Spirituality_Nursing.pdf

EMPIRICAL STUDIES

Intrapersonal self-transcendence, meaning-in-life and
nurse–patient interaction: powerful assets for quality of life
in cognitively intact nursing-home patients

Gørill Haugan PhD, RN (Associate Professor)1, Unni Karin Moksnes PhD, RN (Associate Professor)1 and
Audhild Løhre PhD (Post Doctor)2
1
Faculty of Nursing Science, Center for Health Promotion Research, HIST, Sør-Trøndelag University College, Trondheim, Norway and

2
Center for Health Promotion Research, Faculty of Teaching and Sign Language Interpretation, HiST, Sør-Trøndelag University College,
Trondheim, Norway

Scand J Caring Sci; 2016

Intrapersonal self-transcendence, meaning-in-life and

nurse–patient interaction: powerful assets for quality

of life in cognitively intact nursing-home patients

Background: Spirituality has demonstrated a significant

impact on quality of life in nursing-home patients. Like-

wise, as essential aspects of spirituality, hope, self-trans-

cendence, and meaning are found to be vital resources to

nursing-home patients’ global well-being. Further,

nurse–patient interaction has demonstrated a powerful

influence on patient’s hope, self-transcendence, and

meaning-in-life, as well as on anxiety and depression.

Aim: The present study investigated the associations of

hope, self-transcendence, meaning, and perceived nurse–

patient interaction with quality of life.

Design and method: In a cross-sectional design, a sample of

202 cognitively intact nursing-home patients in Mid-Nor-

way responded to the Herth Hope Index, the Self-Trans-

cendence scale, the Purpose-in-Life test, the Nurse-Patient

Interaction scale, and a one-item overall measure on qual-

ity of life. Using SPSS ordinal regression, bivariate and

multivariate analyses were conducted with quality of life

as dependent variable.

Results: Controlling for gender, age, and residential time, all

the scales were significantly related to quality of life in the

bivariate analyses. Intrapersonal self-transcendence

showed an exceptional position presenting a very high odds

ratio in the bivariate analysis, and also the strongest associ-

ation with quality of life in multivariate analyses. Meaning

and nurse–patient interaction also showed independent

and significant associations with quality of life.

Conclusion: The associations found encourage the idea that

intrapersonal self-transcendence, meaning-in-life, and

nurse–patient interaction are powerful health-promoting

factors that significantly influence on nursing-home

patients’ quality of life. Therefore, pedagogical approaches

for advancing caregivers’ presence and confidence in

health-promoting interaction should be upgraded and

matured. Proper educational programs for developing inter-

acting skills including assessing and supporting patients’

intrapersonal self-transcendence and meaning-in-life

should be utilised and their effectiveness evaluated.

Keywords: health promotion, assets for quality in life,

spirituality, PIL-20, PIL-10, nurse-patient interaction, nur-

sing home, long-term care.

Submitted 20 April 2015, Accepted 8 October 2015

Introduction

The world’s population is rapidly ageing: in 1980, there

were 378 million people in the world aged 60 or above,

whereas this portion was doubled to 759 million in 2009

(1–3). Moreover, by 2050, the segment of those 80 and

older will be 31 percent, up from 18 percent in 1988 (4).

For many of those 80 and more, an increased need for

healthcare services and long-term care in nursing homes

(NH) will take place in the coming decades.

Background

The NH population is generally marked with high age,

physical impairment, and high mortality. Generally, high

prevalence of chronic illness and functional impairments

Correspondence to:

Center for Health Promotion Research, HiST, Faculty of Nursing

Science, Sør-Trøndelag University College, Postbox 2320, 7004

Trondheim, Norway.

E-mail: [email protected]

1© 2016 Nordic College of Caring Science

doi: 10.1111/scs.12307

characterise this population, representing complex medical

states typified by many different, simultaneous diagnoses

(5). Characteristically, NH patients are marked by frailty

and vulnerability. Systematical registrations throughout

the period from 1997 to 2005 in a Norwegian NH providing

150 beds showed a very stable list of patients’ physical

impairments: approximately nine of ten needed help wash-

ing and dressing and were not capable of walking up a stair-

way. Three of four could not feed themselves, and all

needed help getting to the lavatory, while two of three

patients never read a paper (6). The in-house NH life is insti-

tutionalised, representing loss of social relationships, pri-

vacy, self-determination, and connectedness; life quality

(QoL) is often thought to be strongly compromised (7). A

recent systematic qualitative review of care home life (8)

