Anticipating loss and other temporal stressors predict traumatic stress symptoms among partners of metastatic/recurrent breast cancer patients

An examination and proposed definitions of family members' grief prior to the death of individuals with a life-limiting illness: A systematic review

BACKGROUND

Research has extensively examined family members' grief prior to the death of an individual with a life-limiting illness but several inconsistencies in its conceptualization of related constructs, yet significant conceptualization issues exist.

AIM

This study aimed to identify and characterize studies published on family members grief before the death of an individual with a life-limiting illness, and propose definitions based on past studies in order to initiate conceptual clarity.

DESIGN

A mixed-method systematic review utilized six databases and was last conducted July 10, 2021. The search strategy was developed using Medical Subject Headings. This study was prospectively registered on PROSPERO (CRD42020166254).

RESULTS

One hundred thirty-four full-text articles met inclusion criteria. This review revealed across studies a wide variation in terminology, conceptualization, and characterization of grief before the death. More than 18 terms and 30 definitions have been used. In many cases, the same term (e.g. anticipatory grief) was defined differently across studies.

CONCLUSIONS

We found grief occurring before the death of a person with a life-limiting illness, which we termed pre-death grief, is comprised of two distinct constructs: anticipatory grief and illness-related grief. Anticipatory grief is future-oriented and is characterized by separation distress and worry about a future without the person with the life-limiting illness being physically present. Illness-related grief is present-oriented and is characterized by grief over current and ongoing losses experienced during the illness trajectory. These definitions provide the field with uniform constructs to advance the study of grief before the death of an individual with a life-limiting illness.

Relationship Between Post-traumatic Stress Symptoms and Anticipatory Grief in Family Caregivers of Patients With Advanced Lung Cancer: The Mediation Role of Illness Uncertainty

OBJECTIVE

To explore the interrelationship between post-traumatic stress symptoms (PTSS), illness uncertainty (IU), and anticipatory grief (AG).

METHODS

Structural equation modeling with bootstrapping estimation was conducted using data from a convenience sample of 254 family caregivers of patients with advanced lung cancer in China. Participants were recruited from a public cancer hospital in Shenyang, China. The family caregivers completed the Impact of Events Scale-Revised, Uncertainty in Illness Scale Family Caregiver Version, and Anticipatory Grief Scale.

RESULTS

The measurement model has good reliability and validity, and the final model fit the data well. PTSS positively influenced AG (direct effect estimate = 0.391, p = 0.002). Moreover, IU was found to mediate the relationship between PTSS and AG (Indirect effects estimate = 0.168, p = 0.005). The mediating effect of IU accounted for up to 30.1% of the total effect.

CONCLUSION

IU mediated the relationship between PTSS and AG. Healthcare professionals should continuously assess PTSS, IU and AG levels in FCs and provide effective intervention options for mitigation.

Pre-loss grief and preparedness for death among caregivers of terminally ill cancer patients: A systematic review

BACKGROUND

Cancer is one of the most common causes of death. The period of time between receiving a terminal diagnosis of cancer and the death of a loved one has been operationalized as pre-loss grief and, more recently, as preparedness for death. Originally, grief before loss was thought to have positive effects on the bereavement outcome, but some studies have revealed contradictory findings. This systematic review investigates definitions and measurement tools of pre-loss grief and preparedness for death, as well as the associations of both constructs with caregiver characteristics, pre-loss psychological aspects and post-loss adjustment among caregivers of people living with terminal cancer.

METHODS

PubMed/Medline, PsycINFO and Web of Science were searched for studies published up until October 2020. Quantitative empirical studies from peer reviewed journals were included if a measurement tool for pre-loss grief or preparedness for death was used and if they focused on adult caregivers of adult people with cancer in an end-of-life trajectory and were excluded when they were not written in English or were descriptive/qualitative studies. Quality assessment of all studies was performed.

RESULTS

Most studies used convenience samples and had a mean number of 725 participants. Overall, 16,326 participants in 35 articles were included and narratively synthesized. High levels of pre-loss grief, as well as low levels of perceived preparedness for death, were associated with poor post-loss adjustment (e.g., prolonged grief, depressive symptoms, etc.).

