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.

• The sample started with 329 caregiver/patient dyads but decreased at different data collection points.
• Mean caregiver age was 60 years (SD = 15.27); mean patient age was 70.12 years (SD = 12.58).
• The caregiver sample was 14.5% male and 85.5% female (average for three groups).
• Caregivers had to be providing care to adult patients with advanced cancer newly admitted to hospice.
• The average educational level of participants was slightly above high school education. 
• No systematic demographics were found among participants in the three groups. 

• Single site
• Inpatient setting
• Large, nonprofit, community-based hospice in southeastern United States

• End-of-life care phase
• Elder care, palliative care

A three-group randomized controlled trial design was used.

• Caregiver quality of life (QOL) was assessed using the Caregiver Quality of Life Index–Cancer (CQOL-C).
• To assess caregiver symptom-related burden, the authors adapted the patient Memorial Symptom Assessment Scale (MSAS) by asking caregivers to rate their distress associated with 24 patient symptoms.  
• Caregiver general mastery was assessed using a six-item scale where caregivers reported their feelings of control and confidence in caregiving.  
• Caregiver burden and mastery specific to caregiving tasks was assessed using the Caregiver Demands Scale (CDS) to obtain scores for caregiving task burden and caregiving task mastery.

Results of random effect regression models showed significant interactions (time by group) in the intervention group for three of the caregivers’ measured outcomes.

• Caregiver QOL (p = 0.054)
• Caregiver symptom-related burden (burden related to patients’ symptoms) (p = 0.001)
• Caregiving task burden (p = 0.021), with main effect for time (p = 0.014), where increases in task burden scores increased over time

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.

• The intervention might be expensive, impractical, or require training needs.*
• Subject withdrawals were ≥ 10%.
• Other limitations/*explanation: Details about the COPE  intervention that were given in the study were insufficient, which is possibly a result of publication space limitations, but additional detail would have made it easier to fully understand the nature of this intervention (e.g., how long did the COPE training sessions last? When specifically were the sessions conducted with the caregivers? Exactly where did the sessions take place?). However, the authors mentioned that the intervention manual is available upon request to those who may wish to replicate the study or use the intervention in caring for caregivers. The differences between the usual care and support group interventions were not clear.

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.