emphasised the lack of autonomy and difficulty in forming

appropriate relationships with others as the main reasons

for diminished QoL. The dominant NH life themes identi-

fied were as follows: (i) acceptance and adaptation, (ii) con-

nectedness with others, (iii) a homelike environment, and

(iv) caring practices. Accordingly, this review highlighted

the need for relationship-centred approaches to NH care

(ibid.). While representing NH patients’ daily occasions for

connectedness, the nurse–patient relationship might be

crucial to NH patients’ QoL. Recent studies have displayed

significant impact of the nurse–patient interaction on NH

patients’ anxiety and depression (9), as well as the funda-

mental spiritual aspects of hope (10), self-transcendence

(11) and perceived meaning-in-life (12, 13).

Over the past few years, there has been an increas-

ing interest in the importance of spirituality for those

80 and older in care settings. Previous research verifies

the importance of spiritual well-being for physical and

mental health outcomes in the lives of many older

adults (14, 15), in NHs (16–18) and at the end of life

(19–21). Spiritual care has been and continues to be

recognised as an integral part of nursing older people

(22, 23). In the nursing literature, definitions of spiritu-

ality cluster around an individual’s essence as a person,

relationships with others and an infinite being, and the

search for fulfilment, hope, self-transcendence and

meaning-in-life (24–28). Spirituality has shown signifi-

cant impact on QoL in NH patients (16, 22). Spiritual

well-being is described to be a “perception of health

and wholeness”, enhancing self-confidence and self-

esteem in vulnerable populations (29). Furthermore,

spiritual well-being may predict overall life satisfaction

among NH patients (16).

Being a vital aspect of humans’ spirituality, hope is

understood as the act by which the temptation of despair

is actively overcome; this has been largely described in

nursing theories (30, 31). Hope is perceived to be an

available resource for living in the present; an inner

strength regarded as a central aspect of dignified end-of-

lifetime and death among NH patients (32, 33).

Furthermore, as a vital aspect of hope among older

individuals inner strength has been associated with con-

nectedness, firmness, flexibility, creativity, a sense of

competence in oneself yet having faith in others, accept-

ing both the light and the dark side of life, and being the

same person yet growing into a new garment (34–36).

Self-transcendence, the ability to expand one’s rela-

tionship with others and the environment, is identified

as one of the developmental resources that promote

well-being in later adulthood during increased vulnera-

bility (37). Self-transcendence has been found to provide

hope and meaning which helps a person to adapt and

cope with illness. Both interpersonal and intrapersonal

self-transcendence have demonstrated to significantly

affect not only emotional, social and spiritual well-being,

but functional and physical well-being as well among NH

patients (38–40).

As an essential aspect of spirituality, meaning is com-

monly addressed in nursing literature (41) and is seen to

be of particular importance to QoL for many older adults

(14, 15, 42) in NHs (17, 18, 43–45) and at the end of life

(18, 19, 21, 46, 47). Meaning seems to serve as a mediat-

ing variable in psychological (48–54) and physical health

(55) and has been found to be associated with mortality

(56–58), psychosomatic dis s (59), fatigue and over-

all symptoms in breast cancer survivors (60). Meaning

and spiritual well-being are important aspects of mental

well-being in NH patients (42, 61) predicting overall NH

satisfaction (16). Recent research implies that meaning is

important for maintaining not only emotional well-being,

but also physical and functional well-being (62, 63).

In sum, the literature reviewed suggests that spirituality

includes vital QoL resources such as hope, self-transcen-

dence, and meaning. Consequently, we expected hope,

interpersonal self-transcendence, intrapersonal self-trans-

cendence and meaning to positively intercorrelate, as well

as being positively correlated with QoL. However, we did

not know which of these aspects might be the most princi-

pal for NH residents’ QoL. In to competently promote

QoL among NH patients, such knowledge seems essential.

Moreover, the nurse–patient interaction is observed to

foster hope, self-transcendence and meaning, and thereby

influencing on NH patients’ QoL. Finding effective inter-

ventions to support QoL in NH patients requires insight

about how these variables might affect NH patients’ QoL.

Thus, it seems appropriate to examine which of these

aspects should be emphasised in NH care.

