Lung cancer, caring for the caregivers. A qualitative study of providing pro-active social support targeted to the carers of patients with lung cancer

Echoes of Support: A Qualitative Meta-Synthesis of Caregiver Narratives in Lung Cancer Care

Lung cancer stands as one of the prevalent cancers, impacting both men and women globally. Family caregivers, deeply involved in the care of individuals affected by this disease, often endure heightened distress and struggle to navigate the manifold challenges associated with caregiving. Understanding the intricate experiences and challenges of caregivers in the realm of lung cancer care is critical, given its profound impact on their well-being and the quality of patient care. This study aimed to comprehensively examine and synthesize qualitative data concerning caregiver experiences within the context of lung cancer. Six databases were systematically searched for studies with qualitative findings relevant to caregivers and lung cancer. Seventeen studies were included, and findings were reviewed and synthesized. The main challenges identified were: 'Information accessibility', 'Dual roles and family dynamics', 'Coping with emotional challenges and uncertainty', and 'Need for support networks'. These findings underscore the profound challenges faced by caregivers, shedding light on the substantial impact of cancer on their well-being and functionality. Moreover, the study accentuates the pressing need for tailored support systems that can address the emotional toll and information needs of caregivers. This emphasis on supportive interventions is vital to enhance the quality of care and overall well-being for both patients and caregivers within the lung cancer care continuum.

Public health palliative care interventions that enable communities to support people who are dying and their carers: a scoping review of studies that assess person-centered outcomes

Background

Public health palliative care views communities as an integral part of care delivery at the end of life. This community-provider partnership approach has the potential to improve end-of-life care for people who are dying and their carers.

Objective

To identify and appraise the current literature related to public health interventions that enable communities to support people who are dying and their carers.

Methods

A scoping review was conducted, applying Arksey and O'Malley's methods. Data was extracted and synthesized using narrative techniques, and results are reported using PRISMA guidelines.

Results

The search yielded 2,902 results. Eighteen met inclusion criteria and were included in the analysis. Interventions were categorized according to their target population: people with life-limiting illness (ex. facilitated social interaction, helplines and guided discussions about death and dying); carers (ex. social support mapping, psychoeducation, and community resource identification and facilitation); or dyads (ex. reminiscence activities, practical and emotional support from volunteers, online modules to bolster coping mechanisms). Public health palliative care approaches were delivered by key community stakeholders such as community health workers, volunteers, peer mentors, and pre-established support groups. Despite reported challenges in identifying appropriate tools to measure effectiveness, studies report improvement in quality of life, loneliness, social support, stress and self-efficacy.

Conclusion

We found that community-engaged palliative care interventions can lead to appreciable changes in various outcomes, though it was difficult to determine in which contexts this approach works best because of the dearth of contextual information reported. Based on the varied design and implementation strategies, it is clear that no one method for enhancing end of life care will benefit all communities and it is crucial to engage community members at all stages of the design and implementation process. Future research should be grounded in appropriate theory, describe contextual differences in these communities, and should specifically examine how demographics, resource availability, and social capital might impact the design, implementation, and results of public health palliative care interventions.

Caregivers of patients with malignant pleural mesothelioma: who provides care, what care do they provide and what burden do they experience?

PURPOSE

There are limited data on the impact of caregiving for patients with malignant pleural mesothelioma (MPM) on the caregiver. We aimed to identify the demographic characteristics of these caregivers, the caregiving activities they perform and how caregiving burden impacts their work productivity and overall activity.

METHODS

This cross-sectional study collected data from caregivers of patients with MPM across France, Italy, Spain and the United Kingdom January-June 2019. Caregiver demographics, daily caregiving tasks and the impact of caregiving on physical health was collected via questionnaire. The Zarit Burden Interview (ZBI) was used to assess caregiver burden and the Work Productivity and Activity Impairment questionnaire (WPAI) assessed impairment at work and during daily activities. Analyses were descriptive.

RESULTS

Overall, 291 caregivers provided data. Caregivers were mostly female (83%), living with the patient (82%) and their partner/spouse (71%). Caregivers provided over five hours of daily emotional/physical support to patients. ZBI scores indicated 74% of caregivers were at risk of developing depression. Employed caregivers had missed 12% of work in the past seven days, with considerable presenteeism (25%) and overall work impairment (33%) observed. Overall, the mean activity impairment was 40%.

