There is little convincing agreement in the literature on the definition, measurement, and application of hope. The usual platitude—where there's life, there's hope—does not clarify the confusion, and clinical practice puts paid to a simplistic approach to hope. A 28 year-old man with widespread melanoma is hoping the doctor will offer him a new treatment. He hopes he will marry and have a family. The hopes to us are unrealistic—but for him they are tangible, the stuff of life, the dreams that keep him going. What should clinicians do with this man's hopes? Should we support him medically, for the sake of hope? Does hoping prolong life against death? Should we encourage unproven therapies as elixirs of hope? When hope clashes with reality and causes angst, is it better to jettison hope, or reality? What does acceptance of death mean in terms of hope? What can it mean to live without hope?

Objective: This article describes an innovative 8-h training program that provides clinicians with the competencies necessary to conduct efficient, effective, and compassionate advance care planning discussions throughout the trajectory of life-limiting illnesses.

Method: The Advance Care Training Program (ACare) includes 6 h of group workshops and 2 h of one-on-one faculty–learner interaction. In this article, we describe the (1) objectives of ACare; (2) structure, training procedures, and educational rationale of ACare training; and (3) educational outcome studies in progress.

Results: ACare training in various forms has already been provided to over 100 medical professionals (medical students, medical residents, oncology and geriatric fellows, medical attendings, social workers, and nurses). Formative outcome data indicate considerable trainee satisfaction. Emerging summative outcome data indicate improved skills.

Significance of results: Widespread adoption of the program could increase the frequency and quality of advance care planning discussions between patients with life-limiting illnesses, their health care providers, and families.

Objective: The purpose of this study was to gather validity evidence for an innovative experience of hope scale, the Hope Differential-Short (HDS), and evaluate its clinical utility for assessing hope in advanced cancer patients.

Methods: A consecutive sampling approach was used to recruit 96 patients from an inpatient tertiary palliative care unit and three hospice settings. Each participant completed an in-person survey interview, consisting of the following measures: HDS (nine items), Herth Hope Index (HHI), hope visual analog scale (Hope-VAS) and Edmonton Symptom Assessment System (ESAS).

Results: Using factor analytic procedures, a two-factor structure for the HDS was identified, consisting of authentic spirit (Factor I) and comfort (Factor II). The HDS factors had good overall internal consistency (α = 0.83), with Factor I (α = 0.83) being higher than Factor II (α = 0.69). The two factors positively correlated with the HHI, Hope-VAS, and one of the ESAS visual analog scales, well-being (range: 0.38 to 0.64) and negatively correlated with depression and anxiety, as measured by the ESAS (range: −0.25 to −0.42).

Significance of results: This is the first validation study of the HDS in advanced cancer patients. Its promising psychometric properties and brief patient-oriented nature provide a solid initial foundation for its future use as a clinical assessment measure in oncology and palliative care. Additional studies are warranted to gather further validity evidence for the HDS before its routine use in clinical practice.

Objective: The purpose of this study was to evaluate the psychometric properties of the Herth Hope Index (HHI) in a representative sample of the Norwegian population.

Methods: The HHI-N was administered to 4000 people randomly selected from the Norwegian population. 1893 questionnaires were usable, yielding a response rate of 48.5%.

Results: The internal consistency of the HHI-N, estimated by Cronbach's alpha, was 0.81. Factor analysis resulted in a two-factor solution, which explained 38% of the variance. The correlation between hope and overall quality of life was 0.48 (p < 0.001), and between hope and fatigue severity −0.30 (p < 0.001).

Significance of results: Further testing, especially with regard to the dimensionality of the instrument, is recommended.

Objective: Palliative care services have made significant contributions to those needing end-of-life care, but the effect of these services on informal caregivers is less clear. This article reviews the literature and examines the influences of palliative care services on caregivers of people who are dying of cancer, HIV-related illnesses, and illnesses of later life.

Methods: Based on questions that we developed from the literature review, we conducted six focus groups in Toronto, Thunder Bay, and Ottawa, Canada, with informal caregivers about their experiences with caregiving and with palliative care services.

