Coping skills intervention improves quality of life and reduces stress of caregivers

Intervention requires 3 brief sessions

New research shows that a three-session, educational intervention with caregivers of cancer patients in hospice can significantly improve the caregivers' quality of life and reduce burden related to the patients' symptoms and duties.1

Investigators adapted a psycho-educational intervention used in stress research, called Brief COPE, to use with hospice cancer patients, says Susan McMillan, PhD, ARNP, Lyall & Beatrice Thompson professor of oncology quality of life nursing at the University of South Florida College of Nursing in Tampa, FL.1,2

"We realized that the difference in hospice and other cancer patients is by the time they get to hospice they are very ill and fragile and weak," McMillan says. "So we couldn't use an intervention of self-care practices as you might do with healthier patients."

Instead, the intervention is designed for the caregivers since most hospice care in the United States takes place at home, she adds.

"Hospices support family caregivers, so our intervention was designed to support, aid, train, and help the family caregiver," McMillan says.

COPE is an acronym that describes the intervention, as follows:

  • C for creativity: "We want the caregiver to be creative in managing the symptoms," McMillan says.
  • O for optimism: "We want caregivers to believe they can manage the symptoms," McMillan says. "We find a lot of situations where people believe pain cannot be relieved, and so they give up and don't try."
  • P for planning: Caregivers need to plan around events that might cause symptoms, such as pain and shortness of breath, and help patients better cope with them, she says. "For instance, if the family is going to have a get-together, then plan the pain medication around that event so the patient can be comfortable for most of the event."
  • E for expert: When in doubt, caregivers should consult expert sources, such as hospice staff and the COPE manual that they're given, McMillan says.

The manual is in a 3-inch binder, and its sections are written in an accessible style so caregivers can easily refer to chapters of particular interest whenever they have questions or problems, she explains.

Investigators added a chapter on constipation to the COPE manual, McMillan notes.

"Whenever you manage a patient's care with opioids, you almost always cause constipation, so it's foolish to think you'll manage pain and ignore constipation," McMillan says. "It's an under-assessed problem throughout the health care arena."

After modifying the intervention for the hospice caregiver, investigators began to test it to see if it would be effective and immediately translatable to the bedside, McMillan says.

When designing the study with the intervention group and the group that received standard care, researchers decided to add a third arm that would receive standard care plus three extra visits in the home, McMillan says.

"As we were designing the study, we thought the intervention group might benefit from the extra attention," she explains. "Maybe just the effect of the time was what we were measuring, so we added a second control group that we called attention control."

The results showed that the COPE intervention group of caregivers had a significantly better quality of life than both the standard care group and the standard care plus extra time group, McMillan says.

"The intervention group experienced less stress from the patient's symptoms," she says. "Our randomized scheme worked, and it was the training we gave the caregivers that made the difference."

Also, the study found that the COPE intervention decreased burden related to patients' symptoms and caregiving tasks, meaning the caregivers were better able to tolerate patients' pain and constipation or the personal care tasks.1

The study's findings suggest that COPE intervention is a way to improve caregiver's well-being and enhance existing hospice care.1

Typically cancer patients do not stay in hospice care for long, so the intervention was designed to be presented with three visits in nine days, McMillan says.

Registered nurses provided the intervention visits, and the first one was conducted within the first 2-3 days of admission, the second was on days 5 or 6, and the third was on the 7th to 9th day, she says.

The study enrolled only patients who had at least two of three main symptoms, including pain, shortness of breath, and constipation, McMillan says.

The interventions basically were implemented in this way:

• First visit: The RN introduced herself and spoke about the COPE approach, explaining what each letter in the acronym stands for, McMillan says.

"Then we focused on one of the patient's symptoms, letting the caregiver decide which was the priority symptom," she says. "We taught the caregiver how to do the COPE intervention, and gave the caregiver homework about the second symptom."

The first session lasted about 45 minutes, although initially it was supposed to be 1.5 hours long, McMillan notes.

"We cut the time in half because of the caregiver's attention span," she says.

Also, the intervention's first approach was to show caregivers a short video that demonstrates the COPE method, but investigators quickly found that patients didn't have the patience to sit through the video and then concentrate afterwards on what the nurse had to say, McMillan says.

"So we piloted the first 25 patients with the video, and then eliminated it and, instead, had the RN go through the intervention, using the COPE book," she says.

• Second visit: This session focused on the second symptom that concerned the caregiver, going over the homework assignment. Then the nurse briefly would go over the information from the first session, McMillan says.

This session lasts one-half an hour and it includes an assignment regarding the third symptom.

• Third visit: This visit focuses on the third symptom, recapping the information provided for the second symptom.

Also, since this is the last visit, part of the half hour session includes a closure process to make certain the caregiver understands that this particular nurse won't be returning to the home, McMillan says.

The study's COPE intervention is immediately translatable for hospices with cancer patients, and there already have been requests for the COPE manual from hospices around the world, McMillan says.

Eventually the entire intervention and manual will be available electronically so that it might be easily sent to anyone who requests, she adds.

"We manualized this intervention so that we could share it with other investigators or other hospices that asked for it," McMillan says.


1. McMillan SC, et al. Impact of Coping Skills Intervention with Family Caregivers of Hospice Patients with Cancer, A Randomized Clinical Trial. Cancer. 2006;106:214-222.

2. Carver CS. You Want to Measure Coping But Your Protocol's Too Long: Consider the Brief COPE. Int J Behav Med. 1997;4:92-100.

Need More Information?

  • Susan McMillan, PhD, ARNP, Lyall & Beatrice Thompson Professor of Oncology, Quality of Life Nursing, University of South Florida College of Nursing, MDC Box 22, 12901 Bruce B. Downs Blvd., Tampa, FL 33612. Email: