- Research article
- Open Access
- Open Peer Review
Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients
© The Author(s). 2016
- Received: 26 January 2016
- Accepted: 25 July 2016
- Published: 2 August 2016
The balance between hope-hopelessness plays an important role in the way terminally ill patients report quality of life, and personal resilience may be related to hope at the end of life. The objective of this study was to explore associations between personal resilience, hope, and other possible predictors of hope in advanced cancer patients.
A cross-sectional pilot study was carried out with metastatic colorectal cancer patients in a tertiary hospital. The patients answered the Connor-Davidson Resilience Scale, Herth Hope Index, Barthel Index, an instrument addressing family and social support, visual-numeric scales for pain and suffering, a two-item screening for depression, socio-demographic and socio-economic information about the family.
Forty-four patients were interviewed (mean age 56 years; range 29-86). A strong correlation was noted between resilience and hope (0.63; p < 0.05). No correlation was found between hope and independence for activities of daily living, support from family and community, and pain and suffering levels. Of the 44 patients, 20 presented with depressive symptoms. These depressive patients had lower resilience (p = 0.005) and hope (p = 0.003), and higher scores of suffering (p < 0.001). The association between resilience and hope kept stable after adjusting for age, gender, and presence of depression (p < 0.001).
Given that resilience is a dynamic, changeable path that can improve hope, resilience-fostering interventions should be most valued in palliative care settings and should be commenced as soon as possible with cancer patients. Patients with advanced stages of non-malignant conditions would also probably benefit from such interventions.
- Terminal care
- Palliative care
In oncology and palliative care, the balance between hope-hopelessness may play an important role in the way patients report quality of life and quality of dying [1–3]. Hopelessness and other features of spiritual distress may be mismatched with depression, leaving a considerable number of patients tackling existential concerns and discomforts by themselves, despite receiving antidepressants on a regular basis [4, 5].
Spiritual distress is a highly valued concept in nursing care. It is defined by the North American Nursing Diagnosis Association as a state of “disruption in the life principle that pervades a person’s entire being and that integrates and transcends his or her biological and psychological nature”  (p.67). In our context, Caldeira and colleagues validated the diagnosis of spiritual distress in a sample of forty-five elderly cancer patients; in that study, the prevalence of spiritual distress was as high as 42 % . Hopelessness is regarded as a sign indicative of spiritual distress [8, 9]. Anandarajah and Hight  note that spiritual distress occurs when a person is “unable to find sources of meaning, hope, love, peace, comfort, strength, and connection in life or when conflict occurs between their beliefs and what is happening in their life”(pp. 83-84). Morita, in a study with hospice patients, identified three factors in connection with existential/spiritual distress: loss of autonomy, lowered self-esteem, and hopelessness . Hopelessness, as a source of spiritual distress, may seriously contribute to deteriorate the wellbeing of terminally ill cancer patients . Chochinov found in a sample of 196 terminal cancer patients that hopelessness was more highly correlated with suicidal ideation than was depression . Among dying patients, hope is apparently related to concepts of meaning and purpose . Duggleby  reported that maintaining hope was a way for terminally ill patients to endure and cope with their suffering. Hopelessness as an experience among palliative care patients has the power to undermine a sense that life has ongoing value or intrinsic worth .
Since the early 1990’s, Herth has developed assessment tools to measure individual hope in clinical settings. She postulates that such an instrument must apprehend the multidimensionality of the hope construct, instead of only a time-oriented, future focused dimension of hope. So, the last version of the Herth scale includes items focusing on a more global, non-time oriented sense of hope, and hope despite diminished or absent interpersonal relationships, for example . This broader conceptualization of hope is more aligned with the needs of patients facing imminent death. According to clinicians and researchers in palliative care, the sense of hope in a terminally ill patient is usually (or should be) transformed, what may involve acknowledging life the way it is, searching for meaning and positive reappraisal . For patients nearing death, maintaining hope is intimately connected with a sense that life continues to serve some purpose or hold meaning . For these patients, hope is defined in terms of hope for no more suffering, living each day, for a peaceful death, and hope for their families . Reports about comfort and well-being in terminal cancer patients have indicated that maintenance of hope as death approaches may be seen as an indicator of quality of life and quality of dying; thus, dying well seems to be connected with keeping hope until the end [1, 3, 19].
