Measuring Therapeutic Alliance Between Oncologists and Patients with Advanced Cancer: the Human Connection Scale

Overview

Journal Cancer

Publisher Wiley

Specialty Oncology

Date 2009 Jun 2

PMID 19484795

Citations 89

Authors

Jennifer W Mack

Susan D Block

Matthew Nilsson

Alexi Wright

Elizabeth Trice

Robert Friedlander

Elizabeth Paulk

Holly G Prigerson

Affiliations

Soon will be listed here.

Abstract

Background: Patients consider their human connection with a physician an important aspect of end-of-life (EOL) care. In this study, the authors sought to develop and validate a measure of therapeutic alliance between patients with advanced cancer and their physicians and to evaluate the effects of therapeutic alliance on EOL experiences and care.

Methods: The Human Connection (THC) scale was developed to measure the extent to which patients felt a sense of mutual understanding, caring, and trust with their physicians. The scale was administered to 217 patients with advanced cancer along with measures of attributes that have been related hypothetically to therapeutic alliance, including emotional acceptance of terminal illness. EOL outcomes in 90 patients who died during the study also were examined.

Results: The 16-item THC questionnaire was consistent internally (Cronbach alpha = .90) and valid based on its expected positive association with emotional acceptance of terminal illness (r = .31; P < .0001). THC scores were related inversely to symptom burden (r = -.19; P = .006), functional status (Karnofsky performance status; r = .22; P = .001), and mental illness (THC score: 50.69 for patients with any Diagnostic and Statistical Manual [DSM] diagnosis vs 55.22 for patients with no DSM diagnosis; P = .03). THC scores were not associated significantly with EOL discussions (P = .68). Among the patients who died, EOL intensive care unit (ICU) care was associated inversely with therapeutic alliance (THC score: 46.5 for patients who received ICU care vs 55.5 for patients without ICU care; P = .002), so that patients with higher THC scores were less likely to spend time in the ICU during the last week of life.

Conclusions: The THC scale is a valid and reliable measure of therapeutic alliance between patients with advanced cancer and their physicians. In addition, there was no evidence to suggest that EOL discussions harm patients' therapeutic alliance. A strong therapeutic alliance was associated with emotional acceptance of a terminal illness and with decreased ICU care at the EOL among patients with advanced cancer.

Citing Articles

Effects of a communication skills training program to improve capacity to engage in advance care planning in caregivers of patients with malignant gliomas.

Applebaum A, Loschiavo M, Kastrinos A, Schofield E, Behrens M, Gebert R J Psychosoc Oncol Res Pract. 2025; 6(3).

PMID: 39925955 PMC: 11804764. DOI: 10.1097/or9.0000000000000136.

Measuring the quality of patient-provider relationships in serious illness: A scoping review.

Wassef K, Ma K, Durieux B, Brown T, Paladino J, Thorne S Palliat Med. 2025; 39(3):332-345.

PMID: 39915896 PMC: 11877987. DOI: 10.1177/02692163251315304.

Cancer patients' sense of coherence - psycho-oncological consultations and therapeutic alliance as salutogenic factors.

Cecon-Stabel N, Demirer I, Pfaff H, Dresen A Health Psychol Rep. 2024; 12(4):322-336.

PMID: 39619860 PMC: 11604166. DOI: 10.5114/hpr/189462.

A video intervention to improve patient understanding of tumor genomic testing in patients with cancer.

Veney D, Wei L, Toland A, Presley C, Hampel H, Padamsee T Cancer Med. 2024; 13(17):e70095.

PMID: 39258462 PMC: 11387988. DOI: 10.1002/cam4.70095.

Sharing health care wishes among older adults with cognitive impairment in primary care: Results from a randomized controlled trial.

Wolff J, Cagle J, Hanna V, Dy S, Echavarria D, Giovannetti E Alzheimers Dement. 2024; 20(10):7263-7273.

PMID: 39189632 PMC: 11485067. DOI: 10.1002/alz.14210.