Aims

Therefore, this study was designed to investigate the

associations between hope, interpersonal self-transcen-

dence and intrapersonal self-transcendence, meaning,

nurse–patient interaction and QoL in a cognitively intact

NH population. In accordance with previous research and

2 G. Haugan et al.

© 2016 Nordic College of Caring Science

theory, all of these scales were expected to be signifi-

cantly related to QoL. However, we did not know

whether they are equally important or whether any of

them are more outstanding and therefore should be

given the main focus when attempting to increase QoL

among cognitively intact NH patients. Thus, we intended

to test their individual association with QoL by control-

ling for the other scales. The important research question

was as follows: which of these dimensions (hope, inter-

personal self-transcendence and intrapersonal self-trans-

cendence, meaning and nurse–patient interaction) are

the most vital for NH patients’ QoL?

Methods

Design and patient recruitment

The study employed a cross-sectional design. Two coun-

ties in central Norway were selected comprising 48

municipalities in total, of which 25 (at random) were

invited to contribute. In total, 20 municipalities partici-

pated. All the NHs in each of the 20 municipalities were

asked to participate. A total of 44 NHs took part in the

study. Approvals were obtained from the Management

Units at the 44 NHs, the Regional Committee for Medical

and Health Research Ethics in Central Norway

(Ref.nr.4.2007.645), and the Norwegian Social Science

Data Services to maintain a register containing personal

data (Ref.nr 16443).

Method of data collection

A head nurse they knew well approached the NH

patients. The nurse gave both oral and written informa-

tion about their rights as participants and their right to

withdraw from the study at any time. Each participant

provided informed consent. Because this population has

difficulties completing a questionnaire independently,

three trained researchers conducted one-on-one inter-

views in private. To avoid introducing bias into the

respondents’ reporting, researchers with identical profes-

sional background were chosen (RN, MA, trained and

experienced in communication with elderly, as well as

teaching gerontology at an advanced level); they were

trained to conduct the survey interviews as similarly as

possible. A large-print copy of questions and possible

responses was held in front of the participants to avoid

misunderstandings. Inter-rater reliability was assessed by

comparing mean scores between interviewers by means

of Bonferroni-corrected one-way ANOVAs. No statistically

significant differences were found that were not

accounted for by known differences between the areas in

which the interviewers operated. The data were collected

during 2008 and 2009, and the scales used were part of a

questionnaire comprising 130 items.

Sample

Long-term NH care was defined as 24-hour care; short-

term care patients, rehabilitation patients, and patients

suffering from dementia were not included. The inclusion

criteria were as follows: (i) local authority’s assignment

to long-term NH care; (ii) residential time of 6 months or

longer; (iii) informed consent competency recognised by

a responsible doctor and nurse; and (iv) capable of being

interviewed. In total, 250 long-term NH patients met the

criteria and were approached by a head nurse, whom

they knew well. Because 19% declined to participate, the

total sample comprised 202 (81%) of the 250 NH patients

from these 44 NHs.

Measures

Quality of Life was assessed by the QLQ-C15-PAL, a core

palliative care questionnaire (64). The QOL-C15-PAL is

an abbreviated 15-item version of the EORTC QLQ-C30.

The last item assesses global QoL during the last week

and is rated from 1 (very poor) to 7 (excellent) (64). A

Norwegian version of the QLQ-C15-PAL, the EORTC

QLQ-C30 scoring manual and the QLQ-C15-PAL scoring

addendum (65, 66) were used.

Hope was assessed by the Herth Hope Index (HHI)

developed by Key Herth (67) comprising 12 items using

a 4-point Likert response format (from strongly disagree

to strongly agree). Possible scores ranged from 12 to 48,

with higher scores indicating greater hopefulness. Test

items were, for example, “I have a positive outlook

toward life”, “I feel alone” and “I have a deep inner

strength” (Appendix 1). Cronbach’s a in the present
study was 0.76 (Table 1). The HHI (67) was recently vali-

dated among cognitively intact NH patients showing a

good construct validity (68).

Interpersonal self-transcendence and intrapersonal self-trans-

cendence were assessed by the Self-Transcendence Scale

(STS) (37, 69) reflecting expanded self-boundaries (70).