The investigation of comfort and well-being in terminal cancer has also emphasized that symptom burden and functionality constraints are negatively correlated with quality of life at the end of life [20, 21]. On the other hand, family and social support are positively correlated with quality of life at the end of life [22, 23].
Also related to spiritual wellbeing, personal resilience is a construct associated with the ability to adapt when challenged by stressors or adversities, or to strive despite the difficulty of an experienced circumstance [24, 25]. The concept of resilience is far from being a consensus among authors [26, 27]. Deshields summarizes that resilience is variably regarded as a process, a personality trait, a dynamic developmental process, an outcome post-adversity, or a combination of the above . Windle, while accepting the difficulties in accurately defining resilience, proposes that it stands for “the process of negotiating, managing and adapting to significant sources of stress or trauma”  (p.159). Resilience was first studied in individuals who had endured significant adversity or abuse. However, in recent years, chronic stressors (e.g. ill-health and the burdens imposed by chronic life-limiting diseases) have also been a focus for the study of individual resilience [27–29].
According to theories as well as research, some features usually displayed by resilient people have been reported: hardiness, self-esteem, realistic optimism, high positive emotionality, sense of purpose in life, spirituality, moral compass, use of active coping strategies (such as problem solving and planning), ability to find meaning even in traumatic experiences, the tendency to perceive stressful events in less threatening ways and to reframe adverse experiences in a more positive light, and so forth [30–32]. Rutter proposed a model to understand resilience as a dynamic process in which personality traits interact with environmental factors to enhance or decrease resilience throughout one’s life . In review papers, the majority of researchers on the topic acknowledge this model of resilience as a process [24, 29]. According to Coughlin , cancer survivors seem to be resilient individuals and some are likely to have an experience of subtle inner growth while facing cancer symptoms and the burdens of its treatments and limitations.
In the present manuscript, we acknowledge the model of resilience as a process, thus amenable to change over the life span. Also aligned with the work of Connor and Davidson (whose resilience scale was adapted for the context of our study), we accept that spirituality may be constitutive of a resilient self . Spirituality here is taken as a broader construct in relation to religiosity . Indeed, while developing a measure for resilience, Connor and Davidson included items to assess spirituality – in their words, “faith and a belief in benevolent intervention” – as a dimension of the resilience process  (p.77).
The association between resilience and hope is not clear in the literature. While it is common place to state that hope belongs to the domain of spirituality and spirituality is an ingredient of resilience, some researchers on resilience usually point out that hope is constitutive of a resilient self [37, 38], but others do not . In the present pilot study we tested the association between resilience and hope in a sample of advanced colorectal cancer (CRC) patients. We hypothesized a positive strong association between the two constructs; we also hypothesized that resilience would be a better predictor of hope in comparison with other variables, such as intensity of pain, severity of physical limitations (functionality), and family and social support.
To detect a correlation of 0.50 at 90 % power and an alpha of 0.05, we estimated that at least 38 patients should be invited to participate in the study. It was assumed that a correlation of 0.50 is moderate, according to Callegari-Jacques and Abramson [39, 40]. A 15 % margin was added to prevent for losses due to response inconsistencies.
Study subjects, consent, permissions, and procedures
Between October 20, 2014 and February 2, 2015 advanced CRC patients of the department of Clinical Oncology of a tertiary teaching hospital were approached. The responses of the study subjects are shown as an additional file presented with this manuscript (Additional File 1). Consecutive patients from the oncology wards were potentially eligible, unless they demonstrated unwillingness to participate. The aim was conducting complete and valid interviews with a convenience sample of 42 to 44 patients. Medical charts were checked to confirm the disease stage, sites of metastasis, and comorbid conditions. Patients with limitations to oral communication or cognitive deficits were not eligible (exclusion criteria of the study protocol). Detection of cognitive deficits was done by means of the Confusion Assessment Method (CAM), a widely used assessment tool to screen for cognitive deficits. For the present study, a Brazilian Portuguese adapted and validated CAM version was used . If the CAM was positive, the interview was interrupted delicately.
All participants consented to become subjects of the study and answered the questionnaires by themselves in the presence of the interviewer who previously had read each study item and response options to the patient (assisted application). At the beginning of the interview, patients were asked about socio-demographic characteristics, including ability to read and number of years’ formal schooling. At the end, they were asked about socio-economics of their family, according to an A to E Brazilian strata classification, A being wealthier families .