CONCLUSIONS

Caregivers with high levels of pre-loss grief and low levels of preparedness for the death of their loved one would benefit from targeted support for post-loss adjustment. Results are limited by an inconsistent operationalization of both constructs.

Effect of caregiving at end of life on grief, quality of life and general health: A prospective, longitudinal, comparative study

BACKGROUND

Determining the effect of caregiving and bereavement remains a challenge. To date, no study has employed a comparison group to investigate caregivers' grief, quality of life and general health in relation to non-caregivers.

AIM

We aimed to determine how caregivers' grief, quality of life and general health changed following death compared to non-caregivers and whether pre-death grief predicted these outcomes.

DESIGN

A prospective, longitudinal study of family caregivers and a comparison group matched for age, gender and postcode was conducted. All participants completed questionnaires at four points - once pre-death and three times post-death (3-4 months, 6-7 months and 9-10 months).

SETTING/PARTICIPANTS

Participants (N = 70) were family caregivers of persons receiving palliative care, mostly for cancer, recruited from three palliative care providers in Western Australia and matched comparisons recruited from advertisements.

RESULTS

There were significant differences between the caregivers' and comparisons' grief, general health and quality of life at pre-death, 3-4 months and 6-7 months post-death, but not at 9-10 months post-death. The rate of progression in these constructs following death was independent from the intensity of pre-death grief. However, caregiver prolonged grief score significantly predicted prolonged grief score at 6-7 and 9-10 months post-death.

CONCLUSION

It took 9-10 months for the caregivers' grief, general health and quality of life to correspond to the comparison group. These findings present an opportunity for palliative care research and practice to consider how best to support the majority of caregivers without grief complications so that their pre- and post-death support needs are realised.

Development of a home-visit nursing scale for helping spousal caregivers of terminal cancer patients develop positive perspectives of their caregiving experiences: a cross-sectional study

OBJECTIVE

Home-visit nurses play a key role in supporting the spouses of terminal cancer patients and encouraging positive perspectives of the caregiving experience. This study aimed to develop a scale to support nurses in self-assessing their practice around this important role.

DESIGN

Cross-sectional questionnaire study.

SETTING

The Home Nursing Scale to Help Spousal Caregivers (HNS-HSC) questionnaire for self-assessment of home-visit nursing to spouses was developed based on interviews with spouses and literature reviews.

PARTICIPANTS

Overall, 1500 home-visit nurses nationwide who had experience in supporting spousal caregivers and their patients in the predeath and postdeath periods were approached for participation.

MAIN OUTCOME MEASURE

Planned exploratory and confirmatory factor analyses were used to assess the underlying dimensions of the HNS-HSC; Cronbach's α was used to determine the reliability. The Japanese version of Frommelt Attitude Toward Care of the Dying Scale Form B (FAT-COD-B-J) and Grief Care scale were administered to assess convergent and discriminant validity.

RESULTS

Exploratory and confirmatory factor analyses identified 26 items on five factors: 'helping spouses plan their futures' 'helping caregivers alleviate any regrets regarding their care', 'understanding the bond between a couple', 'providing support for anticipatory grief', and 'addressing spousal caregivers' emotions after their spouses' deaths'. The final model showed acceptable goodness-of-fit indices. The Cronbach's α for the entire scale was 0.949 and exceeded 0.822 for each factor. The correlation coefficient with the FAT-COD-B-J, which served as an external validation, was 0.35. The correlation coefficients for the three grief care scales were 0.64, 0.45 and 0.72, respectively.

CONCLUSIONS

This scale is a reliable and valid tool for visiting nurses to self-assess their knowledge, skills and practice around helping spousal caregivers. By using this scale, it is expected to change nursing practice in pursuit of improving quality of life of spouses.

A comparison of psychological well-being and quality of life between spouse and non-spouse caregivers in patients with head and neck cancer: a 6-month follow-up study

OBJECTIVE

The caregivers of patients with head and neck cancer (HNC) may suffer from impaired psychological well-being and a decreased quality of life (QOL) related to the chronic burden of caring for patients' physical conditions and their mood changes. In this study, we aimed to compare the psychological well-being and QOL between spouse caregivers and non-spouse caregivers of patients with HNC over a 6-month follow-up period.