The STS was developed by Pamela Reed and comprises

15 items rated on a four-point Likert-type scale from 1

(not at all) to 4 (very much), with higher scores indicat-

ing higher self-transcendence. The two-factor construct

of self-transcendence (71) was used, comprising ST-1

(interpersonal self-transcendence) and ST-2 (intraper-

sonal self-transcendence). The test items for interpersonal

self-transcendence included questions such as “Having

hobbies and interests I can enjoy”, “Being involved with

other people”, “Sharing my wisdom with others” and

“Having an ongoing interest in learning”. Intrapersonal

self-transcendence covered items such as “Accepting

myself as I grow older”, “Adjusting well to my present

life situation”, and “Accepting death as a part of life”

(Appendix 2). Cronbach’s alpha for ST-1 and ST-2 is

shown in Table 1.

Powerful assets for quality of life 3

© 2016 Nordic College of Caring Science

Meaning-in-life was assessed by the Purpose-in-Life Test

(PIL) developed by Crumbaugh and Maholick (72–74).

The 20 test items included questions such as “My per-

sonal existence is very purposeful and meaningful” and

“In achieving life goals, I have progressed to complete

fulfilment” (Appendix 3). Each statement is scored from

1 to 7 where 4 represents a neutral value, whereas the

numbers from 1 to 7 stretch along a continuum from

one extreme feeling to the opposite kind of feeling. The

range of possible scores is 20–140 and numerically

higher scores reflect increased purposefulness (74). Sev-

eral factor-analytic investigations of the PIL, with mark-

edly differing results, have been published over the

years. A one-factor, different two-factor and three-factor

solutions including a different number of items have

been presented (75). A recent validation of the PIL

among cognitively NH patients (75) supported the for-

merly published two-factor solution comprising ten of

the original 20 items (76, 77). Therefore, we included

both PIL-20 (20 items) and PIL-10 (ten items) in the

ordinal regression analyses. In this study, the Cronbach’s

a was 0.82 and 0.74 for PIL-20 and PIL-10, respectively
(Table 1).

Nurse–patient interaction was assessed by the Nurse-

Patient-Interaction Scale (NPIS) comprising 14 items

identifying essential relational qualities stressed in the

nursing literature (78–84). Haugan et al. (11) developed

the NPIS which is a 10-point scale ranging from 1 (not

at all) to 10 (very much); higher numbers indicate bet-

ter nurse–patient interaction (Appendix 4). Examples of

NPIS items include having trust and confidence in the

staff nurses, the experience of being taken seriously, as

well as experiences of being respected and recognised

as a person, being listened to and feeling good as a

result of nurse–patient interaction. The items were

developed to measure the nursing-home patients’ abil-

ity to derive a sense of well-being and meaningfulness

through the nurse–patient interaction (85–88). The

NPIS was recently validated in NH patients showing

good psychometric properties (11). In this study, a was
0.92 (Table 1). Approvals to use the scales were

obtained.

Statistical analysis

The data were analysed by descriptive and correlational

statistics using SPSS version 20 (IBM: IBM Corp. Released

2011. IBM SPSS Statistics for Windows, Version 20.0.

Armonk, NY: IBM Corp). Cronbach’s a was computed to
estimate the internal consistency of all measures used.