Perceived support from family and community
For the purpose of the present study, a chart recorded information regarding the household constitution (number of people the patient lived with, their names, and category of proximity), and other recorded information on other support people valued by the patient, though not part of the nuclear family (again including names). For each name, the participant was invited to ascribe on a visual-numeric scale ‘how much support could be promptly available from that person’, 0 being ‘no support’ and 10 ‘all that I come to need’. Scores for each person named were then summed and the sum was divided by the number of people named in each of the charts (nuclear family and other relatives/friends). So, two mean scores were generated (varying from 0 to 10), and the variables were respectively labeled ‘family support’ and ‘community support’. (Additional File 2).
Connor-Davidson Resilience Scale (CD-RISC)
The full-length scale  was chosen, since it is currently one of the most used resilience measures worldwide. This 25-item CD-RISC varies from 0 to 100, the higher scores indicating greater resilience. A Brazilian Portuguese culturally adapted version of the CD-RISC has been factor analyzed and exhibited appropriate psychometric properties (Cronbach’s alpha 0.93; intraclass correlation coefficient 0.86) .
Herth Hope Index (HHI)
The HHI was developed in 1990 and has been extensively used to evaluate hope, particularly in palliative care clinical settings . With its 12 items, the HHI varies from 12 to 48, the higher scores indicating greater hope. A Brazilian Portuguese HHI version has been available since 2008, with adequate psychometrics (Cronbach’s alpha 0.83; intraclass correlation coefficient 0.70) .
Barthel Index (BI)
The BI was proposed by Mahoney and Barthel  and is frequently used in oncology and gerontology to assess one’s level of dependency in relation to daily life activities. The BI has ten items and varies from 0 to 100, the higher scores indicating less dependency. Its Brazilian Portuguese version was developed by Cincura et al.  in a sample of post-stroke patients and tested again by Minosso et al. in a sample of elders .
Visual-numeric pain scale
Respondents scored their pain intensity (during the last 24 h) on a 0-10 scale.
Visual-numeric scale for experienced suffering
Respondents scored the intensity of their experienced suffering (during the last 24 h) on a 0-10 scale.
Two-item screening for depression
Descriptive statistics established demographics and clinical characteristics of the sample. Spearman correlation coefficients were calculated for the study variables. The sample was stratified into two subgroups: one without depression and one with depression. The main study variables were compared within these subgroups using the Mann-Whitney test. A generalized linear model with gamma distribution was used to adjust the association between resilience and hope by sex, age, and presence of depression. A statistical significance level of 0.05 was adopted. Statistics were performed using the SPSS statistical package for Windows, version 17.0 .
Socio-demographic and clinical characteristics of the sample
Years of formal schooling
Self-rated ability to reada
Can read reasonably well
Can read well
Can read very well
Ischemic heart disease
Spearman correlation coefficients among the main study variables
Comparison between the subsample without depression and the subsample with depression
No depression (N = 24)
Depression (N = 20)
Years from diagnosis
Association resilience-hope adjusted for gender, age, and presence of depression
This pilot study with advanced CRC patients confirmed a strong association between individual resilience and hope. No association was found between independence for activities of daily living and hope, or between social support and hope. The subsample of depressed patients presented with lower levels of resilience and hope, and higher levels of reported suffering.
These findings suggest that interventions to improve hope at the end of life could be replaced by those aimed at improving personal resilience. This alternative approach might be advantageous because terminally ill individuals are prone to becoming easily bothered by common places to enhance hope (for example, “you have to keep fighting”; or “everything happens for a reason; this too shall pass”). The jargon used to communicate with severely ill people has been subdued by semantic erosion, and now offer some clichés about hope/hopefullness that are no longer useful for the patients. In this sample of advanced CRC patients, hope was related to resilience but not to other variables usually deemed important, such as level of independence, perceived support from family and community, pain and suffering (Table 2). The strong relation between hope and resilience was kept after adjusting for gender, age, and presence of depression (Table 4).