CONCLUSION

Caregivers provide essential care for those with MPM. We show caregiving for patients with MPM involves a range of burdensome tasks that impact caregivers' emotional health and work reflected in ZBI and WPAI scores. Innovations in the management of MPM must account for how caregivers may be impacted and can be supported to carry out this important role.

Family caregiving experiences with hospice lung cancer patients compared to other cancer types

BACKGROUND

Family caregivers of cancer patients are very involved in communication with healthcare teams; however, little is known about their experiences. Limited information is known about how the type of cancer patients have impact caregiving experiences.

OBJECTIVES

This study seeks to compare the caregiving experience of caregivers of hospice lung cancer patients with hospice caregivers of patients with all other cancer types.

METHOD

This study is based on a secondary analysis of data generated from a parent study evaluating a behavioral intervention with caregivers of hospice cancer patients.

RESULTS

When comparing caregiving experiences by patient diagnosis, significant differences were found in caregivers of hospice lung cancer demographics and experiences with caregiver-centered communication. Specifically, caregivers of lung cancer patients have significantly more trouble with exchange of information, fostering relationships, and decision making with their hospice team.

CONCLUSION

More research is needed to understand the impact of lung cancer on caregiver centered communication and the necessary interventions required to address these issues.

"You just need to learn": A qualitative study on the information needs of family caregivers of people with lung cancer

PURPOSE

Lung cancer caregivers often face considerable duties and responsibilities yet frequently feel unprepared for this role. The current study is the first to purposefully explore the information needs of family caregivers throughout the lung cancer trajectory.

METHODS

Semi structured interviews were conducted with nine lung cancer caregivers (7 female) including those bereaved within five years. Interviews were transcribed verbatim and analysed using thematic analysis.

RESULTS

Four main themes emerged: 1) "He knew that I'd ask questions, you see": Information-gathering during appointments; 2) "You can't really ask that with mum there": Discordant information needs between caregiver and the person with lung cancer; 3) "Trying to get the answers": Seeking information beyond the hospital; 4) "It took a while to kind of get into": Learning to adjust to changing roles and circumstances.

CONCLUSIONS

Lung cancer caregivers need reliable information to feel competent in their new roles and responsibilities. In the current study, there were a number of areas in which information was lacking, including those related to treatment, side effects, care services and symptom management. The provision of appropriate and timely information to lung cancer caregivers can ensure they feel supported in their roles and responsibilities. This will in turn benefit lung cancer survivors by ensuring that they understand information in consultations with oncology nurses and other health professionals and receive appropriate support from their caregivers that enhances their quality of life along the cancer trajectory.

Variables associated with distress amongst informal caregivers of people with lung cancer: A systematic review of the literature

OBJECTIVE

Informal caregivers of people with lung cancer often experience a substantial care burden and associated negative consequences due to the often-contracted course of the disease. The objective of this review was to systematically examine the evidence on the factors associated with lung cancer caregiver distress.

METHODS

Five databases (MEDLINE, CINAHL, EMBASE, PsychINFO and Web of Science) were searched for studies investigating factors associated with distress amongst caregivers of people with lung cancer. Empirical studies published up to July 2020 were included if they measured distress using a valid and reliable measure and examined its association with at least one other factor, with a sample of 50 or more caregivers.

RESULTS

Thirty publications describing 27 studies (16 cross-sectional; 6 prospective; 8 intervention) involving 3744 caregivers (primarily spouse or adult child) were included. A narrative synthesis of the findings is presented due to heterogeneity in study design, variables measured and analyses conducted. Patient variables associated with greater distress included: stage of cancer and quality of spousal relationship. Caregiver variables associated with higher distress included: social support, coping strategies and self-efficacy.

CONCLUSIONS

Several variables were associated with distress amongst lung cancer caregivers. Understanding these variables could inform the development of interventions that will enable caregivers to care effectively while maintaining their own well-being. Screening for distress among caregivers may identify those caregivers who would benefit from early intervention.

Pilot Testing of a Brief Couple-Based Mind-Body Intervention for Patients With Metastatic Non-Small Cell Lung Cancer and Their Partners

CONTEXT

Given the generally incurable nature of metastatic lung cancer, patients and their spouses/partners are at risk for psychological and spiritual distress. To address this concern, we developed a couple-based mind-body (CBMB) intervention.