PATIENTS AND METHODS

This study was conducted using a prospective design with consecutive sampling. We recruited study subjects from the outpatient combined treatment clinic of HNC at a medical center in Southern Taiwan. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition was carried out by a trained senior psychiatrist to diagnose caregivers. Furthermore, one research assistant collected the caregivers' demographic characteristics, clinical data, and clinical rating scales, including the Short Form 36 (SF-36) Health Survey, Hospital Anxiety and Depression Scale (HADS), and Family Appearance, Pulse, Grimace, Activity, and Respiration index at the patients' pretreatment, as well as their 3- and 6-month follow-up appointments.

RESULTS

Of the 143 subjects that successfully completed the study, two-thirds of caregivers were spouses. During the 6-month follow-up period, spouse caregivers demonstrated significantly higher rates of depression diagnosis (p=0.032), higher scores in the depression subscale of HADS (HADS-D) (p=0.010), and lower SF-36 mental component summary (MCS) scores (p=0.007) than non-spouse caregivers. Furthermore, during those 6 months, HADS-D (p=0.007) and the anxiety subscale of HADS scores (p<0.001) significantly decreased, while SF-36 MCS scores significantly increased (p=0.015).

CONCLUSION

The mental health of spouse caregivers of HNC patients was more severely affected than that of non-spouse caregivers during the observed 6-month follow-up period. Therefore, clinicians need to pay more attention to caregivers' psychological distress during patient care, especially for spouse caregivers.

Family Anticipatory Grief: An Integrative Literature Review

Despite all the investment in research, uncertainty persists in anticipatory grief (AG) literature, concerning its nuclear characteristics and definition. This review aimed to synthesize recent research in order to develop further knowledge about the family experience of AG during a patient’s end of life. An integrative review was performed using standard methods of analysis and synthesis. The electronic databases Medline, Web of Knowledge, and EBSCO and relevant journals were systematically searched since 1990 to October 2015. Twenty-nine articles were selected, the majority with samples composed of caregivers of terminally ill patients with cancer. From systematic comparison of data referring to family end-of-life experience emerged 10 themes, which correspond to AG nuclear characteristics: anticipation of death, emotional distress, intrapsychic and interpersonal protection, exclusive focus on the patient care, hope, ambivalence, personal losses, relational losses, end-of-life relational tasks, and transition. For the majority of family caregivers in occidental society, AG is a highly stressful and ambivalent experience due to anticipation of death and relational losses, while the patient is physically present and needed of care, so family must be functional and inhibit grief expressions. The present study contributes to a deeper conceptualization of this term and to a more sensitive clinical practice.

Palliative Care Caregivers' Grief Mediators: A Prospective Study

The aim of the study is to identify the mediators of complicated grief in a Portuguese sample of caregivers. Grief mediators were prospectively evaluated using a list of risk factors completed by the palliative care team members, during the predeath and bereavement period. More than 6 months after the death, we applied PG-13 to diagnose prolonged grief disorder (PGD). The sample was composed of 64 family caregivers. Factors associated with PGD were insecure and dependent relationship, unresolved family crisis, and the perceived deterioration and disfigurement of the patient. The results show relational factors are relevant, but we must consider the reciprocal influence among factors, as well as their impact on specific symptoms.

Providing general practice needs-based care for carers of people with advanced cancer: a randomised controlled trial

BACKGROUND

Carers of patients with advanced cancer often have health and psychosocial needs, which are frequently overlooked.

AIM

To meet the needs of carers through a GP consultation directed by a self-completed carer needs checklist.

DESIGN AND SETTING

Randomised controlled trial in general practice with recruitment through specialist oncology clinics, in Brisbane, Australia.

METHOD

Intervention was (a) carer-GP consultations directed by a self-completed checklist of needs at baseline and 3 months; and (b) a GP-Toolkit to assist GPs to address carer-identified needs. Control group received usual care. Outcome measures were intensity of needs, anxiety and depression, and quality of life.