Using SPSS, proportional odds logistic regression (ordinal

regression) (89) analyses were carried out with QoL as

dependent variable in all the bivariate and multivariate

models. p-values <0.05 were considered statistically significant. Results Descriptive statistics Of the 202 participants, 146 (72.3%) were females and 56 (27.7%) were males. Mean age for females were 87 and for males 82 years, and mean residential time was around two and a half years for both genders. Females reported mean 4.84 and males 5.15 on QoL, and the median was 5.0 for both genders. The six measurement scales showed high to low inter-relations (Table 1). HOPE demonstrated the highest correlations with the other scales, ranging from r 0.25 to r 0.66, indicating that HOPE shared much variation with the others. The 10- item and the 20-item scales of PIL were also strongly correlated, with r 0.87. NPIS turned out to be the most free-standing of the scales with weakest bivariate rela- tions to the other scales; the correlations ranged from r 0.37 with PIL-20 to no significant correlation with ST-1. Cronbach’s alpha for the study variables was good to acceptable (Table 1). Hope, self-transcendence, meaning and nurse–patient interaction scale in relation to QoL Controlling for gender, age and residential time, bivariate associations between each of the scales and QoL as well as multivariate associations were assessed in proportional odds logistic regression analyses (Table 2). Bivariate Table 1 Median, interquartile range (IQR), Cronbach’s alpha and correlation coefficients for the study variables Construct Median IQR Items Cronbach’s Alpha Hope ST-1 ST-2 PIL-20 PIL-10 NPIS HOPE 2.91 0.42 12 0.76 1 ST-1 2.67 1.00 7 0.68 0.60** 1 ST-2 3.00 0.50 7 0.51 0.46** 0.31** 1 PIL-20 4.65 0.91 20 0.82 0.66** 0.43** 0.37** 1 PIL-10 4.60 1.20 10 0.74 0.65** 0.46** 0.33** 0.87** 1 NPIS 8.46 2.29 14 0.92 0.25** 0.09 0.24** 0.37** 0.32** 1 **p-value <0.01. Hope = Herth Hope Index. ST-1 = Interpersonal self-transcendence. ST-2 = Intrapersonal self-transcendence. PIL = Purpose-in- life. PIL-20 = PIL including all 20 items. PIL-10 = PIL including 10 of the original 20 items. NPIS = Nurse–Patient interaction. 4 G. Haugan et al. © 2016 Nordic College of Caring Science analyses (left side of Table 2) showed that participants scoring high on HOPE or ST-2 were eight times more likely to report better QoL than those who scored low on HOPE or ST-2, respectively. Participants who scored high on the other scales had 2-4 times higher odds of reporting better QoL than participants scoring low on the respective scales. All associations were highly significant (p-values <0.01). To explore a possible different impact of PIL-20 and PIL-10 in relation to the other scales, two multivariate analyses were run, one with PIL-20 (middle part of Table 2) and the other with PIL-10 (right part of Table 2). In both analyses, ST-2 showed the strongest individual association with QoL: odds ratio, 3.74, 95% CI 1.52–9.16 with PIL-20 included in the analysis and odds ratio, 3.81, 95% CI 1.56–9.31 with PIL-10 included in the analysis. PIL-20 (middle part of Table 2) was also strongly related to QoL (odds ratio, 2.65, 95% CI 1.54– 4.57), whereas PIL-10 (right part of Table 2) showed a nonsignificant association. Further, NPIS contributed individually to QoL when the other scales were adjusted for; participants with high scores on NPIS were 1.2–1.3 times more likely to report higher QoL than those reporting low scores on NPIS. On the other hand, HOPE and ST-1 showed no individual contributions to QoL in the two multivariate analyses. Discussion The correlations between the different scales were strong (Table 1), indicating that some of the scales measure the same phenomenon. However, a high correlation between PIL-10 and PIL-20 is common sense, since the ten items in PIL-10 are also part of PIL-20. Contrariwise, the high correlations between PIL-20 and HOPE (r = 0.66) as well as between ST-1 and HOPE (r = 0.60) are not uncomplicated. The high correlations indicate that the HOPE concept might share characteristics with the concepts of interpersonal self-transcendence (ST-1) and meaning (PIL-20). Nevertheless, while looking at the items included in the Herth Hope Index (involving a positive outlook towards life, short and long goals, feel- ing alone, able to see the light in the tunnel, feeling scared about the future, having faith that gives comfort, having a deep inner strength, a sense of direction, etc.), the similarity between HOPE and ST-1 (involving having hobbies/interests, being involved with other people, sharing once wisdom, helping others, interest in learn- ing) is not obvious. Therefore, future studies exploring the intercorrelations as well as the wording of these concepts/scales are needed. On the other hand, the simi- larities between some of the HOPE items and PIL-20 are more apparent, while both scales include items involving a sense of direction, goals, purpose, and sort of value and worth. Furthermore, all the six scales demonstrated strong bivariate associations with QoL, especially HOPE and ST- 2. However, in the multivariate analyses, ST-2 was the most outstanding variable, showing that participants scor- ing high on ST-2 were nearly four times more likely to report better QoL. Intrapersonal