 0.67 0.65

11. Feeling no longer who I was 1.98 1.19 0.73 1.15 0.48 0.67 0.62Loss of Autonomy: a¼ 0.84, 10.9%a

1. Not able to perform tasks of daily living 1.49 0.85 0.42 1.56 1.25 0.74 0.862. Not able to attend to bodily functions 1.28 0.73 0.47 2.68 6.27 0.81 0.82

PCA¼ principal component analysis; PDI-G¼German version of the Patient Dignity Inventory; M ¼ mean (1 ¼ not a problem to 5 ¼ an over-whelming problem); ri(t-i)¼ discriminatory power (corrected); h2 ¼ communalities.aVariance explained (after rotation).

Vol. - No. - - 2013 5German Version of PDI

translation of PDI and, therefore, the futureuse of PDI-G in patients with cancer undergo-ing curative or palliative treatment. The princi-pal component analysis gave strong support toa four-dimensional factor structure of PDI-G,accounting for 71% of the overall variation.In contrast to the original five-dimensional fac-tor solution provided by Chochinov et al.,12

the four-factor solution based on the Germanversion of PDI captures all 25 Items. With theexception of four items, mainly all itemsstrongly cluster on single components, which,

Table 4Inter-Subscale Correlat

Correlation Matrix of Subscales

SubscaleLoss of Sense of

Worth and Meaning

Loss of Sense of Worth and Meaning 1Anxiety and Uncertainty 0.79***Physical Symptom Distress and Body Image 0.64***Loss of Autonomy 0.38***

***P< 0.001.

therefore, can be labeled adequately: The fac-tor Loss of Sense of Worth and Meaning com-prises 12 items concerning aspects of notbeing handled respectfully, concerns regard-ing spiritual life, not feeling supported ade-quately, as well as not feeling worthwhile orvalued. Interestingly, this factor absorbs Cho-chinov’s components labeled Peace of Mindand Social Support12 but shows stronger inter-nal consistency. PDI-G items loading on thefactor Anxiety and Uncertainty include feelinguncertain and anxious and being worried

ions of PDI-G

Anxiety andUncertainty

Physical SymptomDistress and Body Image

Loss ofAutonomy

10.72*** 10.31*** 0.43*** 1

Table 5Correlations Among PDI Subscales and Concurrent Validity Measures

Measures PDI-G

PDI-G Subscales

F1 F2 F3 F4

Emotional distressPsychosocial distress (DT) 0.33*** 0.18 0.36*** 0.43*** 0.23*Depression (PHQ) 0.58*** 0.47*** 0.57*** 0.64*** 0.31***Anxiety (GAD) 0.66*** 0.78*** 0.68*** 0.55*** 0.21*Demoralization (DS) 0.67*** 0.60*** 0.69*** 0.57*** 0.17Hopelessness (BHS) 0.51*** 0.44*** 0.49*** 0.41*** 0.23*

Quality of Life (EORTC QLQ-C30)Global health status L0.42*** �0.32*** �0.40*** �0.40*** �0.19*Physical functioning L0.22* �0.19* �0.12 �0.32*** �0.21*Role functioning L0.27** �0.18 �0.21* �0.46*** �0.21*Cognitive functioning L0.38*** �0.29** �0.33*** �0.46*** �0.20*Emotional functioning L0.57*** �0.44*** �0.82*** �0.51*** �0.29**Social functioning L0.40*** �0.32*** �0.40*** �0.41*** �0.19*

Symptom Scales (EORTC QLQ-C30)Fatigue 0.40*** 0.33*** 0.30*** 0.46*** 0.33***Nausea 0.30*** 0.24** 0.30*** 0.46*** 0.33***Pain 0.30*** 0.34** 0.23* 0.39*** 0.22*Dyspnea 0.29** 0.23* 0.21* 0.41*** 0.16Insomnia 0.34*** 0.25** 0.28** 0.40*** 0.30***Loss of appetite 0.38*** 0.30** 0.35*** 0.42*** 0.28**Constipation 0.08 0.03 0.07 0.11 0.23*Diarrhea 0.36*** 0.32*** 0.34*** 0.31*** 0.18Financial difficulties 0.17 0.16 0.11 0.23* �0.02

Life Attitude (LAP-R)Personal meaning index L0.20* �0.18 �0.24* �0.19* �0.04Death acceptance L0.25** �0.18 �0.34*** �0.18 �0.09Goal seeking 0.03 0.04 0.04 0.02 �0.05Choice/responsibleness L0.13 �0.14 �0.13 �0.05 �0.07Existential vacuum 0.45*** 0.41*** 0.46*** 0.40*** 0.05