RESULTS

Total recruitment 392. Overall, no significant differences were detected in the number or intensity of need between groups. Compared to controls, intervention participants with baseline clinical anxiety showed improvements in mental wellbeing (P = 0.027), and those with baseline clinical depression had slower development of anxiety (P = 0.044) at 6 months. For those not anxious, physical wellbeing improved at 1 month (P = 0.040). Carers looking after patients with poor functional status had more physical needs (P = 0.037) at 1 month and more psychological and emotional needs at 3 months (P = 0.034). Those caring for less unwell patients showed improved mental wellbeing at 3 months (P = 0.022).

CONCLUSION

The intervention did not influence the number or intensity of needs reported by carers of people with advanced cancer. There was limited impact in people with pre-existing clinical anxiety and depression. For the carer of those most severely affected by advanced cancer, it drew attention to the needs arising from the caregiving role.

Cancer as a Criterion A Traumatic Stressor for Veterans: Prevalence and Correlates

The diagnosis of cancer is an uncontrollable stressor posing the threat of death and disfigurement, often followed by repeated exposure to aversive reminders in the form of noxious treatments, persisting side effects, reengagement at times of surveillance, and the threat of recurrence. The phenomenon of cancer as a traumatic stressor is explored in this study, with a focus on the prevalence and correlates of posttraumatic stress disorder (PTSD) Criterion A in a sample of 170 mostly male adults who received health care at VA Medical Centers in Boston or Houston. Participants were interviewed 6 months after diagnosis with head and neck, gastro-esophageal, or colorectal cancers. Approximately half-42.9% to 65.9% depending on cut-score used-perceived cancer to be a traumatic stressor involving actual/threatened death or injury or threat to physical integrity as well as fear, helplessness, or horror. Younger veterans and those with current combat PTSD symptoms were more likely to perceive cancer as a traumatic stressor, as were those who perceived their prognosis as uncertain; 12% had PTSD symptoms above a PCLC cut score of 50, which is similar to incidence rates of PTSD associated with other traumatic stressors. Cancer, therefore, appears to be a serious and for some, traumatic stressor, suggesting the importance of screening for cancer related PTSD in cancer survivors, particularly those most at risk.

Changes in the attitudes and behavior of relatives of breast cancer patients concerning cancer prevention and screening

BACKGROUND

Changes in the attitudes and behavior of relatives of breast cancer patients concerning cancer prevention and screening after diagnosis in a loved one were evaluated.

MATERIALS AND METHODS

Forty-three questions were used to collect data from the relatives of the breast cancer patients who had been living with their relatives for at least one year.

RESULTS

The study group was composed of 171 female relatives (median age: 43, range: 17-82 yr). After the patients were diagnosed with breast cancer, changes in the attitudes and behavior of their relatives toward the prevention and screening of cancer were evident in 78 (45.6%) of the study participants (e.g. eating habits, quit or reduced smoking , exercise habits). In addition, it was noted that some characteristics of the relatives had different effects on different attitudes and behavior.

CONCLUSIONS

Awareness on breast cancer among the relatives of breast cancer patients is useful for the management of health and social problems that can be seen in these individuals. At the same time, this information could help countries determine whether their actual level of healthcare for early cancer diagnosis, prevention, and screening are adequate.

Physical, psychosocial, relationship, and economic burden of caring for people with cancer: a review

The aim of this article is to provide an overview of the issues faced by caregivers of people diagnosed with cancer, with a particular emphasis on the physical, psychosocial, and economic impact of caring. A review of the literature identified cancer as one of the most common health conditions in receipt of informal caregiving, with the majority of caregivers reporting taking on the role of caring because of family responsibility and there being little choice or no one else to provide the care. For some, caregiving can extend for several years and become equivalent to a full-time job, with significant consequent health, psychosocial, and financial burdens. Having a better understanding of the critical and broad roles that caregivers play in the oncology setting and the impact of these on their health and well-being may assist health care professionals in supporting caregivers with these tasks and targeting services and interventions toward those most in need.