self-transcendence (ST-2) Accordingly, intrapersonal self-transcendence (ST-2) revealed an exceptional position among the six included scales in relation to QoL; ST-2 presented a very high odds ratio in the bivariate analysis and showed the strongest association with QoL in both of the two multivariate analyses. Thus, intrapersonal self-transcendence (ST-2) comprising, for example, self-acceptance and adjustment appeared to be a key asset for QoL. When individuals are accepting and adjusting well (ST-2), they experience more inner peace; this association was recently demon- strated among NH patients (38). Given that inner peace is seen to be strongly and significantly related to meaning (89, 90), the present results seem plausible and theoreti- cally meaningful. Intrapersonal self-transcendence (ST-2) covers NH patients’ acceptance of oneself as growing Table 2 Proportional odds ordinal regression with Quality of Life as dependent variable Variables Bivariate analyses Multivariate analysis Model PIL-20 Multivariate analysis Model PIL-10 Odds ratio (95% CI) p-value Odds ratio (95% CI) p-value Odds ratio (95% CI) p-value HOPE 8.25 (3.70–18.40) <0.001 1.56 (0.47–5.12) 0.466 2.81 (0.88–8.98) 0.082 ST-1 1.89 (1.18–3.04) 0.008 0.81 (0.45–1.46) 0.488 0.83 (0.46–1.50) 0.541 ST-2 8.04 (3.59–18.00) <0.001 3.74 (1.52–9.16) 0.004 3.81 (1.56–9.31) 0.003 PIL-20 3.95 (2.60–5.99) <0.001 2.65 (1.54–4.57) <0.001 – – PIL-10 2.14 (1.60–2.86) <0.001 – – 1.45 (0.99–2.12) 0.058 NPIS 2.81 (0.88–8.98) <0.082 1.20 (1.00–1.43) 0.047 1.26 (1.06–1.50) 0.010 All models adjusted for gender, age and residential time. Hope = Herth Hope Index. ST-1 = Interpersonal self-transcendence. ST-2 = Intrapersonal self-transcendence. PIL = Purpose-in-life. PIL-20 = PIL including all 20 items. PIL-10 = PIL including 10 of the original 20 items. NPIS = Nurse- Patient Interaction scale. Powerful assets for quality of life 5 © 2016 Nordic College of Caring Science older, accepting death as a part of life, adjusting well to changes in physical abilities and the present life situation, letting others help when this is needed, besides finding meaning in past experiences. These aspects covered by ST-2 are considered as internal attitudes and processes connected with inner resources such as self-confidence, self-esteem and a positive life orientation; for example, self-transcendence has been found to be a mediator of optimism among seriously ill older individuals (92). Accepting death and accepting oneself growing older are considered inner aspects related to personal maturity (37) and intrapersonal dignity (93). Thus, intrapersonal self- transcendence is part of an individual’s personality and personal maturity, but still, it is a resource which can be supported and strengthened from the outside. The intrapersonal self-transcendence (ST-2) also covers the aspect of adjusting well to changes in physical abilities and the present life situation. Adjustment is essential for finding meaning and coping with illness and disabilities (94). NH patients’ self-reported coping mechanisms are reported to include positive attitudes, a sense of reality, family support (95) and meaning-based coping variables such as positive reappraisal and perceived uplifts (96, 97). Hence, a respecting, listening, supporting, understanding and acknowledging nurse–patient interaction is likely to enhance coping, and thus self-acceptance (ST-2) and QoL. Also, a meaningful dialogue about death as part of life might be vital to NH patients’ intrapersonal self-transcen- dence, and thus QoL. However, not all old individuals feel like openly and frankly addressing their inner thoughts about death with caregivers; staff nurses need to be aware of and respect the individual’s needs and preferences. Pos- sibly, some NH patients would rather talk about death to a priest or somebody they know well or count on, than young caregivers who not yet have developed a mature attitude towards death. Meaning and purpose-in-life Meaning (PIL-20) presented a solid association with QoL, whereas, surprisingly, the PIL-10 showed a nonsignificant relation. This indicates that the ten items excluded from PIL-20, that is the original PIL test (Appendix 3), were more noteworthy to NH patients QoL than the ten items kept in PIL-10. The following items were excluded: PIL1 (“I am usually bored – enthusiastic”), PIL4 (“My personal existence is: utterly meaningless, without purpose-purposeful and meaningful”), PIL6 (“If I could choose, I would prefer never to have been born-want nine more lives just like this”), PIL9 (“My life is: empty, filled only with despair-running over with exciting things”), PIL11 (“In thinking over my life, I: often wonders why I exist-always see reasons for being here”), PIL12 (“In relation to my life, the world: completely confuses me-fits meaningfully with my life”), PIL13 (“I am a: very irre- sponsible person-very responsible person”), PIL14 (“Concerning freedom to choose, I believe humans are: completely bound by limitations of heredity and environment–totally free to make all life choices”), PIL15 (“With regard to death, I am: unprepared and frightened-prepared and unafraid”), and PIL16 (“Regard- ing suicide, I have: thought of it seriously as a way out-never given it a second thought”). The themes of …