Chi, N., Demiris, G., Lewis, F.M., Walker, A.J., & Langer, S.L. (2016). Behavioral and educational interventions to support family caregivers in end-of-life care. American Journal of Hospice and Palliative Medicine, 33, 894–908.
STUDY PURPOSE: To collect, review, and report on the current evidence on behavioral and educational interventions used to support family caregivers of patients who are receiving end-of-life care
TYPE OF STUDY: Systematic review
PHASE OF CARE: End-of-life care
APPLICATIONS: Palliative care
Educational and behavioral interventions for caregivers of patients with advanced cancer at the end of life appear to be effective. They are difficult to study because of high attrition rates, in part because of the point in the illness trajectory in which one is asked to participate. However, increasing evidence supports that these types of interventions will benefit caregiver competence and well-being. Ongoing study is needed to identify more specifics about the interventions, what makes them successful, and the methods of delivery, the timing, and the dose, as well as what outcomes should be measured and with what instruments. Perhaps some consistency should be developed. The cost-effectiveness of interventions should be considered as well.
Educational and behavioral interventions for caregivers appear to be helpful in improving caregiver outcomes, with statistical improvement seen in a variety of caregiver domains. The type of intervention strategy used seems to influence the specificity and breadth of outcomes influenced, with some showing more results on competence and knowledge and others expanding beyond competence and knowledge to include an additional impact on the emotional well-being and quality of life of the caregiver. All three types of interventions appear to have positive impact. Care must be taken when choosing an intervention, considering what outcome is desire.
Langford, D. J., Lee, K., & Miaskowski, C. (2012). Sleep disturbance interventions in oncology patients and family caregivers: a comprehensive review and meta-analysis. Sleep Medicine Reviews, 16, 397–414.
To synthesize findings from intervention studies for sleep disturbance in patients with cancer and their caregivers.
Databases searched were PubMed, CINAHL, and PsycINFO.
Search keywords were sleep, sleep disturbance, insomnia, intervention, cancer, oncology, and caregivers.
Studies dated through 2010 that evaluated sleep disturbance/sleep quality as the primary or secondary outcome were included.
Intervention groupings analyzed via meta-analysis included cognitive-behavioral therapy (CBT), education, exercise, and complementary and alternative therapies. Effect sizes appeared to be slightly over 1.0 for CBT, close to 0 for education, slightly over 1.0 for exercise, and slightly over 0 for complementary and alternative therapies. Specific effect sizes were only shown graphically, and actual data were not presented. No separate analysis of caregiver effects could be determined. Modes of delivery of interventions varied widely across studies.
Findings suggest at least moderate effects of CBT and exercise for improvement in sleep disturbances for patients with cancer. No substantial effects of exercise and education were demonstrated.
The review was limited by the lack of any data regarding heterogeneity in the meta-analysis, variability of interventions, and modes of delivery to enable any firm conclusions.
Insufficient evidence was provided to draw any conclusions regarding intervention effects for caregivers.
Northouse, L.L., Katapodi, M.C., Song, L., Zhang, L., & Mood, D.W. (2010). Interventions with family caregivers of cancer patients: Meta-analysis of randomized trials. CA: A Cancer Journal for Clinicians, 60, 317–339.
To provide a meta-analysis that examines interventions delivered to family caregivers of patients with cancer in published randomized controlled trials and their effects on multiple caregiver outcomes
The final sample of studies used in the meta-analysis was 29, including a total of 3,495 subjects across all studies.
Intervention Types
Appraisal Domain Results
Coping Resources Domain
Quality of Life Domain
Effect of Intervention Characteristics
Nurses participated in delivery of the intervention in about half of the studies examined. Interventions focused on three broad areas: patient caregiving, marital/family care, and caregiver care, although there was considerable variability in the emphasis of each area in all studies and many interventions focused mostly on the patient, with a peripheral addressing of caregiver needs. The meta-analysis noted there is a consensus that these are essential content for caregiver-focused intervention protocols. Many of the 29 studies used theoretical models to structure their protocols and had plans to assess integrity of the interventions. Interventions were found to not be effective in decreasing caregiver depression, perhaps a result of the type of cancer or high predominance of females in the 29 studies. On the other hand, interventions aimed at improving caregiver coping were more effective, particularly if the intervention included more sessions and lasted a longer time. Coping outcomes improved more often with face-to-face or group-delivered interventions and if the focus was on promoting active caregiver coping and reducing avoidance and denial behaviors. Although the meta-analysis showed a large intervention effect with decreasing caregivers’ need for knowledge (and most studies had a significant educational component), few studies measured caregiver change in knowledge as an outcome.