Supportive Care Needs (SCNS)Overall supportive care needs 0.35*** 0.34*** 0.32*** 0.25* 0.11Need for psychological support 0.62*** 0.55*** 0.65*** 0.48*** 0.15Need for support concerning health system 0.26** 0.29** 0.23* 0.07 0.27*Need for support in daily routine 0.27* 0.15 0.26* 0.37** 0.24*Need for maintenance and help 0.35** 0.41*** 0.30* 0.21 0.01Need for support concerning sexual issues 0.28* 0.32* 0.29* 0.17 �0.06

PDI-G¼German version of PDI; DT¼NCCN Distress Thermometer; PHQ¼ Patient Health Questionnaire; GAD¼Generalized Anxiety Disor-der; DS¼Demoralization Scale; BHS¼ Beck Hopelessness Scale; EORTC QLQ-C30¼ European Organisation for Research and Treatment ofCancer Quality of Life Questionnaire-Core 30; LAP-R¼ Life Attitude Profile-Revised; SCNS¼ Supportive Care Needs Survey.***P< 0.001, **P<0.01, *P<0.05.

6 Vol. - No. - - 2013Sautier et al.

about the future, in keeping with not beingable to fight the challenges of illness. The fac-tor Physical Symptom Distress and Body Imagesubsumes four items assessing concerns ofphysically distressing and restricting symptomsas well as feelings of altered body image. Itemsloading on the factor labeled Loss of Auton-omy were endorsed less by participants andcomprise the constrained ability to performtasks of daily living and to attend to bodilyfunctions.

Equally, based on the high intercorrelations ofthe subscales of PDI-G, our data provide plausi-ble evidence for interpreting dignity-related dis-tress in cancer patients one-dimensionally andusing the total score of PDI-G (a¼ 0.96) to assessan overall amount of dignity-related distress.

Despite the absence of a gold standard, corre-lation analysis with several measures assessingaspects of distress identified within the Modelof Dignity in the Terminally Ill7,11 strengthensthe concurrent validity of the underlying con-cept of perceived dignity-related distress andits associations with physical and psychosocialhealth as well as spiritual and existential issues.Associations are strongest between PDI-G totalscore and anxiety, demoralization andhopeless-ness, as well as inversely with each subscale as-sessing functional health status according toEORTC QLQ-C30. Moreover, results elucidatethe strong relationship between patient dignityand a broad range of physical symptoms. Giventhe presumption regarding a strong associationbetween patient dignity and spiritual and

Vol. - No. - - 2013 7German Version of PDI

existential issues, correlations between PDI-Gand LAP-R were examined. Analysis revealedhighly significant correlations with ExistentialVacuum and inversely with Personal Meaningand Death Acceptance. Most interestingly,results show that dignity-related distress accord-ing to the total score of PDI-G was significantlycorrelated with unmet supportive care needs(SCNS), largely with the subscale Need for Psy-chological Support, indicating further supportof requirements for psychosocial interventions.

Although a variety of measures exist that ad-dress psychological well-being and quality oflife, they fail to indicate the impact of physicalsymptom burden and psychosocial distress onthe sense of dignity. Measuring sense of dignityraises the awareness of individual supportivecare needs and thus contributes to better care.The measurement aim of PDI-G may be bothdiscriminative and evaluative for an oncologytarget population. Sense of dignity could fur-ther be an important outcome criterion in inter-ventional studies in those with serious diseases.

A major limitation of our research concernsthe relatively small study sample. Only 112 par-ticipants couldbe included,which subsequentlymay limit the factor validity of PCA. Therefore,we considered the Kaiser-Meyer-Olkin measureto verify the sampling adequacy and ensure thevalidity of the factor analysis. In addition, ourresearch sample comprised patients with ad-vanced cancer; however, our population wasnot homogeneous with regard to palliativetreatment intent alone. Furthermore, we arenot able to report results regarding test-retestreliability, general acceptance, or sensitivity tochange, which may be addressed in future ef-forts regarding the measurement properties ofPDI-G.

Future research efforts may focus on evaluat-ing the existing factor solutions and clarifyingconfirmatory model fit on other research sam-ples. Thereafter, a more precise concurrentvalidation of the resulting PDI-G dimensionsshould be anticipated as well.

Disclosures and AcknowledgmentsThis research was supported by the German

Cancer Aid within the psychosocial oncologyfunding priority program. The authors declareno conflicts of interest.

Special thanks go to Harvey Max Chochinovfor his support and permission for the Germantranslation of PDI.

References1. Gaeta S, Price KJ. End-of-life issues in criticallyill cancer patients. Crit Care Clin 2010;26:219e227.