OBJECTIVES

This formative research aimed at examining the intervention's acceptability and initial efficacy in patients with metastatic lung cancer undergoing treatment and their spouses.

METHODS

Intervention content evaluation sessions and an ensuing single-arm trial were conducted. To evaluate intervention content, participants performed intervention exercises and then participated in semistructured interviews and completed written evaluations. In the single-arm trial, four intervention sessions were delivered over two weeks, focusing on cultivating mindfulness, interpersonal connection, gratitude, and purpose. Newly recruited couples completed measures of depressive symptoms, cancer distress, spiritual well-being, and sleep disturbances before and after the intervention.

RESULTS

Content evaluations by seven dyads of patients and their partners revealed high acceptability ratings for the CBMB intervention (e.g., all participants would recommend the intervention). Consent and adherence rates (54% and 67%, respectively) were acceptable in the single-arm trial. All patients (n = 7 dyads; 67% male; mean age, 55 years) and partners (33% male; mean age, 59 years) rated the intervention as useful. Paired t-test analyses revealed large effect sizes for reduced sleep disturbances (d = 1.83) and medium effect sizes for cancer-specific distress (d = 0.61) for patients and large effect sizes for depressive symptoms (d = 0.90) for partners.

CONCLUSION

Based on these results, the CBMB intervention appears to be acceptable and subjectively useful. In addition, we observed preliminary evidence of quality of life gains in both patients and their partners.

Involvement of patients with lung and gynecological cancer and their relatives in psychosocial cancer rehabilitation: a narrative review

INTRODUCTION

Getting cancer is stressful for most patients and their relatives, and research has shown that psychosocial support is needed. Still, cancer care fails to appropriately address psychosocial problems associated with cancer. Research on this topic is often seen from the perspective of either the patient or the relative, even though it is suggested that psychosocial support is beneficial for the patient and the relative as a pair. Furthermore, research on the need for psychosocial support rarely involves patients with gynecological and lung cancer and their relatives, even though they often suffer from isolation and stigmatization. The aim of this review was therefore to summarize knowledge about psychosocial support with regard to individual needs, involvement of significant others, and providers of psychosocial support focusing on this specific population.

METHOD

A narrative review procedure was chosen. This method is a specific kind of review, which summarizes, explains, and interprets evidence on a selected topic. The review process was structured according to typical scholarly articles with attention to the search and review process.

RESULTS

A total of 16 studies were included in the review. The studies were divided into two main categories: (1) studies focusing on needs for psychosocial support; and (2) studies focusing on interventions. The needs studies were analyzed, and three themes emerged: the needs of the patient and the significant other across the cancer trajectory; the needs of the significant other as a carer; and needs and ongoing and tailored support. The intervention studies were directed toward the patient and the relative, the patient, or the relative. Five interventions comprising various forms of support that were purely supportive and were carried out by healthcare professionals were identified.

CONCLUSION

There were overlaps between the needs of the patient and the relative, but there were also distinctive characteristics of the needs in the two groups. The needs varied during the cancer trajectory, and we therefore recommend that support be offered continuously. It was also evident that the relatives should be involved in the patients' care and that the involvement was beneficial for both the patient and the relative.

Individual difficulties and resources - a qualitative analysis in patients with advanced lung cancer and their relatives

PURPOSE

Lung cancer is a disease with a high percentage of patients diagnosed in an advanced stage. In a situation of palliative treatment, both patients and their relatives experience diverse types of distress and burden. Little research has been done to identify the individual difficulties and resources for patients with advanced lung cancer and their relatives. Especially, standardized questionnaire-based exploration may not assess the specific distressing issues that pertain to each individual on a personal level. The purpose of this qualitative study is to explore and compare individual difficulties and resources for lung cancer patients and their relatives within the palliative care context.

METHODS

Data were collected by qualitative interviews. A total of 18 participants, nine patients diagnosed with advanced lung cancer (International Classification of Diseases, tenth edition, diagnosis C-34, stage IV) starting or receiving palliative treatment and nine relatives, were interviewed. Data were interpreted through qualitative content analysis.

RESULTS

We identified four main categories of difficulties: communication and conflicts, home and everyday life, thinking about cancer, and treatment trajectory. In general, difficulties were related to interpersonal relationships as well as to impact of chemotherapy. Family, professional caregivers, and social life were significant resources and offered support to both patients and relatives.

CONCLUSION

Results suggest that patient and relative education could reduce difficulties in several areas. Patients seem to struggle with the fear of not having any perspective in therapy. Relatives seem to experience helplessness regarding their partner's deterioration and have to handle their own life and the care work simultaneously. The most important resource for both patients and relatives is their family. In addition, professional lung cancer nurses support relatives in an emotional and organizational way. Intense supportive care for relatives should be standardized.

The lung cancer patient, the pneumologist and palliative care: a developing alliance

Considerable evidence is now available on the value of palliative care for lung cancer patients in all stages and at all times during the course of the disease. However, pneumologists and their institutions seem to be widely in arrears with the implementation of palliative care concepts and the development of integrated structures.

This review focuses on the available evidence and experience of various frequently unmet needs of lung cancer patients, especially psychological, social, spiritual and cultural ones. A PubMed search for evidence on these aspects of palliative care as well as on barriers to the implementation, on outcome parameters and effectiveness, and on structure and process quality was performed with a special focus on lung cancer patients.

As a consequence, this review particularly draws pneumologists’ attention to improving their skills in communication with the patients, their relatives and among themselves, and to establish team structures with more far-reaching competences and continuity than existing multilateral cooperations and conferences can provide. Ideally, any process of structural and procedural improvement should be accompanied by scientific evaluation and measures for quality optimisation.

Integrating social work into palliative care for lung cancer patients and families: a multidimensional approach

Lung cancer patients and their family caregivers face a wide range of potentially distressing symptoms across the four domains of quality of life. A multidimensional approach to addressing these complex concerns with early integration of palliative care has proven beneficial. This article highlights opportunities to integrate social work using a comprehensive quality of life model and a composite patient scenario from a large lung cancer educational intervention National Cancer Institute-funded program project grant.

Family caregiver burden, skills preparedness, and quality of life in non-small cell lung cancer

PURPOSE/OBJECTIVES

To describe burden, skills preparedness, and quality of life (QOL) for caregivers of patients with non-small cell lung cancer (NSCLC), and describe how the findings informed the development of a caregiver palliative care intervention that aims to reduce caregiver burden, improve caregiving skills, and promote self-care.

DESIGN

Descriptive, longitudinal.

SETTING

A National Cancer Institute-designated comprehensive cancer center in southern California.

SAMPLE

163 family members or friends aged 18 years or older and identified by patients as being a caregiver.

METHODS

All eligible caregivers were approached by advanced practice nurses during a regularly scheduled patient clinic visit. Informed consent was obtained prior to study participation. Outcome measures were completed at baseline and repeated at 7, 12, 18, and 24 weeks. Descriptive statistics were computed for all variables, and one-way repeated-measures analysis of variance was used to test for change over time for all predictor and outcome variables.

MAIN RESEARCH VARIABLES

Caregiver burden, skills preparedness, psychological distress, and QOL.

FINDINGS

Caregivers were highly functional. Caregiver burden related to subjective demands increased significantly over time. Perceived skills preparedness was high at baseline but decreased over time. Psychological distress was moderate but increased in the study period. Overall QOL was moderate at baseline and decreased significantly over time. Psychological well-being had the worst QOL score.

CONCLUSIONS

Caregivers experienced high levels of caregiver burden and reported deteriorations in psychological well-being and overall QOL.

IMPLICATIONS FOR NURSING

Oncology nurses need to ensure that caregivers receive information that supports the caregiving role throughout the cancer trajectory.

KNOWLEDGE TRANSLATION

Although family caregivers are profoundly impacted by a loved one's lung cancer diagnosis, the literature about caregiver burden, skills preparedness, and QOL is limited. Current evidence suggests that family caregivers can be negatively impacted by a loved one's cancer diagnosis. Caregiver-specific support interventions are needed to eliminate the burden of caregiving in lung cancer.

Why do patients and caregivers seek answers from the Internet and online lung specialists? A qualitative study

Background

Since its launch in 2003, the Dutch Lung Cancer Information Center’s (DLIC) website has become increasingly popular. The most popular page of the website is the section “Ask the Physician”, where visitors can ask an online lung specialist questions anonymously and receive an answer quickly. Most questions were not only asked by lung cancer patients but also by their informal caregivers. Most questions concerned specific information about lung cancer.

Objective

Our goal was to explore the reasons why lung cancer patients and caregivers search the Internet for information and ask online lung specialists questions on the DLIC’s interactive page, “Ask the Physician”, rather than consulting with their own specialist.