This meta-analysis of 29 studies, with variant use of theoretical models, offers insight into effective interventions that improve the life of cancer caregivers and those for whom they care for. Despite the diversity in interventions found in the studies, caregivers reported better outcomes in illness appraisal, coping resources, and quality of life following research study involvement. Positive and long-term intervention effects occurred for caregiver coping, self-efficacy, and distress/anxiety outcomes across all studies. Continued emphasis must be placed on weaving theoretical models throughout studies to generate hypotheses, select components of intervention to ensure integrity, and identify outcomes.
O'Toole, M.S., Zachariae, R., Renna, M.E., Mennin, D.S., & Applebaum, A. (2016). Cognitive behavioral therapies for informal caregivers of patients with cancer and cancer survivors: A systematic review and meta-analysis. Psycho-Oncology. Advance online publication.
STUDY PURPOSE: To evaluate the overall effect of interventions using cognitive behavioral therapy (CBT) components and to explore possible moderators of this effect, including trial design, outcomes evaluated, demographic variables, intervention duration and modality of delivery, illness-related variables among patients, and study quality
TYPE OF STUDY: Meta-analysis and systematic review
A small statistically significant effect of CBTs (Hedges' g = 0.08, p = 0.014) was revealed, which disappeared when RCTs were evaluated alone (Hedges' g = 0.04, p = 0.2). A number of variables were explored as moderators. Only the percentage of female participants was positively associated with the effect size. More specifically, females were more responsive to CBT interventions with an effect on physical health and mastery.
Based on the negligible effect of CBTs across outcomes, future studies should consider moving beyond traditional CBT methods, as these do not appear efficacious. Future interventions should orient toward advances in the basic affective sciences and derived therapies to better understand and treat the emotional struggles experienced by ICs.
Translating CBT interventions to practice has been a challenge in the nursing discipline. These findings suggest that, although CBT techniques like problem solving could be meaningful, CBT may be one component of a mulitmodual intervention for the best effect for the family caregiver. Nurses should also recognize that gender may influence the possible benefit patients experience from a CBT intervention.
Bevans, M., Castro, K., Prince, P., Shelburne, N., Prachenko, O., Loscalzo, M., . . . Zabora, J. (2010). An individualized dyadic problem-solving education intervention for patients and family caregivers during allogeneic hematopoietic stem cell transplantation: A feasibility study. Cancer Nursing, 33(2), e24–e32.
To evaluate the feasibility of providing an individualized problem-solving education intervention to patient-caregiver dyads during stem cell transplantation
The intervention was based on the COPE model involving creativity, optimism, planning, and expert information. Sessions used an active problem identified by each dyad to apply the COPE problem solving model. The clinician interventionist guided the dyad in problem identification, review of related expert information, and development of a plan to address the problem. Scripting, peer supervision, and session audiotapes were used to ensure integrity of the intervention. Data were collected with a log and subject interviews. Audiotaped interviews were transcribed for analysis, and a second transcriber did quality monitoring on 100% of the tapes to ensure accuracy and completeness. Four sessions were provided—prior to transplantation, at the time of hospital discharge, two weeks after discharge, and four weeks after discharge. Dyads also attended usual admission and discharge education classes provided as part of usual care. Data collection occurred at baseline, each of these time points, and six weeks after initial hospital discharge.
A single group repeated measures mixed method design was used.
Ninety-four percent of scheduled sessions were completed. Session length was a median of 45 minutes, ranging from 15–60 minutes. Clinicians reported session scheduling as the greatest challenge.