Results: We outline the major themes relating to the 42 focus group participants' experiences of giving support and getting help.

Significance of results: Our findings help us better understand the common concerns of caregivers of terminally ill seniors, people with HIV/AIDS, and people with cancer. The article discusses the implications of participants' experiences for palliative care service providers.

Objective: Hospice staff members have concerns about the appropriateness of enrolling terminally ill people in research studies. These concerns can have profound implications for the advancement of palliative and hospice care as they can impede the empirical investigation of interventions for improving the quality of life of patients with advanced disease. This survey study was designed to examine hospice staff attitudes, beliefs, and values about research with their patients and family members.

Methods: This study utilized a cross-sectional, anonymous survey design to measure hospice staff members' beliefs, attitudes, and values. The survey contained questions derived by hospice and palliative care experts from their experience and review of the literature. It was handed out at staff meetings and returned via mail. The survey contained 14 questions and was able to be completed in less than 5 min.

Results: A total of 225 participants (56.25% response rate) completed the survey and were included in the data analysis. Hospice staff members were largely supportive about the idea of conducting research with patients and family members (mean agreement of 4.08–4.44 on several perception items about research on a 1–5 scale). They also acknowledged a mixture of being protective of controlling access to patients (52% wanted to be the ones to approach patients) and not having enough time for research (59% either had no time or would be willing to spend no more than 10 min on research).

Significance of results: Although many of the opinions derived from the survey appear to indicate a willingness to embrace research in a hospice setting, significant barriers, especially time constraints and protective attitudes, remain. Educational efforts and firsthand involvement in the research process might be a useful first step in attempting to address these barriers and traditionally held beliefs against using hospice patients and families in research.

Objective: The standards of care for patients at risk for or with a pressure ulcer in hospitals and nursing homes focus on prevention and ulcer healing using an interdisciplinary approach. Although not a primary hospice condition, pressure ulcers are not uncommon in dying patients. Their management in hospices, particularly the involvement of family caregivers, has not been studied. The objective of this study is to identify the factors that influence care planning for the prevention and treatment of pressure ulcers in hospice patients and develop a taxonomy to use for further study.

Methods: A telephone survey was conducted with 18 hospice directors of clinical services and 10 direct-care nurses. Descriptive qualitative data analysis using grounded theory was utilized.

Results: The following three themes were identified: (1) the primary role of the hospice nurse is an educator rather than a wound care provider; (2) hospice providers perceive the barriers and burdens of family caregiver involvement in pressure ulcer care to be bodily location of the pressure ulcer, unpleasant wound characteristics, fear of causing pain, guilt, and having to acknowledge the dying process when a new pressure ulcer develops; and (3) the “team effect” describes the collaboration between family caregivers and the health care providers to establish individualized achievable goals of care ranging from pressure ulcer prevention to acceptance of a pressure ulcer and symptom palliation.

Significance of results: Pressure ulcer care planning is a model of collaborative decision making between family caregivers and hospice providers for a condition that occurs as a secondary condition in hospice. A pressure ulcer places significant burdens on family caregivers distinct from common end-of-life symptoms whose treatment is directed at the patient. Because the goals of pressure ulcer care appear to be individualized for a dying patient and their caregivers, the basis of quality-of-care evaluations should be the process of care rather than the outcome of an incident pressure ulcer.

Objectives: This article synthesizes the published literature related to the construct of meaning in the adult cancer population.

Methods: The databases CancerLit, CINAHL, Medline, PsychINFO, and the Journal of Psychosocial Oncology and PsychoOncology were searched to identify all studies related to meaning. The methodological aspects of all studies are described and the conceptual aspects are summarized only from those studies that met criteria for methodological rigor and validity of findings. The definitions for global meaning, appraised meaning, search for meaning, and meaning as outcome as proposed by Park and Folkman were used to interpret the findings.

Results: Of 44 studies identified, 26 met the criteria for methodological rigor. There is strong empirical and qualitative evidence of a relationship between meaning as an outcome of and psychosocial adjustment to cancer.