For the patient, keeping hope while facing impending death is of utmost importance. Palliative care researchers and practitioners sometimes tend to equate hope with quality of life (and quality of death) [51, 52]. If resilience is amenable to improvement, and if there is a means to intervene over one’s level of resilience, and if there is a strong association between resilience and hope, such interventions to enhance resilience should be a necessary part of treatment.
Some authors have designed interventions to enhance resilience among cancer patients. Friborg  developed a group psychotherapy program for breast cancer in which patients are taught better skills to alleviate stress and reinforce resilience factors. Nelson et al.  proposed some psychotherapeutic strategies for enhancing resilience and quality of life of adolescents with cancer (the Resilience Enhancement Adolescent Profile), music therapy being one of these strategies. Burns  and Robb  also developed a video-music intervention aimed at improving resilience and diminishing symptom distress among adolescents and young adults undergoing stem-cell transplantation.
It is also possible that other psychotherapeutic approaches that address hope at the end of life in cancer patients do so by means of strengthening resilience, although not explicitly . Breitbart and colleagues [57, 58] created a program of meaning-centered group psychotherapy to advanced cancer patients that could well be an example. While addressing topics on hope and meaning with patients  – embedded in Viktor Frankl’s biographical accounts on survivorship from Nazi camps – it is very possible that resilience factors are being propelled in those patients. Again, derived from Frankl’s work, the meaning-making intervention  allegedly improves cancer patients’ self-esteem, optimism, and self-efficacy. Since these three constructs are supposed to be ingredients of personal resilience, it seems plausible to think such an approach could be viewed as resilience-fortifying. Also, the method proposed by Kissane et al. (cognitive existential group therapy) , whilst addressing the patient’s concepts of mastery, hope, and quality of life when coping with cancer, seems to deal with one’s resilience. The work of Chochinov in developing Dignity Therapy for advanced cancer patients has also to be cited . While discussing themes such as hope, maintenance of pride, role preservation, continuity of self (and so forth) with advanced cancer patients, these patients probably become more resilient. Actually, the author listed “resilience/fighting spirit” as one of the subthemes among the dignity-conserving perspectives of the Dignity Model .
In a previous review, we advocated that the burdens of approximating death by a malignant condition are by no means different from approximating death by other chronic non-malignant diseases, such as aids, heart disease, chronic obstructive pulmonary disease and renal disease . Therefore, one could expect approaches to enhance resilience and hope at the end of life also to be beneficial to patients dying from chronic non-malignant conditions. Indeed, Evers et al. have reviewed some interventions to reduce stress and promote resilience among patients with chronic rheumatic diseases . Brown and Gerbarg  proposed meditation and Yoga breathing for augmenting stress resilience in geriatric samples. There is still much room to test resilience-fortifying approaches, with cancer or non-cancer patients.
The present pilot study, with its cross-sectional design, is ineffective in asserting that personal resilience predicts hope. It is possible that hope is one more ingredient of resilience. Nonetheless, other authors have indicated that resilience is predictive of hope at the end of life. Some resilience factors, like self-esteem, connectedness with significant others, and spiritual connectedness, are regarded as predictors of higher levels of hope among terminally ill cancer patients . Miller  also suggested that higher levels of hope are anteceded by optimism, sense of meaning, and connectedness with God, which are thought to be constitutive of resilience as a construct. It is plausible to think that the above mentioned therapeutic approaches designed to help cancer patients better cope with their disease, limitations and treatment burdens, are resilience-fostering strategies that can ultimately enhance hope at the end of life.
Besides the study design, the findings presented here are also limited by the sample size. Nevertheless, this is unlikely to have influenced the strong association elicited between resilience and hope that could have been detected even in smaller samples. Going beyond this pilot study, researching larger samples of oncologic and non-oncologic patients will probably test again the association between hope at the end of life and personal resilience, as with other potential hope predictors, like social support, pain, functional status, and physical limitations. This study confirmed an initial hypothesis on the existence of an association between resilience and hope at the end of life – one that is stronger than that between social support and hope, or severity of limitations and hope. Another limitation of this study is due to the fact that the measure of social support utilized was not validated. Further studies will be necessary to test the adequacy, reliability and validity of simple visual-numeric scales to assess social support, as perceived by highly debilitated patients.
This pilot study found an association between resilience and hope in a sample of advanced CRC patients. It is plausible to expect this association to be replicable in samples of patients with other cancers and also among patients facing advanced stage non-malignant conditions. There is much room for further and larger studies, in different cultural settings.