Themes that emerged from qualitative analysis were “opportunity to talk,” “expert information,” and “creative thinking.” Effect sizes for each measure for patients and caregivers over time were reported. Subjects’ SPSI-R scores were within normative group range, suggesting effective problem solving ability prior to the intervention. Patient baseline distress was significantly related to a change in SPSI-R scores over the course of the study (r = 0.8, p = 0.031). It was noted that the caregiving experience was not limited to a spouse, and the study experience pointed to the need to expand the network to all those involved. Effect sizes of change in measures were provided, but there were no differences in outcomes over time.
Provision of this type of intervention appears to be feasible, and although scheduling sessions was shown to be challenging to clinicians, a high proportion of sessions were completed. The study provides some initial effect size data in the outcome variables measured. Authors identified the need to include a broader network of caregivers and further explore alternative timing and scheduling approaches for this type of intervention.
Findings suggest that provision of individualized counseling and problem solving sessions using the COPE model is feasible with patients who have undergone stem cell transplant. In provision of caregiver support, nurses need to consider involving a number of caregivers because the network of individuals who are involved is often beyond a dyad. A broader involvement may also be helpful in dealing with session scheduling difficulties because of competing spouse priorities. Further research is warranted to evaluate effect sizes, different dosage, and timing of such interventions and involving various cultural groups. Further research including control groups is warranted as other similar studies have shown improvement in various patient and caregiver measures as a function of time alone.
Boele, F.W., Hoeben, W., Hilverda, K., Lenting, J., Calis, A.L., Sizoo, E.M., . . . Klein, M. (2013). Enhancing quality of life and mastery of informal caregivers of high-grade glioma patients: A randomized controlled trial. Journal of Neuro-Oncology, 111, 303–311.
To determine factors that impact health-related quality of life (HRQOL) and mastery of caregivers of patients with high-grade glioma, and to investigate if a structured intervention consisting of psycho-education and cognitive behavioral therapy (CBT) leads to an improvement in the mental component of HRQOL and mastery of caregivers
Caregiver dyads randomly were assigned to the intervention group or care as usual group. The intervention group consisted of six one-hour sessions with a psychologist for CBT and psycho-education regarding disease-specific symptoms. Participants completed questionnaires concerning their perception of the patients' HRQOL, neurologic functioning, cognitive functioning, their own HRQOL perceptions, and feelings of caregiver mastery at baseline (prior to randomization) and every two months thereafter until eight months later, five times total.
Caregivers' HRQOL and caregiver mastery were associated with patient-related factors at baseline. A positive correlation was found between a positive mental functioning (MCS) of the patient and a positive MCS of the caregiver. Feelings of mastery in the intervention group increased over time, while feelings of mastery in the control group showed the opposite pattern. Those who received the intervention maintained a more stable level of mental functioning and showed modest improvement in feelings of mastery in comparison to the control group. Patients' HRQOL and neurologic functioning were found to be related to HRQOL and feelings of mastery of the informal caregiver at baseline. The intervention helped caregivers in maintaining a stable level of HRQOL and improved feelings of mastery over an eight-month period.
The findings from this RCT suggest that informal caregivers can benefit from a psychological CBT intervention because it is a helpful tool in maintaining a stable level of mental functioning and caregiver mastery.
Future nursing practice should focus on offering supportive interventions to patients with high-grade glioma and their informal caregivers. Further research should continue to look at the effects of a psychological intervention on HRQOL and feelings of mastery of informal caregivers of the high-grade glioma patient population. Findings suggest that CBT interventions can be of benefit to caregivers.
Campbell, L.C., Keefe, F.J., Scipio, C., McKee, D.C., Edwards, C.L., Herman, S.H., . . . Donatucci, C. (2007). Facilitating research participation and improving quality of life for African American prostate cancer survivors and their intimate partners. A pilot study of telephone-based coping skills training. Cancer, 109(Suppl. 2), 414–424.