Significance of results: The qualitative findings are considered useful for the development of psychosocial interventions aimed at helping cancer patients cope with and even derive positive benefit from their experience. However, variations in the conceptual and operational definitions, frequent reliance on homogeneous and convenience sampling, and the lack of experimental designs are considered to be methodological limitations that need to be addressed to advance the study of meaning in the context of cancer.

Indigenous community health outreach workers (CHWs), who serve as a bridge between underserved, difficult-to-reach minority populations and health professionals, can play a critical role in bringing palliative care to patients dying of AIDS and other illnesses in the inner city. Although the contribution of CHWs in the delivery of “curative” and preventive services has been well established, little attention has been given to CHWs in palliative care.

Integrating the medical literature with experiences of a team providing HIV palliative care in the Bronx, a descriptive typology of critical stages and components in the work of CHWs in end-of-life care in the inner city is presented. A longitudinal case narrative, told from the perspective of the CHW, is used to demonstrate the richness and complexity of the CHW's role.

The article concludes with a description of the experience of the CHW, straddling two worlds—the world of the inner city patient and the world of the health care providers—and explores the special characteristics of the individuals who can fill this vital role in palliative care.

Objective: Cancer patients often encounter sexual concerns during the diagnosing, treatment, and recovery phase of their illness. However, the sexual concerns of these patients are often overlooked. Brain cancer patients are no exception to this oversight.

Methods: A case report of a 39-year-old patient with a history of high-grade anaplastic astrocytoma presented to the Sexual Health Program at the Memorial Sloan-Kettering Cancer Center complaining of vaginal discharge and several months of amenorrhea. Although the patient was administered extensive aggressive antineoplastic treatments, her disease rapidly progressed.

Results: Despite the patient's terminal illness she continued to have normal sexual thoughts, feelings, and desires; however, she had difficulty discussing these issues with her partner and caregiver, who was her mother. An examination by the sexual medicine gynecologist noted no clinical signs of genital infections; however, there was minimal vaginal atrophy. Her sexual health laboratory evaluation was extensively abnormal. Her treatment consisted of intravaginal non-hormonal moisturizers and vaginal lubricants, counseling, and sexual education. The patient successfully engaged in sexual contact with her partner by the third counseling session.

Significance of Results: Almost all oncology patients have sexual concerns during or following cancer treatment. These patients should be referred to comprehensive sexual health programs for treatment, if available.

I have been living with Multiple Sclerosis (MS) for 20 years. For 20 years I have gone to sleep with MS, awakened with MS, worked with MS, fell in love with MS, got married with MS, went through five miscarriages with MS, gave birth to a beautiful son with MS, raised a son whose life would be marked by the MS of a parent, and most importantly, I will go on living with MS for as long as fate allows. My wife Rachel has MS.

End-of-life care provides an opportunity to help a patient find meaning in the experience of dying. This is a challenge because the experience of dying can rob a patient of meaning. The first step is to look at death as being a process of life rather than an event. This is brought about by welding the broken pieces of the mind–body connection. Medicine cannot always fix broken pieces, but spiritual welding always puts us back together again. Compassionate end-of-life care helps a patient connect spirituality with the search for meaning and transcendence.

He was slim in build, and even as he sat in his wheelchair, you could see that he was tall. Infected, he claimed, by a serious bout of sexual promiscuity with women and too much alcohol. He gave me an overenthusiastic grin, trying just a bit too hard to be nonchalant, and said “Hey good-looking, coming to see me next?” I nodded absent-mindedly, trying to get through the note I was writing and simultaneously fending off the 20-odd patients clamoring the halls, all keen to get a word in with the doctor before their chance at an intervention disappeared for another week. Even though we frequented the nursing home far more often than mandated by state regulations, there still seemed to be so much to do and such little time to do it in. I told Mr. J I'd be with him in a minute, and he smiled affably. “I'll be waiting in my room,” he said pointedly, knowing full well it would take me too long to get to him.

Clinical update: Literature abstracts.

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