Considering an association between resilience and hope, resilience being a process amenable to change over time, resilience building interventions should be systematically tested in palliative care to evaluate certain outcomes, like hope and quality of life. After confirmed a desirable effect, such interventions could become common practices in palliative care facilities, and should commence as soon as possible, either to cancer or non-cancer patients assisted by hospice and/or palliative care teams.
BI, Barthel Index; CAM, confusion assessment method; CD-RISC, Connor-Davidson Resilience Scale; COPD, chronic obstructive pulmonary disease; CRC, colorectal cancer; HHI, Herth Hope Index
The authors thank the following members of the Department of Clinical Oncology of the A.C. Camargo Cancer Center: Aldo Dettino, Ludmilla Chinen, Sandra Serrano, and João Duprat Neto.
Availability of data and materials
Supplementary files for this manuscript were added during the submission process: (1) the data set, from which personal identifiers of the participants were excluded; (2) the questionnaire to collect information about family and community support, developed for the purposes of the study.
JCS conceived and designed the study protocol, conducted data analysis and interpretation, and drafted the manuscript. AGS and IAS participated in data collection and analysis. HA and JEV contributed to subsequent drafts and commented on the final draft paper. All authors read and approved the final manuscript.
JCS has formerly worked as a palliative care practitioner, and now is a psychiatrist at the Pain Control Group. AGS is a registered nurse in a Clinical Oncology ward. IAS is a medical student. HA is a specialist in Anesthesia and Pain Control, and head of the Pain Control Group. JEV is associate professor of Anesthesia.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
This study was approved by the Institutional Review Board of the A.C. Camargo Cancer Center, in São Paulo, under the protocol number 1447/10.
This study was approved by the “Comitê de Ética em Pesquisa” of A.C. Camargo Cancer Center, in São Paulo, under the protocol n. 1447/10.
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- Sachs E, Kolva E, Pessin H, Rosenfeld B, Breitbart W. On sinking and swimming: the dialectic of hope, hopelessness, and acceptance in terminal cancer. Am J Hosp Palliat Care. 2013;30(2):121–7.View ArticlePubMedGoogle Scholar
- Breitbart W, Rosenfeld B, Gibson C, Pessin H, Poppito S, Nelson C, et al. Meaning-centered group psychotherapy for patients with advanced cancer: a pilot randomized controlled trial. Psychooncology. 2010;19(1):21–8.View ArticlePubMedPubMed CentralGoogle Scholar
- Mystakidou K, Tsilika E, Parpa E, Pathiaki M, Galanos A, Vlahos L. The relationship between quality of life and levels of hopelessness and depression in palliative care. Depress Anxiety. 2008;25(9):730–6.View ArticlePubMedGoogle Scholar
- Neuberger J. A healthy view of dying. BMJ. 2003;327(7408):207–8.View ArticlePubMedPubMed CentralGoogle Scholar
- Chochinov HM. Thinking outside the box: depression, hope, and meaning at the end of life. J Palliat Med. 2003;6(6):973–7.View ArticlePubMedGoogle Scholar
- NANDA. Nursing Diagnosis: Definitions and Characteristics. Philadelphia: NANDA; 1992.Google Scholar
- Caldeira S, Timmins F, de Carvalho EC, Vieira M. Nursing Diagnosis of “Spiritual Distress” in women with breast cancer: prevalence and major defining characteristics. Cancer Nurs. 2016;39(4):321-7.Google Scholar
- Kearney M, Mount B. Spiritual care of the dying patient. In: Chochinov HMB, Breitbart W, editors. Handbook of Psychiatry in Palliative Medicine. New York: Oxford University Press; 2000. p. 357–74.Google Scholar