To examine the feasibility and effect of a telephonic cognitive behavioral intervention to facilitate research participation and enhance quality of life among African American prostate cancer survivors and their partners
Consenting patients and their partners provided pretreatment measures and then were randomly assigned to either partner-assisted coping skills training (CST) or usual care (control condition). In the control group, individuals received routine care provided through their medical outpatient program. The CST intervention was designed to train survivors and partners in skills for managing symptoms, including provision of information about prostate cancer and possible long-term side effects, teaching problem solving skills and training in cognitive and behavioral coping skills such as communication, relaxation, and activity pacing. CST was provided in six one-hour telephone calls approximately once a week. Sessions were audiotaped and reviewed for protocol adherence. All subjects completed post-treatment study measures at the end of the six-week period.
A randomized controlled trial design was used.
Seven couples initially randomized to the treatment group withdrew (approximately 30%) primarily because of difficulties in scheduling treatment sessions.
Men who participated in the CST reported significantly higher quality of life related to bowel symptoms (p = 0.042). There were no significant differences between groups in general health, negative mood among partners, caregiver strain, or caregiver self-efficacy. Within the CST group, pre-post treatment measurement demonstrated significant improvement in reported bowel symptoms (p < 0.05), hormonal symptoms (p < 0.05) and self-efficacy (p < 0.05). There were no significant differences between pre and post-treatment measures among the partners (no effect on caregivers).
The telephone intervention was able to be delivered to the majority of participants, suggesting that this approach may be feasible for the delivery of coping skills training. Significant effects to improve caregiver self-efficacy and experience were not seen. This type of intervention appears to be helpful to patients in the area of managing side effects of prostate cancer.
Telephonic approaches to provide education, counseling, and CST is a promising approach for the provision of patient care, but scheduling sessions, particularly when patients and caregivers are working full-time, is a challenge. This type of intervention appears to be effective in terms of symptom and side-effect management among patients who are receptive to this type of approach, but the impact on caregiver strain and burden is unclear.
Carter, P.A. (2006). A brief behavioral sleep intervention for family caregivers of persons with cancer. Cancer Nursing, 29(2), 95–103.
To test the feasibility and effectiveness of a brief behavioral sleep intervention for family caregivers of persons with advanced stage cancer
Each caregiver received an Actigraph on the wrist of the dominant hand and was asked to wear it for the next three days. During this time, the caregiver completed a sleep log to illustrate times out of bed, time to bed, awakening and out of bed, and times of disturbance. At week two, intervention group caregivers (n = 15) received the CASI (author developed sleep intervention), and the attention control group caregivers received body mechanics information and training. All caregivers completed the Pittsburgh Sleep Quality Index (PSQI), Center for Epidemiological Studies—Depression Scale (CES-D), and Caregiver Quality of Life Index—Cancer (CQOLC) at week three and provided sleep log and Actigraph data. A booster CASI session was delivered to the intervention group at week four, and the attention group received a booster of the body mechanics material. The intervention incorporated stimulus control, relaxation therapy, cognitive therapy, and sleep hygiene. Participants were educated on sleep promotion techniques within the context of caregiving. Measurements of all study variables from both groups occurred in week five and two, three, and four months post-baseline.
A repeated measures experimental design was used.
Pearson product correlations reported on how sleep duration and efficiency were “strongly negatively associated” with caregiver depression and quality of life over time; however, actual statistical results were not provided in this report. Overall sleep quality (PSQI) and sleep latency were strongly and consistently correlated with caregiver depression and quality-of-life scores over time. Quality-of-life scores were strongly and consistently positively correlated with depressive symptoms over time, according to the author. Caregiver quality of life and self-reported sleep quality improved for both groups over the duration of the study. Intervention caregivers showed greater improvements in PSQI total scores than did control caregivers at each time measurement. The difference between groups in PSQI score was only statistically significant at month four in the study (p = 0.03), in favor of the intervention group.
Delivery of a home-based caregiver sleep intervention may be helpful for caregivers who report sleep disturbances that dramatically influence their personal quality of life and ability to provide care to a family member with cancer. This intervention appears to be feasible and can be tailored to the caregiver.
Findings suggest that an intervention to improve caregiver sleep quality may be helpful and that poor sleep quality is associated with lower quality of life and depressive symptoms.
