Medicine:Distress in cancer caregiving

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An informal or primary caregiver is an individual in a cancer patient's life that provides unpaid assistance and cancer-related care.[1] Due to the typically late onset of cancer, caregivers are often the spouses and/or children of patients, but may also be parents, other family members, or close friends. Informal caregivers are a major form of support for the cancer patient because they provide most care outside of the hospital environment. This support includes:

  • Physical support: management of side effects and late effects of treatment[1][2][3][4] and assistance with personal tasks such as bathing.[3][4]
  • Emotional support[2][3][4]
  • Financial assistance: helping cover the expenses associated with cancer treatment[3][4]
  • Practical assistance: treatment monitoring,[1][2][3] assistance with decision making[4] and assistance with non-personal tasks such as grocery shopping[4]
  • Spiritual support[3]

History

With medical advances in cancer screening and treatment, cancer has become a chronic rather than an acute disease with the result that patients survive longer with cancer.[4] As a result, there has been a push towards outpatient care in recent years.[4][5][6] Consequently, informal caregivers are now taking on the responsibility of caring for a loved one with cancer. Informal caregivers have become so essential that they are estimated to provide an average of 55% of the care needed.[4] For years, research has been reporting the physical, psychological, financial, social, and spiritual repercussions of cancer on the patient. With the discovery of the distress, particularly psychological, that cancer could cause in patients, researchers also began to investigate whether caring for someone with cancer could have similar effects on informal caregivers. Over the years, many stressors have been identified and the effects of caring for a loved one with cancer are becoming well documented. Research in this area is continuing not only to better understand the caregiver's experience, but also to learn how their adjustment to the caregiver role impacts their ability to provide care to the cancer patient.

Psychological repercussions

Patient-caregiver differences

While both the cancer patient and caregiver are psychologically affected by cancer, the way it can affect them differs in many respects. While both patients and caregivers report significant unmet needs in the areas of managing daily life, emotions, and social identity, it has been found that patients are less concerned with these issues than caregivers are.[7] This may be due to caregivers neglecting their own needs in order to improve the care of the patient.[1] Men and women may have different perceptions of the cancer and its effects depending on their role as either the patient or the caregiver.[8]

Phases of the cancer trajectory

Many researchers and clinicians have divided the cancer trajectory in order to explain the changes that occur to the patient and caregiver at various points throughout the cancer trajectory.

Initial or acute phase

The initial or acute phase encompasses the time of diagnosis.[6] A number of stressors can lead to caregiver psychological distress with the diagnosis of treatment. At this point in the trajectory, the most salient psychological outcomes revolve around fear,[1][9] uncertainty,[3][9] sadness[9] and feelings of powerlessness or helplessness.[1][9] Additionally, in studies where cancer recurrence was not evaluated, caregivers report the highest levels of anxiety and post-traumatic stress symptoms during this phase.[10] Caregivers are often frightened and upset by the diagnosis of their loved one, but they have an additional responsibility of trying to support the patient as they go through this difficult time. In the process of providing support, caregivers are often overlooked and have no one to turn to with their own concerns.[2] This period is full of uncertainty, with both the patient and the caregiver not knowing what to expect in terms of treatment, recovery, and overall outcome.[9] This can lead to significant psychological distress for some caregivers.

Chronic phase

The chronic phase encompasses the treatment for cancer.[6] Along with the psychological repercussions typical of the initial phase, many other psychological outcomes become relevant as the patient undergoes cancer treatment due to a number of additional stressors that the caregiver must deal with. These additional stressors may cause "intrapsychic strain, such as guilt or changes in the caregiver's self-concept" (Haley, 2003, p. 153).[2] For a minority of caregivers, they may meet the criteria for a psychiatric diagnosis, typically of depression or an anxiety disorder.[11] But for the majority, any distress they experience does not reach clinically diagnosable levels, although they may exhibit depressive symptoms.[3] Currently, it remains uncertain how levels of psychological distress change with time. Some studies report that psychological distress decreases over time, but others report that it increases.[11] This increase may be a result of caregivers neglecting their own needs while caring for the patient. For some, this emotional repression may lead to feelings of resentment towards the patient.[6] At this point of the trajectory (and ongoing), caregivers may also begin to exhibit symptoms of burnout due to the increased work-burden of caring for someone with cancer.[6] There are many physical and emotional components to burnout. Amongst the emotional components, caregivers may experience frustration, anger, depression, resentment and insecurity.[6]

Resolution phase

The resolution phase encompasses the completion of treatment, but there are a number of directions that the cancer trajectory can go from this point.[6] For some families, resolution may consist of the movement into palliative care and bereavement. For others, this may involve a transition into survivorship, where the patient may go into remission or may experience cancer recurrence. Caregivers may experience the same fears, uncertainties, burnout and feelings of guilt or sadness as caregivers in the previous stages. However, depending on the path that the family experiences after treatment, there are additional psychological repercussions for caregivers.