Methods

This research consisted of a qualitative study with semistructured telephone interviews about medical information-seeking behavior (eg, information needs, reasons for querying online specialists). The sample comprised 5 lung cancer patients and 20 caregivers who posed a question on the interactive page of the DLIC website.

Results

Respondents used the Internet and the DLIC website to look for lung cancer–related information (general/specific to their personal situation) and to cope with cancer. They tried to achieve a better understanding of the information given by their own specialist and wanted to be prepared for the treatment trajectory and disease course. This mode of information supply helped them cope and gave them emotional support. The interactive webpage was also used as a second opinion. The absence of face-to-face contact made respondents feel freer to ask for any kind of information. By being able to pose a question instantly and receiving a relatively quick reply from the online specialist to urgent questions, respondents felt an easing of their anxiety as they did not have to wait until the next consultation with their own specialist.

Conclusions

The DLIC website with its interactive page is a valuable complementary mode of information supply and supportive care for lung cancer patients and caregivers.

Quality of life of family caregivers and challenges faced in caring for patients with lung cancer

Family caregivers (FCGs) of patients with lung cancer face multiple challenges that affect their quality of life and well-being. Whether challenged physically, emotionally, socially, or spiritually, distress in one area may compound challenges in other areas. To maintain function and health of FCGs as they provide valuable care for the health and well-being of the patient, attention must be given to the needs of FCGs for support and education. The purpose of this article is to describe the multifaceted challenges that FCGs of patients with lung cancer experience using case studies selected from a National Cancer Institute-funded program project. The cases are discussed in terms of how the FCG's quality of life is impacted by the caregiver role, as well as how stressors in one or more domains of quality of life compound difficulties in coping with the demands of the role. The importance of the oncology nurse's assessment of FCGs' needs for support, education, and self-care through the lung cancer illness trajectory is discussed while presenting accessible community resources to meet those needs.

The role of blame in the psychosocial adjustment of couples coping with lung cancer

BACKGROUND

Lung cancer patients and their spouses may engage in blame attributions regarding the cancer cause, which may adversely affect their psychological adjustment.

PURPOSE

The aim of this study was to examine whether dyadic adjustment and network support moderate the association between blame and distress in couples affected by lung cancer.

METHODS

Patients and their spouses completed questionnaires within 1 month of treatment initiation (baseline) and at 6-month follow-up.

RESULTS

Multilevel modeling of data from 158 couples revealed that, at baseline, dyadic adjustment moderated the association between blame and distress for patients but not spouses (p < 0.05). Controlling for baseline distress, baseline blame predicted later distress (p < 0.05) for both patients and spouses regardless of dyadic adjustment. Network support moderated this association at follow-up.

CONCLUSION

For patients experiencing low dyadic adjustment, blame was associated with increased distress. Not initially but later, network support may protect against low levels but not high levels of blame in patients and spouses.

Caregivers' quality of life and quality of services for children with cancer: a review from iran

Objective:

Caregivers of cancer patients are exposed to different types of psychosocial stress which influence their quality of life. The purposes of this study were to assess quality of life in caregivers of children with cancer and to investigate the relationship between the caregivers’ quality of life and quality of services in the social work section.

Method:

125 caregivers were recruited. Quality of life was measured by the Iranian version of the WHOQOL-BREF questionnaire and data concerning service quality were obtained from the Iranian version of the SERVQUAL questionnaire.

Findings:

Scores in physical health, psychological status and environmental conditions for caregivers of children with cancer were significantly lower than the general population. There was a negative correlation between the tangible domain of SERVQUAL and the psychological status and environmental conditions of quality of life. The tangible dimension was the only aspect of service quality to predict caregivers’ quality of life regarding psychological status and environmental conditions.

Conclusion:

Caregivers of children with a disease are care consumers and, like all consumers, they expect good service. Delivering high quality services consistently is difficult but profitable for a service organization. In other words, trying to deliver more appropriate services than patients expect to receive from their social work care is one of the most reliable ways to promote caregivers’ satisfaction and quality of life.

How can informal caregivers in cancer and palliative care be supported? An updated systematic literature review of interventions and their effectiveness

INTRODUCTION

Informal caregivers needs in cancer/advanced disease are largely unmet. The science of carer intervention evaluation is methodologically challenging, and the evidence historically weak.