Chambers, S.K., Girgis, A., Occhipinti, S., Hutchison, S., Turner, J., McDowell, M., . . . Dunn, J. C. (2014). A randomized trial comparing two low-intensity psychological interventions for distressed patients with cancer and their caregivers. Oncology Nursing Forum, 41(4), E256–E266.
To compare the effectiveness of nurse- and psychologist-delivered psychoeducational interventions for distressed patients and caregivers who had called a cancer helpline seeking support
Individuals who called the helpline were randomized to a five-session psychologist intervention using a cognitive behavioral approach or a single nurse-delivered session for education and support for self-management. All sessions were provided by telephone. Those in the single-session group were mailed a self-management resource kit, including written advice about stress management, problem solving, healthy lifestyle, and mobilizing support networks, along with an audio CD about relaxation exercises. All participants completed a baseline distress thermometer, and those who had a score of 7 or greater also received a follow-up phone call after the nurse session three weeks later. Study measures were obtained at baseline and at 3, 6, and 12 months. Caregivers and patients were not dyads because helpline calls were done individually.
Of the patients and caregivers, 93% completed the single-session intervention and 53% completed all five psychologist interventions. In the nurse arm, the mean intervention duration was 46.51 minutes, and the psychologist mean session duration was 46.43 minutes. Distress-related outcomes decreased over time, and positive adjustment increased over time in both groups. Effects size over 12 months was 0.19 in the nurse intervention group and 0.2 in the psychologist group. Cancer-specific distress decreased significantly over time for caregivers (p < .001), and positive adjustment increased (p < .001) with no significant difference between groups. Thirty-five percent of those in the nurse group received a follow-up phone call because of their distress score, and 3% were referred for additional support services.
Both the brief nurse contact for psychoeducation and self-management support and the telephonic CBT approach interventions provided by a psychologist were associated with reduction in distress and improvement in positive adjustment among caregivers of patients with cancer who had contacted a cancer helpline.
Findings suggest that caregivers, as well as patients, can benefit from a single-session nursing psychoeducational session provided by telephone and supported by self-management resource materials. Findings also showed that five telephonic sessions provided by a psychologist with a CBT approach also were helpful. Specifically, cancer-related distress can be approached effectively with a short, practical telephonic intervention for patients who identified a need for support by calling a helpline. Although this study has some design limitations in terms of sampling frame, it is very applicable for a real-world situation.
Cohen, M., & Kuten, A. (2006). Cognitive-behavior group intervention for relatives of cancer patients: A controlled study. Journal of Psychosomatic Research, 61, 187–196.
To compare the effectiveness of a cognitive behavioral (CB) group intervention for relatives of patient with cancer with a control group
The cognitive behavioral (CB) intervention consisted of nine structured, 90-minute group sessions. Individual groups had five to seven participants and were conducted by a senior social worker with psycho-oncology experience as well as training in group therapy and CB therapy. Participants were provided written materials at every session and audiocassettes or compact discs for home practice of relaxation with guided imagery. The CB intervention had a cognitive and a behavioral component. Cognitive techniques were taught to identify and challenge negative and automatic thinking patterns and beliefs. Participants were taught to restructure thoughts into more adaptive patterns, reframe, problem-solve, and find alternative strategies to use with recurrent and stressful situations. Behavioral techniques taught were relaxation, guided imagery, and deep breathing.
Active antitumor treatment
A repeated measures, controlled trial design was used.
There were significant group X time interactions for all of the psychosocial variables in the CB group but not in the control group. Significant main group effects were for psychological distress, psychosocial adjustment, and sleep problems but not for perceived support in the CB group but not the control group. Significant main time effect was for sleep difficulties and psychosocial adjustment. The between group effect size difference was 0.11–0.18.
There were significant improvements in perceived support from time 1 to time 3 (p < 0.0001) for the CB group but not for the control group.
Reliable Change Index (RCI) is a measure of clinical significance. RCI (6.5) showed clinically significant improvement in psychological distress from preintervention to follow-up in 30.8% (n = 16) of the participants in the CB group as compared to 3.9% (n = 2) of the participants in the control group. Psychological adjustment, sleep problems, and perceived support levels for the CB group were also clinically significant (for PAIS, RCI = 2.2; for sleep difficulties, RCI = 14.8; for perceived support, RCI = 3.2).