Palliative care and bereavement

Palliative care is an especially demanding task for cancer caregivers than less progressive cancer because the care required for those with terminal cancer tends to be more demanding.[11] Caregivers in this situation often report high caregiver burden lasting the entire period.[3] Caregiver distress also tends to increase as patients progress through this phase, causing a lower caregiver quality of life.[11][12] Having a difficult time with caregiving increases distress caregivers face as they enter the bereavement period after the death of their loved one,[13] whereas finding meaning in caring for their loved one may relate to better long term adjustment for caregivers.[14] Before bereavement, loved ones often face anticipatory grief, where they mourn and prepare for the loss of their loved one.[14] Families often react with fears of abandonment, anxiety, hopelessness and helplessness, and an intensified attachment to their loved one. Upon the death of their loved one, caregivers typically experience grief, which in a minority of cases may be complicated by a diagnosis of Major Depressive Disorder later in the grief process.[14]

Survivorship

As patients and caregivers enter the survivorship period after the completion of primary treatment, they often feel uncertain and overwhelmed by what lies before them.[15] Patients often leave their last treatment session without much direction as to what they should expect next.[16] This is distressing for the caregiver as well because caregiving continues into this phase of the cancer trajectory because of the long-term and late effects of treatment, the psychological distress patients face, and any other related factors. A common concern faced by survivors and their caregivers is how to return to their "normal" life without cancer.[17] As well, survivors and caregivers are often uncertain and fearful about death and cancer recurrence,[3] even in the absence of cancer-related symptoms.

Recurrence

Cancer recurrence has been called "one of the most stressful events in the course of illness for both patients and their families".[3] Research on the effect that recurrence has on caregivers is mixed. Some caregivers may report even poorer quality of life than the recurrent survivors themselves, as well as depressive moods, fears about recurrence and hopelessness (Kim & Given, 2008). In contrast, some caregivers report lower levels of strain in recurrence than with the initial cancer, presumably because they had adapted to the stress of chronic illness.[18]

Physical repercussions

Along with psychological repercussions of cancer, some caregivers also experience physical effects due to caregiving. This is particularly true of highly burdensome caregiving,[3] as is typically the case with older or palliative patients. Commonly, caregivers report sleep disturbances, such as fatigue or insomnia.[1][4][9][12][19] In caregivers of advanced stage patients, these disturbed sleep patterns are associated with symptoms of depression.[3][19] Sometimes, caregivers may also experience a loss of appetite or may meet the criteria for an eating disorder.[4][9] For caregivers experiencing burnout, there are also often physical effects. These include: headaches, insomnia, backaches, lethargy, lingering colds, gastrointestinal upset, and cardiovascular problems.[6] Other reported physical repercussions of caregiving include: impaired immunity,[1][6] high blood pressure,[1] and arthritis.[3] As is the case with psychological distress, research suggests that the physical repercussions that caregivers experience may be due to them neglecting their own needs and physical health in order to improve the care of the patient.[1]

Stressors

Social

A number of factors regarding relationships with the patient, spouse, family or others can increase caregiver distress. One major factor is the social role changes they often face[2][3][11] – for example, being a caregiver and a parent. Caregiving can also cause a decrease in the social activities that the caregiver usually engages in because they are required to take on extra tasks to help their loved one.[2] For some caregivers, this role strain can cause depression, resentment, or a loss of intimacy with the patient. In some families, the stress of caregiving can also lead to increased family conflict.[2] For most ill patients and their spousal caregivers, scores of marital satisfaction tend to be very similar to the normal population.[20][21] But for a minority, cancer and caregiving can cause relationship strain and can impact the couple's intimacy.[3] Depending on the type of cancer, caregivers have also reported changes in their sexual relationships (usually decreases in sexual activity).[3][9] This may be because of the physical changes and body image issues certain cancer patients can face from treatment or from the cancer itself.[22][23]

Lack of knowledge or experience

There are often issues cited with the dissemination of practical knowledge for caregivers of cancer patients.[1][5][9][24] Caregivers often feel underprepared when taking on a caregiver role because they are misinformed, or don't have full information, on the progression the disease may take or the treatment needed for it.[1][24] There is also a lack of information or communication between the caregiver and medical staff regarding how they should provide care.[1][24] Often, caregivers have little knowledge of the resources available to them to assist in their roles, or to help them cope with the psychological difficulties they themselves are having.[1] Educating the caregiver has been shown to decrease stress levels.[25]

Economic

Caregivers with low income tend to have a more negative caregiver experience.[4] Some spousal caregivers may feel required to quit their job in order to fulfill care requirements.[26] Other partners may choose to work more in order to try to offset some of the financial pressures.[1][6][9] The fiscal pressures of losing an income source, increasing expenditures to pay for treatment, and having a lower household income to pay for daily expenditures[2][26] have been linked with causing significant distress in caregivers.[1][3]