- Speck P. Spiritual issues in palliative care. In: Doyle D, Hanks G, MacDonald N, editors. Oxford Textbook of Palliative Medicine. New York: Oxford University Press; 1998. p. 805–16.Google Scholar
- Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician. 2001;63(1):81–9.PubMedGoogle Scholar
- Morita T, Tsunoda J, Inoue S, Chihara S. An exploratory factor analysis of existential suffering in Japanese terminally ill cancer patients. Psychooncology. 2000;9(2):164–8.View ArticlePubMedGoogle Scholar
- Chochinov HM. Dying, dignity, and new horizons in palliative end-of-life care. CA Cancer J Clin. 2006;56(2):84–103.View ArticlePubMedGoogle Scholar
- Chochinov HM, Wilson KG, Enns M, Lander S. Depression, Hopelessness, and suicidal ideation in the terminally ill. Psychosomatics. 1998;39(4):366–70.View ArticlePubMedGoogle Scholar
- Chochinov HM, Hack T, McClement S, Kristjanson L, Harlos M. Dignity in the terminally ill: a developing empirical model. Soc Sci Med. 2002;54(3):433–43.View ArticlePubMedGoogle Scholar
- Duggleby W. Enduring suffering: a grounded theory analysis of the pain experience of elderly hospice patients with cancer. Oncol Nurs Forum. 2000;27(5):825–31.PubMedGoogle Scholar
- Herth K. Abbreviated instrument to measure hope: development and psychometric evaluation. J Adv Nurs. 1992;17(10):1251–9.View ArticlePubMedGoogle Scholar
- Duggleby W, Wright K. Transforming hope: how elderly palliative patients live with hope. Can J Nurs Res. 2005;37(2):70–84.PubMedGoogle Scholar
- Duggleby W, Wright K. Elderly palliative care cancer patients’ descriptions of hope-fostering strategies. Int J Palliat Nurs. 2004;10(7):352–9.View ArticlePubMedGoogle Scholar
- Cohen SR, Mount BM, Tomas JJ, Mount LF. Existential well-being is an important determinant of quality of life. Evidence from the McGill Quality of Life Questionnaire. Cancer. 1996;77(3):576–86.View ArticlePubMedGoogle Scholar
- Deshields TL, Potter P, Olsen S, Liu J. The persistence of symptom burden: symptom experience and quality of life of cancer patients across one year. Support Care Cancer. 2014;22(4):1089–96.View ArticlePubMedGoogle Scholar
- Fangel LM, Panobianco M, Kebbe LM, Almeida AM, Gozzo TO. Quality of life and daily activities performance after breast cancer treatment. Acta Paul Enferm. 2013;26(1):93–100.View ArticleGoogle Scholar
- Applebaum AJ, Stein EM, Lord-Bessen J, Pessin H, Rosenfeld B, Breitbart W. Optimism, social support, and mental health outcomes in patients with advanced cancer. Psychooncology. 2014;23(3):299–306.View ArticlePubMedGoogle Scholar
- Crothers MK, Tomter HD, Garske JP. The relationships between satisfaction with social support, affect balance, and hope in cancer patients. J Psychosoc Oncol. 2005;23(4):103–18.View ArticlePubMedGoogle Scholar
- Luthar SS, Brown PJ. Maximizing resilience through diverse levels of inquiry: Prevailing paradigms, possibilities, and priorities for the future. Dev Psychopathol. 2007;19(3):931–55.View ArticlePubMedPubMed CentralGoogle Scholar
- Tiet QQ, Bird HR, Davies M, Hoven C, Cohen P, Jensen PS, et al. Adverse life events and resilience. J Am Acad Child Adolesc Psychiatry. 1998;37(11):1191–200.View ArticlePubMedGoogle Scholar
- Maluccio A. Resilience: a many-splendored construct? Am J Orthopsychiatry. 2002;72(4):596–9.View ArticleGoogle Scholar
- Deshields TL, Heiland MF, Kracen AC, Dua P. Resilience in adults with cancer: development of a conceptual model. Psychooncology. 2016;25(1):11–8.View ArticlePubMedGoogle Scholar
- Windle G. The contribution of resilience to healthy ageing. Perspect Public Health. 2012;132(4):159–60.View ArticlePubMedGoogle Scholar
- Johnston MC, Porteous T, Crilly MA, Burton CD, Elliott A, Iversen L, et al. Physical disease and resilient outcomes: a systematic review of resilience definitions and study methods. Psychosomatics. 2015;56(2):168–80.View ArticlePubMedGoogle Scholar