On average, the amount of thought monitoring was performed 2.7 (SD = 2.5) times per week at time 2 and 1.9 (SD = 1.7) times per week at time 3. Relaxation with guided imagery was performed 3.4 (SD = 3.8) (time 2) to 2.3 (SD = 2.9) times per week (time 3).
The results from this study indicate that the CB group intervention was effective in reducing psychological distress and sleep problems, and improving psychological adjustment for relatives of patients with cancer who participated. The CB intervention had a long-term effect that was maintained over the four-month follow-up.
Greater preintervention distress and a greater amount of home-practice thought monitoring and relaxation/guided imagery compliance were significant predictors of the total change in participants’ level of distress.
The CB intervention was administered by a social worker who was highly experienced and familiar with psycho-oncology, group therapy, and CB therapy. Consequently, the study social worker was highly prepared to administer this CB group intervention. This indicates that the individual administering the CB intervention should be highly trained to replicate the successes of this research.
The CB group intervention can be effective for improving psychological distress, psychological adjustment to illness, and sleep difficulties of relative caregivers of patients with cancer. This intervention can have both short-term and long-term psychosocial effects. Nurses can provide referrals for a CB intervention for highly distressed caregivers or those who are having sleeping problems and issues with adjustment to their relatives’ illness.
Further research is needed to replicate this study using a randomized controlled design. Additionally, an abbreviated CB intervention for relatives of patients with cancer needs to be developed for caregivers who have time constraints.
Given, B., Given, C.W., Sikorski, A., Jeon, S., Sherwood, P., & Rahbar, M. (2006). The impact of providing symptom management assistance on caregiver reaction: Results of a randomized trial. Journal of Pain and Symptom Management, 32(5), 433–443.
Dyads in the experimental group received four contacts over a 10-week intervention. (Two in-person contacts coinciding with regular visits to the oncology center; alternated with two telephone contacts approximately two weeks following each in-person contact.)
Cognitive behavioral intervention was directed toward the patient and caregiver dyad. Patients received information on self-care, cognitive reframing, coping strategies, and techniques for communicating needs for assistance with family members. Interventions for caregivers focused on etiology and strategies for managing symptoms, how to integrate into everyday activities, and how to better communicate with the patient and healthcare providers about symptom management. The intervention nurse assessed the caregivers’ perception of their involvement in and reaction to assisting the patient with symptom management; collaboratively selected strategies to implement; and evaulated the success of strategies to either continue or be revised.
A properly designed randomized clinical trial was used.
Caregivers in the experimental intervention group reported significantly lower total negative reactions and fewer assistances at 10 weeks than caregivers in the standard of care arm (p < 0.01).
Patients of caregivers in the experimental group reported significantly lower levels of symptom severity for which caregivers provided assistance.
Female caregivers in the experimental group reported less negative reactions to providing assistance than female caregivers in the control group (p < 0.01). Males in the control group reported less negative reactions per assistance than males in the experimental group (p = 0.08).
Caregivers who were younger than their patients reported less negative reactions to assisting with symptom management than caregivers who were the same age or older than their patients (p = 0.06).
Manne, S.L., Kissane, D.W., Nelson, C.J., Mulhall, J.P., Winkel, G., & Zaider, T. (2011). Intimacy-enhancing psychological intervention for men diagnosed with prostate cancer and their partners: A pilot study. Journal of Sexual Medicine, 8(4), 1197–1209.
To evaluate (a) the impact of an intimacy-enhancing therapy (IET) versus a usual care (UC) program on survivor and partner psychological outcomes, including distress, well-being, and relationship outcomes (relationship satisfaction and intimacy), (b) the impact of an IET on relationship communication, and (c) the role of preintervention levels of each outcome variable on post-IET intervention outcome variables
Participants received assignment to either an IET or a UC group. The IET intervention consisted of five 90-minute couple sessions delivered by a trained therapist. This person focused on improving couples’ ability to comfortably share their thoughts and feelings to promote mutual understanding and support for cancer concerns and to facilitate emotional intimacy. The IET program techniques evolved from cognitive-behavioral and behavioral marital therapy practice and other published communication skills interventions adapted for prostate cancer. Careful attention was made to ensuring treatment fidelity by videotaping sessions and using manuals to structure the intervention. UC group participants received standard clinic psychosocial care. The IET group received the same surveys following the fifth and final session of the IET (approximately two months post-baseline). The UC and IET participants who did not complete sessions received a second round of surveys eight weeks after baseline assessment.
A pre/post-test pilot design was used.
Seventy-three percent of IET couples attended 80% or more of the sessions, but another 21.6% of the IET group did not attend any sessions following random assignment to the IET group. Treatment fidelity on 114 of 138 sessions averaged 87.4%. Intervention survivors and partners rated the sessions as “quite successful,” but only 72% of the intervention group reported completion of homework assignments as part of the IET program. With study attrition, an intent-to-treat statistical analysis approach was used.
There were no significant treatment effects for general distress, cancer-specific distress, and relationship intimacy for either survivors or partners. There were no significant treatment differences for relationship communication for either survivors or partners. IET effects were largely moderated by baseline couple relationship and psychosocial factors (individual distress). Survivors who had high levels of cancer concerns at baseline significantly reduced those concerns post-IET. Moderating effects of preintervention levels for self-disclosure and perceived partner disclosure and responsiveness resulted from the intervention. The IET program improved cancer-specific distress, low intimacy, martial satisfaction, and communication if a couple experienced problems in these areas before the intervention.
The IET had a marginally significant (p = 0.08) main effect on survivor well-being and improved overall outcomes for couples with fewer personal and relationship resources. Couples with more resources (e.g., higher educational level, stronger marital ties) experienced no improvement from the IET program.
Interventions such as the IET may prove valuable for couples challenged by treatment and outcomes of prostate cancer treatment. As members of the healthcare team, nurses have an obligation to assess prostate cancer survivors about their overall coping skills, learning, and relationship needs to offer patient- and couple-centered interventions to improve the quality of their relationships and adjustment to living with prostate cancer.
McMillan, S.C., Small, B.J., Weitzner, M., Schonwetter, R., Tittle, M., Moody, L., & Haley, W.E. (2006). Impact of coping skills intervention with family caregivers of hospice patients with cancer: A randomized clinical trial. Cancer, 106, 214–222.
To evaluate whether adding a brief problem-solving intervention (i.e., COPE) to caregivers of patients receiving hospice cancer care would be superior to either standard hospice care alone or standard hospice care with emotional support
Intervention group: In addition to standard hospice care, the intervention involved giving three training sessions to caregivers using the COPE problem-solving technique as a coping skill to manage caregiving stress. COPE involves training caregivers how to use Creativity, Optimism, Planning, and obtaining Expert information when needed as well as how to use a homecare guide for advanced cancer. The intervention was done during visits to the caregiver by a trained nurse while a home health aide stayed with the patient. The visits were conducted within seven to nine days of recruitment, but the schedule was not clearly reported.
Control group II: Caregivers and patients received standard hospice care and supportive visits that focused on emotional support only. These visits were scheduled at the same times and frequencies as the COPE training occurred in the intervention group.
A three-group randomized controlled trial design was used.
Results of random effect regression models showed significant interactions (time by group) in the intervention group for three of the caregivers’ measured outcomes.
There were statistically significant group by time effects, showing that caregiver QOL was higher in the COPE (p = 0.033) and support groups, and symptom burden was lower in the COPE (p < 0.001) and support groups when compared to the usual care group.
Overall, the study findings show strong evidence of effectiveness of the COPE treatment among caregivers of patients in hospice care. In this group of caregivers, COPE improved caregivers’ overall QOL and caregiver symptom-related burden.
Nursing care of caregivers of patients in hospice should involve focused interventions that extend beyond emotional support. COPE is an intervention that can be used with caregivers of patients with cancer in general, hospice or otherwise. This intervention is very promising. The fact that it improved some caregivers’ outcomes in hospice suggests that it can also be very effective under different contexts.
Meyers, F.J., Carducci, M., Loscalzo, M.J., Linder, J., Greasby, T., & Beckett, L A. (2011). Effects of a problem-solving intervention (COPE) on quality of life for patients with advanced cancer on clinical trials and their caregivers: Simultaneous care educational intervention (SCEI): linking palliation and clinical trials. Journal of Palliative Medicine, 14(4), 465–473.
To examine effects of a standardized cognitive-behavioral educational intervention on quality of life (QOL) of patients and their caregivers
Patients designated one caregiver as their coparticipant in the study. Dyads were randomly assigned to intervention or standard care control groups. Those in the intervention arm received a copy of The Home Care Guide for Cancer and participated in three educational sessions with a trained educator. The first session was up to seven days prior to or on the day of entry into a clinical trial. Two additional sessions were done within the next 30 days. Sessions were used to reinforce learning by focusing on patient- or caregiver-identified problems. Usual care was not described. Data were collected at baseline and at 30, 60, 90, 120, and 180 days.
A randomized controlled trial design was used.
Approximately 25% of dyads in both groups withdrew from the study by their own choice. Among patients, there was a five-point decline (100-point scale) in QOL over six months, with no difference between study groups. Among caregivers, those in the control group had QOL scores decline more than those in the intervention group (p = 0.02), according to reported predicted decline from baseline. Caregivers did not show any significant changes in problem-solving skills over time in either study group. The intervention was associated with a slower rate of decline in spiritual aspect of the QOL measure. Caregivers overall showed a decrease in rational problem-solving skills over time, and there were no significant differences between groups, suggesting that the slower decline in QOL with the intervention were not likely a direct result of improved problem-solving skills.
Findings show some potential benefits in the intervention group, but as pointed out by the authors, differences were not likely as a result of improved problem-solving skills, which was the emphasis of the intervention. The study does not demonstrate convincing effects of this intervention for caregivers.
The study's drop-out rate suggests that this intervention may not be practical or acceptable because most of these were by individual participant choice. The study does not provide convincing evidence of effectiveness of this intervention on quality of life for patients or caregivers.
Onyechi, K.C., Onuigbo, L.N., Eseadi, C., Ikechukwu-Ilomuanya, A.B., Nwaubani, O.O., Umoke, P.C., . . . Utoh-Ofong, A.N. (2016). Effects of rational-emotive hospice care therapy on problematic assumptions, death anxiety, and psychological distress in a sample of cancer patients and their family caregivers in Nigeria. International Journal of Environmental Research and Public Health, 13, E929.
To evaluate the degree to which a rational emotive behavioral approach and techniques can benefit patients and family members in hospice care
A manual for the intervention approach was developed to guide the treatment process. It was based on a cognitive behavioral approach, including cognitive restructuring, confrontation, therapeutic alliance, acceptance, dialogue, reframing, use of metaphors worksheets, and motivational activities. The intervention was provided for 10 weeks in 45-minute sessions weekly, with four weeks of follow-up meetings in each household. Study assessments were conducted at baseline, after the 10-week intervention, and after the four weeks of follow-up, using self-report instruments and structured interviews. Participants randomized to the control intervention received usual care involving spiritual support, caregiving, counseling, etc., for the same amount and duration of time.
Randomized, controlled trial
Overall baseline problematic assumptions and death anxiety were high, and distress scores showed severe distress. Respeated measures analysis of variance (ANOVA) showed that the intervention program had a significant effect on problematic assumptions (p = 0.00), death anxiety (p = 0.00), and distress (p = 0.00) in caregivers and patients compared to those in usual care. This difference was maintained at follow-up.
The findings show that cognitive behavioral techniques and the specific approach used here were effective in reducing problematic assumption, death anxiety, and psychological distress among patients with cancer and their family caregivers.
The findings demonstrated that cognitive behavioral approach techniques are helpful in reducing stress and anxiety in patients in hospice and their informal caregivers. Nurses can incorporate these types of approaches into usual counseling and supportive interventions with caregivers and patients.