2. Lo C, Zimmermann C, Rydall A, et al. Longitu-dinal study of depressive symptoms in patients withmetastatic gastrointestinal and lung cancer. J ClinOncol 2010;28:3084e3089.

3. Cheung WY, Barmala N, Zarinehbaf S, et al. Theassociation of physical and psychological symptomburden with time to death among palliative canceroutpatients. J Pain Symptom Manage 2009;37:297e304.

4. Morita T, Kawa M, Honke Y, et al. Existentialconcerns of terminally ill cancer patients receivingspecialized palliative care in Japan. Support CareCancer 2004;12:137e140.

5. Steinhauser KE, Christakis NA, Clipp EC, et al.Factors considered important at the end of life bypatients, family, physicians, and other care pro-viders. JAMA 2000;284:2476e2482.

6. Portenoy RK, Thaler HT, Kornblith AB, et al.The Memorial Symptom Assessment Scale: an in-strument for the evaluation of symptom prevalence,characteristics and distress. Eur J Cancer 1994;30:1326e1336.

7. Chochinov HM. Dignity-conserving careda newmodel for palliative care: helping the patient feelvalued. JAMA 2002;287:2253e2260.

8. Chochinov HM, Hack T, Hassard T, et al. Dig-nity and psychotherapeutic considerations in end-of-life care. J Palliat Care 2004;20:134e142.

9. Chochinov HM, Hack T, Hassard T, et al. Dig-nity therapy: a novel psychotherapeutic interventionfor patients near the end of life. J Clin Oncol 2005;23:5520e5525.

10. Ostlund U, Brown H, Johnston B. Dignity con-serving care at end-of-life: a narrative review. Eur JOncol Nurs 2012;16:353e367.

11. Chochinov HM, Hack T, McClement S,Kristjanson L, Harlos M. Dignity in the terminallyill: a developing empirical model. Soc Sci Med2002;54:433e443.

12. Chochinov HM, Hassard T, McClement S, et al.The Patient Dignity Inventory: a novel way of mea-suring dignity-related distress in palliative care.J Pain Symptom Manage 2008;36:559e571.

13. Chochinov HM, Hassard T, McClement S, et al.The landscape of distress in the terminally ill. J PainSymptom Manage 2009;38:641e649.

14. Bracken B, Barona A. State-of-the-art proce-dures for translating, validating, and using

8 Vol. - No. - - 2013Sautier et al.

psychoeducational tests for cross-cultural assess-ment. Sch Psychol Int 1991;12:119e132.

15. Vehling S, Lehmann C, Oechsle K, et al. Is ad-vanced cancer associated with demoralization andlower global meaning? The role of tumor stageand physical problems in explaining existential dis-tress in cancer patients. Psychooncology 2012;21:54e63.

16. Mehnert A, Koch U, Schulz H, et al. Prevalenceof mental disorders, psychosocial distress and needfor psychosocial support in cancer patients: studyprotocol of an epidemiological multi-center study.BMC Psychiatry 2012;12:70.

17. Mehnert A, M€uller D, Lehmann C, Koch U. Diedeutsche Version des NCCN Distress-Thermome-ters: Empirische Pr€ufung eines Screening-Instru-ments zur Erfassung psychosozialer Belastung beiKrebspatienten. [The German Version of theNCCN Distress Thermometer: Validation of aScreening Instrument for Assessment of Psychoso-cial Distress in Cancer Patients.]. [in German].Z Psychiatr Psych Ps 2006;54:213e223.

18. L€owe B, Kroenke K, Herzog W, Gr€afe K. Measur-ing depression outcome with a brief self-report

instrument: sensitivity to change of the PatientHealth Questionnaire (PHQ-9). J Affect Disord2004;81:61e66.

19. Mehnert A, Vehling S, H€ocker A, Lehmann C,Koch U. Demoralization and depression in patientswith advanced cancer: validation of the German ver-sion of the demoralization scale. J Pain SymptomManage 2011;42:768e776.

20. Aaronson NK, Ahmedzai S, Bergman B, et al.The European Organization for Research andTreatment of Cancer QLQ-C30: a quality-of-life in-strument for use in international clinical trials inoncology. J Natl Cancer Inst 1993;85:365e376.

21. Mehnert A, Koch U. Psychometric evaluation ofthe German version of the Life Attitude Profile-Revised (LAP-R) in prostate cancer patients. PalliatSupport Care 2008;6:119e124.

22. Lehmann C, Koch U, Mehnert A. Psychometricproperties of the German version of the Short-FormSupportive Care Needs Survey Questionnaire(SCNS-SF34-G). Support Care Cancer 2012;20:2415e2424.