Relational mechanisms and psychological outcomes in couples affected by breast cancer: a systematic narrative analysis of the literature

INTRODUCTION

Relationships are a significant dimension of illness experience. At the couple level, partners will respond to illness as an interpersonal unit rather than individuals in isolation. Research adopting a relational perspective have focused on communication, relational coping and relationship functioning and satisfaction. To our knowledge, there is no published systematic review of literature that reports associations between a couple's relationship and psychological outcomes of patients and partners affected by breast cancer.

AIM

To review studies that examine the impact of relational mechanisms on psychological outcomes in couples affected by breast cancer and thereby improve understanding of the connections between patient, disease and family.

METHODS

A systematic search for literature was conducted, which was followed by a thematic analysis of study findings and a narrative synthesis.

RESULTS

Sixteen papers were included. Papers were published relatively recently between 1988 and 2010. Three relational components were identified: (i) couple coping, (ii) relationship functioning and satisfaction, (iii) communication. While the literature indicates associations between relational and psychological variables, with such a small evidence base, the use of different terminology and different theoretical frameworks makes it almost impossible to draw definitive conclusions about which relational component holds greatest potential for effecting change on psychological well-being.

CONCLUSIONS

While there remain many opportunities for contributing to the theoretical and empirical work in this field, there is sufficient evidence to propose a relational approach to supporting people affected by cancer.

[Quality of life and satisfaction of family caregivers in palliative care - results of postmortem interviews with bereaved family members]

INTRODUCTION

Family caregivers play an important role in palliative care. However, the number of studies focussing on the quality of life of these family caregivers is limited. The current study evaluates quality of life and satisfaction with medical care in bereaved family members.

MATERIAL AND METHODS

Comparisons were made between (1) male vs. female family caregivers (N = 44) and (2) bereaved family caregivers vs. general population (EORTC QLQ-C30). Furthermore, the satisfaction of the family caregivers with medical care was assessed after the death of their relatives (ZUF HOPE). The interviews were conducted between six and eight weeks following the death of the palliative patients.

RESULTS

Regarding quality of life, bereaved family caregivers suffered from both reduced emotional functioning and general quality of life. Female caregivers had lower functional values and stronger symptoms of insomnia, fatigue and pain than male caregivers. Bereaved family caregivers had a lower quality of life than the general population. Retrospectively, family caregivers were very satisfied with most aspects of outpatient palliative care. The only aspect criticised by the bereaved family members was a lack of psycho-social support.

CONCLUSION

Family caregivers need stronger support in order to prevent burnout and to improve outpatient care. In this context, gender differences must also be considered.

Patient and spouse illness beliefs and quality of life in prostate cancer patients

OBJECTIVE

Among married prostate cancer (PC) patients, the spouse is often the primary provider of emotional support and personal care. However, few studies have investigated spouses' illness beliefs (i.e. about disease duration and treatment control) and their impact on patients' quality of life (QOL). Spouses' beliefs about disease duration (timeline) were hypothesised to mediate relationships between spouses' treatment control beliefs and patients' QOL six months later.

METHODS

Fifty-three patients who underwent localised treatment for PC, and their spouses, completed an illness beliefs measure (the revised Illness Perception Questionnaire). Patients completed a QOL measure (the Functional Assessment of Cancer Therapy - General) six months later.

RESULTS

Spouse timeline beliefs mediated the association between spouse treatment control beliefs and patient QOL six months later (total indirect effect = -0.71, 95% CI 0.02-2.03). That is, spouse beliefs that the treatment would control their loved one's illness led to beliefs that the disease would be of shorter duration, which in turn led to improved patient QOL six months later. This relationship did not occur with patients' beliefs.

CONCLUSION

Results highlight the important influence of spouse illness beliefs over time on patient QOL with implications for clinical care and dyadic research.