OBJECTIVE

This systematic review updates an earlier effectiveness review to determine both the effectiveness of subsequently published intervention studies, and the current state of science.

METHOD

The evidence was identified and appraised using a comprehensive search strategy. Articles were searched from 2001 to 2010 using the following electronic databases: Medline, PsychINFO and CINAHL. Inclusion criteria were studies reporting intervention data for informal adult caregivers of a patient with a diagnosis of cancer or receiving palliative care. The design and evidence rigour were assessed using the Jadad Rating Scale, and the Quality Rating Scale.

RESULTS

33 studies met inclusion criteria. From the original review, an encouraging increase was identified in the number of evaluations (from 8 to 33), in carer-specific interventions (from 6 to 17) and in the robustness of the study design (an increase from 2 to 12 studies with before/after measures, comparison groups and prospective data).

CONCLUSIONS

The evidence suggests a rapid increase in the number of robust intervention studies. However, the range of models remains narrow in relation to caregivers' needs and preferences.

Complicated grief symptoms in caregivers of persons with lung cancer: the role of family conflict, intrapsychic strains, and hospice utilization

Guided by a stress process conceptual model, this study examines social and psychological determinants of complicated grief symptoms focusing on family conflict, intrapsychic strains, and the potential moderating effect of care quality and hospice utilization. Relying on data from 152 spouse and adult child lung cancer caregiver survey respondents, drawn from an ancillary study of the Assessment of Cancer CarE and SatiSfaction (ACCESS) in Wisconsin, hierarchical multiple regression analysis was used to examine determinants of complicated grief. After controlling for contextual factors and time since death, complicated grief symptoms were higher among caregivers with less education, among families with lower prior conflict but higher conflict at the end-of-life, who had family members who had difficulty accepting the illness, and who were caring for patients with greater fear of death. Additionally, hospice utilization moderated the effect of fear of death on complicated grief. Findings suggest that family conflict, intrapsychic strains, and hospice utilization may help to explain the variability found in complicated grief symptoms among bereaved caregivers. Implications for enhancing complicated grief assessment tools and preventative interventions across the continuum of cancer care are highlighted.

Information needs of informal caregivers of older adults with chronic health conditions

OBJECTIVE

To systematically examine current evidence pertaining to information needs of informal caregivers of older adults with chronic health conditions.

METHODS

Structured search of MEDLINE, MEDLINE IN-PROCESS, CINAHL, and PsycINFO databases to identify studies of caregiver information needs, followed by data extraction and syntheses.

RESULTS

The 62 articles that met the stated inclusion criteria highlighted extensive needs among informal caregivers for practical, accessible, timely information.

CONCLUSION

The identified information needs of informal caregivers can inform organizations and agencies that seek to provide disease and illness-related information.

PRACTICE IMPLICATIONS

Existing evidence supports the implementation of a health information delivery system designed to meet the needs of informal caregivers of older adults with chronic health conditions.

Archetypal trajectories of social, psychological, and spiritual wellbeing and distress in family care givers of patients with lung cancer: secondary analysis of serial qualitative interviews

OBJECTIVE

To assess if family care givers of patients with lung cancer experience the patterns of social, psychological, and spiritual wellbeing and distress typical of the patient, from diagnosis to death.

DESIGN

Secondary analysis of serial qualitative interviews carried out every three months for up to a year or to bereavement.

SETTING

South east Scotland.

PARTICIPANTS

19 patients with lung cancer and their 19 family carers, totalling 88 interviews (42 with patients and 46 with carers).

RESULTS

Carers followed clear patterns of social, psychological, and spiritual wellbeing and distress that mirrored the experiences of those for whom they were caring, with some carers also experiencing deterioration in physical health that impacted on their ability to care. Psychological and spiritual distress were particularly dynamic and commonly experienced. In addition to the "Why us?" response, witnessing suffering triggered personal reflections in carers on the meaning and purpose of life. Certain key time points in the illness tended to be particularly problematic for both carers and patients: at diagnosis, at home after initial treatment, at recurrence, and during the terminal stage.

CONCLUSIONS

Family carers witness and share much of the illness experience of the dying patient. The multidimensional experience of distress suffered by patients with lung cancer was reflected in the suffering of their carers in the social, psychological, and spiritual domains, with psychological and spiritual distress being most pronounced. Carers may need to be supported throughout the period of illness not just in the terminal phase and during bereavement, as currently tends to be the case.