- Picardi A, Bartone PT, Querci R, Bitetti D, Tarsitani L, Roselli V, et al. Development and validation of the Italian version of the 15-item dispositional resilience scale. Riv Psichiatr. 2012;47(3):231–7.PubMedGoogle Scholar
- Southwick S, Charney D. Resilience - The Science of Mastering Life’s Greatest Challenges. New York, U.S.: Cambridge University Press; 2012.View ArticleGoogle Scholar
- Connor KM, Zhang W. Recent advances in the understanding and treatment of anxiety disorders. Resilience: determinants, measurement, and treatment responsiveness. CNS Spectr. 2006;11(10 Suppl 12):5–12.View ArticlePubMedGoogle Scholar
- Rutter M, Moffitt TE, Caspi A. Gene-environment interplay and psychopathology: multiple varieties but real effects. J Child Psychol Psychiatry. 2006;47(3-4):226–61.View ArticlePubMedGoogle Scholar
- Coughlin SS. Surviving cancer or other serious illness: a review of individual and community resources. CA Cancer J Clin. 2008;58(1):60–4.View ArticlePubMedGoogle Scholar
- Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76–82.View ArticlePubMedGoogle Scholar
- Astrow AB, Puchalski CM, Sulmasy DP. Religion, spirituality, and health care: social, ethical, and practical considerations. Am J Med. 2001;110(4):283–7.View ArticlePubMedGoogle Scholar
- Gillespie BM, Chaboyer W, Wallis M. Development of a theoretically derived model of resilience through concept analysis. Contemp Nurse. 2007;25(1-2):124–35.View ArticlePubMedGoogle Scholar
- Lloyd TJ, Hastings R. Hope as a psychological resilience factor in mothers and fathers of children with intellectual disabilities. J Intellect Disabil Res. 2009;53(12):957–68.View ArticlePubMedGoogle Scholar
- Callegari-Jacques S. Bioestatística: princípios e aplicações. Porto Alegre: ArtMed; 2003.Google Scholar
- Abramson JH. Making Sense of Data : Self-instruction Manual on the Interpretation of Epidemiological Data. 2 Revth ed. N. Y: Oxford University Press; 1994.Google Scholar
- Fabbri RM, Moreira MA, Garrido R, Almeida OP. Validity and reliability of the Portuguese version of the Confusion Assessment Method (CAM) for the detection of delirium in the elderly. Arq Neuropsiquiatr. 2001;59(2-A):175–9.View ArticlePubMedGoogle Scholar
- Associação Brasileira de Empresas de Pesquisa/ABEP. Critério de classificação econômica Brasil. Brazil: ABEP; 2008.Google Scholar
- Solano J, Bracher E, Faisal-Cury A, Ashmawi H, Carmona M, Lotufo Neto F, et al. Factor structure and psychometric properties of the Connor-Davidson resilience scale among Brazilian adult patients. Sao Paulo Med. J. [Internet]. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016005003104&lng=en. Accessed 1 Aug 2016. In press 2016. Epub May 13, 2016. http://dx.doi.org/10.1590/1516-3180.2015.02290512.
- Sartore AC, Grossi SA. Herth Hope Index--instrument adapted and validated to Portuguese. Rev Esc Enferm USP. 2008;42(2):227–32.View ArticlePubMedGoogle Scholar
- Mahoney FI, Barthel DW. Funcional evaluation: The Barthel index. Md State Med J. 1965;14:61–5.PubMedGoogle Scholar
- Cincura C, Pontes-Neto OM, Neville IS, Mendes HF, Menezes DF, Mariano DC, et al. Validation of the National Institutes of Health Stroke Scale, modified Rankin Scale and Barthel Index in Brazil: the role of cultural adaptation and structured interviewing. Cerebrovasc Dis. 2009;27(2):119–22.View ArticlePubMedGoogle Scholar
- Minosso JSM, Amendola F, Alvarenga M, Oliveira MA. Validação, no Brasil, do Índice de Barthel em idosos atendidos em ambulatórios. Acta Paul Enferm [Internet]. 2010;23(2):218–23. Available from: www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002010000200011&lng=pt. Accessed 1 Aug 2016.View ArticleGoogle Scholar
- Chochinov HM, Wilson KG, Enns M, Lander S. “Are you depressed?” Screening for depression in the terminally ill. Am J Psychiatry. 1997;154(5):674–6.View ArticlePubMedGoogle Scholar