Perceived Benefits and Psychosocial Outcomes of a Brief Existential Family Intervention for Cancer Patients/Survivors

This study assessed a range of benefits from participation in a brief existential intervention consisting of a semi-structured videotaped interview with cancer patients and their families designed to illuminate a life legacy for the family (the Life Tape Project [LTP]). Results indicated the majority reported intervention-specific benefits, especially in the areas of symbolic immortality (passing on personal values and philosophy), self-reflection and growth, and improved family cohesion and communication. Participants, particularly those who had perceived their cancer as a threat of death, serious injury, or threat to their physical integrity, and responded with intense fear or helplessness, also reported more general reductions in mood disturbance, improvements in aspects of well-being (including overall quality of life), satisfaction with the understanding they received, and enhanced cancer-related posttraumatic growth. In short, the LTP is a brief, inexpensive, existential intervention that can yield broad positive psychosocial changes for a majority of participants.

A GP Caregiver Needs Toolkit versus usual care in the management of the needs of caregivers of patients with advanced cancer: a randomized controlled trial

BACKGROUND

Caring for a person with progressive cancer creates challenges for caregivers. However the needs of caregivers are often not assessed or recognised by health care providers. Research is also lacking in this area, with little knowledge relating to effective strategies to address the specific needs of caregivers. This paper outlines a study protocol aimed at developing and evaluating the effectiveness of a general practice-based intervention to better meet the needs of caregivers of patients with advanced cancer.

METHODS/DESIGN

Two hundred and sixty caregivers will be randomised into each of two arms of the intervention (520 participants in total) through patients with advanced cancer attending medical and radiation oncology outpatient clinics at two tertiary hospital sites. Consenting caregivers will be followed up for six months, and telephone surveyed at baseline, 1, 3 and 6 months following their entry into the study or until the patient's death, whichever occurs first. Assessment and management of the unmet needs of caregivers in the intervention arm will be facilitated through a specifically developed general practice-based strategy; caregivers in the control group will receive usual care. Qualitative interviews will be conducted with a sample of up to 20 caregivers and 10 GPs at the conclusion of their participation, to explore their views regarding the usefulness of the intervention.

DISCUSSION

This study will determine whether systematic assessment of caregiver needs supported by caregiver-specific information for General Practitioners is effective in alleviating the unmet needs experienced by caregivers caring for patients with advanced cancer.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN43614355.

Anticipatory grieving among parents living with a child with cancer

AIM

This paper is a report of a comparative study of anticipatory grief of parents of children newly diagnosed with cancer and those whose children were diagnosed 6-12 months earlier.

BACKGROUND

Public perceptions of cancer as a fatal illness persist despite improved prognosis for children. Parents may experience feelings of despair, hopelessness, and worthlessness - the most common psychological expressions of anticipatory grief. With a focus on developing more effective therapeutic intervention, healthcare professionals have developed greater interest in the concept of anticipatory grief.

METHOD

One hundred and forty parents, divided between 'newly diagnosed' and '6-12 months after diagnosis' groups, were recruited in 2006 from two hospitals representative of the healthcare sector in Jordan. Structured interviews were conducted to assess anticipatory grief, using the Marwit and Meuser Caregiver Inventory: Childhood Cancer. Analysis was performed using t-tests.

RESULTS

Fewer than half of the parents in both groups reported being at peace with themselves and their situation in life. Parents of newly diagnosed children reported more severe anticipatory grief responses than those in the second group. No statistically significant differences were found in responses between mothers and fathers.

CONCLUSION

Healthcare professionals should encourage parents to discuss negative feelings related to their child's illness and potential outcome. Hospital policies need to include the provision and promotion of support group services for parents, and nurses should encourage parents to exploit such services.

The psychosocial impact of recurrence on cancer survivors and family members: a narrative review

AIM

This paper is a report of a review undertaken to identify, critically analyse and synthesize the psychosocial experience of cancer recurrence for survivors and family members.

BACKGROUND

Recurrence of cancer is an event after which life changes for families. Individuals move from being short- or long-term survivors of cancer to being patients once more. Families move from a state of fear of recurrence to one of uncertainty and distress as a result of the new crisis.

DATA SOURCES

MEDLINE, CINAHL and CancerLit databases were searched for the period January 1980-2007. Reference lists of papers were conducted for relevant studies. The search terms recurrence, recurrent cancer, experience, survivor and family were searched for separately and in combination.

REVIEW METHODS

A narrative review was conducted. Data were categorized in terms of issues during survivorship and concerns after recurrence.

