Pain and Hope in Patients With Cancer: A Role for Cognition

Mei-Ling Chen, PhD, RN

Disclosures

Cancer Nurs. 2003;26(1) 

In This Article

Discussion

The levels of pain intensity of various forms found in this study were quite similar to those of other studies with the Taiwanese cancer population.[13,25] This study found no difference in hope levels between patients with cancer who had pain and those who did not have pain. This finding suggests that the presence of pain itself does not influence patients' hope, although it may be seen as a threat to hope. A similar conclusion was drawn by Greene et al,[33] whose study of hope with 60 hospitalized patients showed that stressful personal circumstances do not inevitably lead to feelings of hopelessness.

For the patients with pain, this study found that among the sensory dimensions of pain assessed, only bearable pain intensity correlated with hope. On the other hand, cognitive dimensions of pain, such as meaning of cancer pain, were significantly correlated with hope in an expected direction. These findings are contradictory to those of Huang,[13] who found that pain intensity was significantly correlated with hope, as measured by the HHI. The levels of pain intensity in these two studies are similar. Comparison of the sample profiles from the two studies, however, shows some differences. First, the mean level of hope was lower in Huang's[13] study (mean, 31.55 ± 8.64) than in the current study (pain group mean, 37.04 ± 5.34). Second, functional status, as measured by KPS in both studies, was slightly higher in this study (mean, 73.85%) than in Huang's[13] (mean, 65.67%), indicating better health condition and independence in the current study. Pain and functional status may interact and affect hope levels. In other words, for patients with low functional performance, pain intensity and hope could be correlated, but for those with high functional performance, this correlation may not exist. This possibility, however, was not supported by the data from the current study and needs to be verified in a future study.

According to Herth's[16] qualitative findings, uncontrolled pain would interfere with the ability of patients who have cancer to maintain hope. The data from the current study do not support this statement because pain relief and pain duration, two likely indicators for the extent of pain control, were not correlated with hope. On the other hand, the data indicate that the more pain a patient can tolerate, the higher level of hope he or she tends to have. This finding has important clinical implications because a patient's report of bearable pain intensity reflects his or her beliefs and experiences of pain. In other words, a person's cognition of pain may play a significant role in how he or she rates the level of bearable pain intensity, and it is this cognition of pain that influences the individual's level of hope. This finding does not suggest, however, that nurses should encourage patients to bear their pain. The levels of pain endurance that patients believe they have may not be equivalent to their actual pain behavior (eg, not taking pain medicines).

The most important finding from this study is the significant correlation between pain cognition and hope. Three meanings ascribed to cancer pain (challenge, loss, and threat) were significantly correlated with hope. Patients who ascribed more positive meaning to their pain, such as viewing pain as a challenge, tended to have a higher degree of hope. On the contrary, patients who interpreted their pain negatively, such as viewing pain as a threat or a profound loss, tended to have a lower degree of hope. No previous studies have specifically examined the relation between the meaning of pain and hope, but three studies have examined the relation between meaning of pain and coping strategies[34] as well as depression[27,35] in patients with cancer. Patients who ascribed a meaning of challenge to their pain reported significantly lower depression scores than those who perceived pain as an enemy or punishment.[35] Because hopelessness is a major component of depression, the findings of the current study add new evidence to the relation between the meaning of cancer pain and psychological well-being.

Besides this correlation between the cognitive dimensions of pain and hope, the data indicate that perceived treatment effect was significantly correlated with hope, whereas disease stage was not. Perceived treatment effect reflects a subjective cognition of disease progress, whereas disease stage reflects an objective measure. Again, this result demonstrates a link between subjective cognition and hope. Patients who answered 'unknown' to the question of treatment effect had a level of hope similar to that of patients who believed that treatment had improved their disease condition. Uncertainty about one's disease situation may create room for positive future expectations, leading to hopefulness.[36] Patients who are uncertain about their treatment effect may be anxious,[31] but their sense of hope can be preserved. Dealing with patients' uncertainty creates a challenge for clinical nurses and doctors, who must learn how to deliver information, especially bad news, in a hopeful manner.

The author proposes that the patient's cognition or interpretation of events or crises determines his or her level of hope rather than relatively objective measures of stressful events such as pain intensity or disease stage. The spirit of this proposition is similar to the notion of illness perception presented by Weinman and Petrie.[37] Their central idea, originating from the illness representation theory proposed by Leventhal et al,[20] is that individuals facing illness construct their personal cognitive models of illness, which reflect their pooled understanding of previous experiences. Personal cognitive models of illness or illness perceptions not only direct their coping responses to the illness, but also influence health-related outcomes such as adherence, emotional distress, and disability.

Because the current study was limited by its cross-sectional design, the opposite view could be argued, that hope influences a person's perception of illness and pain. In that case, hope would be treated as a relatively stable personality style that influences how people view the crises encountered in life. However, previous studies have shown hope to be a dynamic phenomenon that does change over time.[16,38] Furthermore, interventional studies have suggested that hope can be improved in patients with cancer.[39,40] Therefore, the more plausible explanation for the data is that cognition of crises such as pain and disease progression influences an individual's level of hope.

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