- Akechi T, Okuyama T, Sugawara Y, Shima Y, Furukawa TA, Uchitomi Y. Screening for depression in terminally ill cancer patients in Japan. J Pain Symptom Manage. 2006;31(1):5–12.View ArticlePubMedGoogle Scholar
- SPSS Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. USA 2008.Google Scholar
- Houck K, Avis NE, Gallant JM, Fuller AF, Goodman A. Quality of life in advanced ovarian cancer: identifying specific concerns. J Palliat Med. 1999;2(4):397–402.View ArticlePubMedGoogle Scholar
- Berterö C, Vanhanen M, Appelin G. Receiving a diagnosis of inoperable lung cancer: patients’ perspectives of how it affects their life situation and quality of life. Acta Oncol. 2008;47(5):862–9.View ArticlePubMedGoogle Scholar
- Friborg O, Sørlie T, Rosenvinge JH. Breast cancer: a manual for a proposed group treatment integrating evidence based resilience factors. Psychol Rep. 2005;97(1):77–97.View ArticlePubMedGoogle Scholar
- Nelson AE, Haase J, Kupst MJ, Clarke-Steffen L, Brace-O'Neill J. Consensus statements: interventions to enhance resilience and quality of life in adolescents with cancer. J Pediatr Oncol Nurs. 2004;21(5):305–7.View ArticlePubMedGoogle Scholar
- Burns DS, Robb SL, Haase JE. Exploring the feasibility of a therapeutic music video intervention in adolescents and young adults during stem-cell transplantation. Cancer Nurs. 2009;32(5):E8–E16.View ArticlePubMedGoogle Scholar
- Robb SL, Burns DS, Stegenga KA, Haut PR, Monahan PO, Meza J, et al. Randomized clinical trial of therapeutic music video intervention for resilience outcomes in adolescents/young adults undergoing hematopoietic stem cell transplant: a report from the Children’s Oncology Group. Cancer. 2014;120(6):909–17.View ArticlePubMedPubMed CentralGoogle Scholar
- Breitbart W. Spirituality and meaning in supportive care: spirituality- and meaning-centered group psychotherapy interventions in advanced cancer. Support Care Cancer. 2002;10(4):272–80.View ArticlePubMedGoogle Scholar
- Greenstein M, Breitbart W. Cancer and the experience of meaning: a group psychotherapy program for people with cancer. Am J Psychother. 2000;54(4):486–500.PubMedGoogle Scholar
- Breitbart W. Reframing hope: meaning-centered care for patients near the end of life. Interview by Karen S. Heller. J Palliat Med. 2003;6(6):979–88.View ArticlePubMedGoogle Scholar
- Lee V, Robin Cohen S, Edgar L, Laizner AM, Gagnon AJ. Meaning-making intervention during breast or colorectal cancer treatment improves self-esteem, optimism, and self-efficacy. Soc Sci Med. 2006;62(12):3133–45.View ArticlePubMedGoogle Scholar
- Kissane DW, Bloch S, Smith GC, Miach P, Clarke DM, Ikin J, et al. Cognitive-existential group psychotherapy for women with primary breast cancer: a randomised controlled trial. Psychooncology. 2003;12(6):532–46.View ArticlePubMedGoogle Scholar
- Chochinov HM, Kristjanson LJ, Breitbart W, McClement S, Hack TF, Hassard T, et al. Effect of dignity therapy on distress and end-of-life experience in terminally ill patients: a randomised controlled trial. Lancet Oncol. 2011;12(8):753–62.View ArticlePubMedPubMed CentralGoogle Scholar
- Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31(1):58–69.View ArticlePubMedGoogle Scholar
- Evers AW, Zautra A, Thieme K. Stress and resilience in rheumatic diseases: a review and glimpse into the future. Nat Rev Rheumatol. 2011;7(7):409–15.View ArticlePubMedGoogle Scholar
- Brown RP, Gerbarg PL. Yoga breathing, meditation, and longevity. Ann N Y Acad Sci. 2009;1172:54–62.View ArticlePubMedGoogle Scholar
- Alidina K, Tettero I. Exploring the therapeutic value of hope in palliative nursing. Palliat Support Care. 2010;8(3):353–8.View ArticlePubMedGoogle Scholar
- Miller JF. Hope: A construct central to nursing. Nurs Forum. 2007;42:12–9.View ArticleGoogle Scholar