RESULTS

Three main categories were identified that explained survivors' and families' experiences of recurrent cancer: (1) fear of recurrence during survivorship, (2) when cancer recurs: families facing new challenges and (3) distress because of recurrence.

CONCLUSION

Recurrence is a distressing experience for survivors and families because they have to face again psychosocial effects of cancer, such as uncertainty, distress and concerns about death. Care should not be addressed simply to survivors, but should include the general well-being of families beyond their survivorship and support to manage better psychosocial issues occurring when a member has a recurrence of cancer.

CBT for emotional distress of people with cancer: some personal observations

The detrimental effect of a helpless coping response on the quality of life of cancer patients is well documented. Helplessness is significantly related to emotional distress. There is also evidence that this coping response is an independent prognostic factor associated with a significantly increased risk of disease recurrence and death. These findings highlight the need to develop specific strategies to enable patients to overcome helplessness. Recent research in patients with advanced cancer indicates that emotional distress appears to be caused by low levels of positive effect. Consequently, attention should be paid to the much neglected study of positive psychological states such as fighting spirit and resilience. In the meantime, some suggestions-based on clinical experience-of inducing and fostering positive effect in our patients are outlined.

A partnership in like-minded thinking-generating hopefulness in persons with cancer

A conceptual model of a partnership in 'like-minded thinking' consists of the following components: a relationship, a shared goal with mutual agreement to work toward that goal, and reciprocal encouragement between two people. A like-minded alliance is a relationship that offers support while at the same time encourages hope and establishes a reciprocating emotional attitude of hopefulness. The discussion focuses on the principles of such a model that is designed primarily as a lay intervention for anyone who has a close friend with cancer and who wants to assist the friend in maintaining a hopeful attitude in the face of illness. While this model is not directed at healthcare professionals it may be transferable into psychosocial interventions to assist persons toward sustaining hopefulness in the context of the cancer trajectory. Much has been written in the literature about how hopelessness spawns despair for individuals who have cancer and in those near the end of life; it may even create a desire for hastened death (Breitbart W., Heller K.S.: 2003, 'Reframing Hope: Meaning-Centered Care for Patients Near the End of Life'. Journal of Palliative Medicine 6, 979-988; Jones J.M., Huggins M.A., Rydall A.C., Rodin G.M.: 2003, 'Symptomatic distress, hopelessness, and the desire for hastened death in hospitalized cancer patients', Journal of Psychosomatic Research 55, 411-418). Therefore, the aim of this paper is to explore how like-minded thinking for a person with cancer and his or her support person provides a framework for a personal shared worldview that is hope-based, meaningful and coherent.

A longitudinal study of depression, pain, and stress as predictors of sleep disturbance among women with metastatic breast cancer

OBJECTIVE

Sleep disturbances are common among women with breast cancer and can have serious consequences. The present study examined depression, pain, life stress, and participation in group therapy in relation to sleep disturbances in a sample of women with metastatic breast cancer.

METHODS

Ninety-three women with metastatic breast cancer participated in a large intervention trial examining the effect of the group therapy on their symptoms. They completed measures of depression, pain, life stress, and sleep disturbance at baseline, 4, 8 and 12 months.

RESULTS

The results showed that higher initial levels of depression at baseline predicted problems associated with getting up in the morning, waking up during the night, and daytime sleepiness. Increases in depression over the course of 12 months were associated with fewer hours of sleep, more problems with waking up during the night and more daytime sleepiness. Higher levels of pain at baseline predicted more problems getting to sleep. Increases in pain predicted more difficulty getting to sleep and more problems waking up during the night. Greater life stress at baseline predicted more problems getting to sleep and more daytime sleepiness.

CONCLUSIONS

Depression, pain, and life stress scores were each associated with different types of negative change in self-reported sleep disturbances. Depression, especially worsening depression, was associated with the greatest number of types of negative change. The relationships found between sleep disturbance and depression, pain, and life stress suggest specific ways to address the problem of sleep disturbance for women with metastatic breast cancer and show how different types of disturbed sleep may be clinical markers for depression, pain, or life stress in this population.