References

Curtis J, Wenrich M, Carline J, Shannon S, Ambrozy D, Ramsey P . Understanding physicians' skills at providing end-of-life care perspectives of patients, families, and health care workers. J Gen Intern Med. 2001; 16(1):41-9. PMC: 1495161. View

Carver C . You want to measure coping but your protocol's too long: consider the brief COPE. Int J Behav Med. 1997; 4(1):92-100. DOI: 10.1207/s15327558ijbm0401_6. View

Sullivan A, Lakoma M, Block S . The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003; 18(9):685-95. PMC: 1494921. DOI: 10.1046/j.1525-1497.2003.21215.x. View

Joyce A, Ogrodniczuk J, Piper W, McCallum M . The alliance as mediator of expectancy effects in short-term individual therapy. J Consult Clin Psychol. 2003; 71(4):672-9. DOI: 10.1037/0022-006x.71.4.672. View

Butow P, Dowsett S, HAGERTY R, Tattersall M . Communicating prognosis to patients with metastatic disease: what do they really want to know?. Support Care Cancer. 2002; 10(2):161-8. DOI: 10.1007/s005200100290. View

Gordon E, Daugherty C . 'Hitting you over the head': oncologists' disclosure of prognosis to advanced cancer patients. Bioethics. 2003; 17(2):142-68. DOI: 10.1111/1467-8519.00330. View

Maddigan S, Majumdar S, Johnson J . Understanding the complex associations between patient-provider relationships, self-care behaviours, and health-related quality of life in type 2 diabetes: a structural equation modeling approach. Qual Life Res. 2005; 14(6):1489-500. DOI: 10.1007/s11136-005-0586-z. View

Williams J, GIBBON M, First M, Spitzer R, Davies M, Borus J . The Structured Clinical Interview for DSM-III-R (SCID). II. Multisite test-retest reliability. Arch Gen Psychiatry. 1992; 49(8):630-6. DOI: 10.1001/archpsyc.1992.01820080038006. View

Clayton J, Butow P, Arnold R, Tattersall M . Fostering coping and nurturing hope when discussing the future with terminally ill cancer patients and their caregivers. Cancer. 2005; 103(9):1965-75. DOI: 10.1002/cncr.21011. View

10.

Schneider J, Kaplan S, Greenfield S, Li W, Wilson I . Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. J Gen Intern Med. 2004; 19(11):1096-103. PMC: 1494791. DOI: 10.1111/j.1525-1497.2004.30418.x. View

11.

Wenrich M, Curtis J, Ambrozy D, Carline J, Shannon S, Ramsey P . Dying patients' need for emotional support and personalized care from physicians: perspectives of patients with terminal illness, families, and health care providers. J Pain Symptom Manage. 2003; 25(3):236-46. DOI: 10.1016/s0885-3924(02)00694-2. View

12.

Connolly Gibbons M, Crits-Christoph P, De La Cruz C, Barber J, Siqueland L, Gladis M . Pretreatment expectations, interpersonal functioning, and symptoms in the prediction of the therapeutic alliance across supportive-expressive psychotherapy and cognitive therapy. Psychother Res. 2012; 13(1):59-76. DOI: 10.1093/ptr/kpg007. View

13.

Kaplan S, Greenfield S, Ware Jr J . Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989; 27(3 Suppl):S110-27. DOI: 10.1097/00005650-198903001-00010. View

14.

Leavitt M . Medscape's response to the Institute of Medicine Report: Crossing the quality chasm: a new health system for the 21st century. MedGenMed. 2001; 3(2):2. View

15.

Zaslavsky A, Zaborski L, Ding L, Shaul J, Cioffi M, Cleary P . Adjusting Performance Measures to Ensure Equitable Plan Comparisons. Health Care Financ Rev. 2014; 22(3):109-126. PMC: 4194711. View

16.

McGuire R, McCabe R, Priebe S . Theoretical frameworks for understanding and investigating the therapeutic relationship in psychiatry. Soc Psychiatry Psychiatr Epidemiol. 2002; 36(11):557-64. DOI: 10.1007/s001270170007. View

17.

Miyaji N . The power of compassion: truth-telling among American doctors in the care of dying patients. Soc Sci Med. 1993; 36(3):249-64. DOI: 10.1016/0277-9536(93)90008-r. View

18.

Luborsky L, Barber J, Siqueland L, Johnson S, Najavits L, Frank A . The Revised Helping Alliance Questionnaire (HAq-II) : Psychometric Properties. J Psychother Pract Res. 2012; 5(3):260-71. PMC: 3330423. View

19.

Charlson M, Pompei P, Ales K, MacKenzie C . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40(5):373-83. DOI: 10.1016/0021-9681(87)90171-8. View

20.

Cohen S, Mount B, Strobel M, Bui F . The McGill Quality of Life Questionnaire: a measure of quality of life appropriate for people with advanced disease. A preliminary study of validity and acceptability. Palliat Med. 1995; 9(3):207-19. DOI: 10.1177/026921639500900306. View