Patient characteristics

The physical and mental impairments that are caused by cancer may also cause significant problems for the caregiver.[1][4][10][25] The patients' ability to function on their own and to independently take care of themselves, termed functional status, has a strong effect on caregivers.[1][4] Caregivers of patients with low functionality, or who almost entirely rely on the caregiver for their needs, may cause particular distress for the caregiver.[25] Strongly linked to this, the type of help that caregivers are required to provide may be a stronger predictor of their caregiver burden than the time they must commit to helping.[4] This is a function of the patient's functional status: having to help with personal tasks because the patient is unable to take care of himself or herself tends to cause greater caregiver burden than having to engage in non-personal tasks. Survivors who suffer from a decreased mental capacity, much like low functioning survivors, also put increased strain on their caregivers. The duration of care, and the patient's ability to cope with the symptoms of cancer and cancer treatment have also been linked to the levels of distress reported by caregivers. In addition, patients who show more distress, concern or hopelessness, or who appraise the illness or caregiving more negatively tend to have caregivers with a lower quality of life.[4]

Other variables

Gender

Results about the differential effects of gender on patient and caregiver distress are mixed, but a recent meta-analysis has indicated that regardless of role (i.e. patient or caregiver), women are more distressed by cancer than men.[27]

Age

The age of the patient and caregiver can affect the psychological effect that cancer has on them. However, which age group of caregivers (young adult, middle age or elderly) are more distressed by caregiving is still unconfirmed. Some suggest that younger caregivers suffer from more psychological distress,[3] but others suggest that elderly caregivers are more at risk for distress.[28] This may be a function of the phase of the cancer trajectory that caregivers are undergoing: studies tend to find high distress amongst younger caregivers in the acute and chronic phases, and high distress amongst elderly caregivers in the resolution (specifically, bereavement) phase of caregiving.[3] Elderly caregivers are also at greater risk for negative effects on their physical health than are younger caregivers.[1] Older caregivers are more likely to have comorbid health conditions and decreased physical ability. In relation to their psychological health, older caregivers may be at higher risk because of a higher likelihood of social isolation than younger caregivers. However, older caregivers are usually more satisfied with their role than are younger caregivers.[29] Among women, this may be explained by the finding that younger female caregivers tend to perceive demands on their time due to role strain more negatively.[30] Role strain tends to be more severe for later middle age caregivers due to their many responsibilities with family and work.[31] Caregivers in this age group may also be more prone to emotional distress, and ultimately, a decreased quality of life.[28] This is because the caregivers are at higher risk of experiencing social isolation, career interruption, and a lack of time for themselves, their families and their friends.[32] The age of the cancer patient can also affect the physical and psychological burden on caregivers. Given that the highest percentage of individuals with cancer are older adults, caregiving for older cancer patients can be complicated by other comorbid diseases such as dementia.[2] The spouses of elderly cancer patients are likely to be elderly themselves, which may cause the caregiving to take an even more significant toll on their well being.

Socioeconomic status

Individuals of lower socio-economic status may experience the increased burden of financial strain due to the expenses involved in cancer care.[3][4] This may cause them to experience more psychological distress from cancer caregiving than other caregivers. Caregivers with lower levels of education have been shown to report more satisfaction from caregiving.[4]

Outlook/perspective

Caregivers can sustain their quality of life by deriving self-esteem from caregiving.[4] Caregivers' beliefs and perceptions can also strongly impact their adjustment to caregiving. For instance, caregivers who believe their coping strategies are effective, or caregivers who perceive sufficient help from their support networks, are less likely to be depressed.[18] In fact, these factors relate more strongly to their levels of depression than stress does.

Personality factors and coping patterns

Personality factors may play a role in caregiver adjustment to cancer. For instance, caregivers that are high on neuroticism are more likely to suffer from depression.[11] On the other hand, caregivers that are more optimistic[2] or who acquire a sense of mastery from caregiving[1] tend to adjust better to the experience. Along these lines, caregivers who use problem-solving coping strategies or who seek social support are less distressed than those that use avoidant or impulsive strategies.[23] Some caregivers also report that spirituality helps them cope with the difficulties of caregiving and watching a loved one endure their cancer.[9]

Relationship to patient

The caregiver's relationship to the patient can be an important factor in their adjustment to caregiving. Spouses, followed by adult daughters, are the most likely family members to provide care.[2] Spouses generally tend to have the most difficulty adjusting to this experience,[2][4] although adult daughters also tend to express difficulty. However, this may be a factor of age more-so than the relationship to the patient in that spouses tend to be older caregivers than adult children.

Interventions

Many studies have suggested that intervention may curb stress levels of caregivers.[1][2][3][24] There are many types of interventions available for cancer caregivers including: educational,[2] problem-solving skills training[1][2] and grief therapy.[1][2] Family-focused grief therapy has been shown to significantly improve overall distress levels and depression in those affected by cancer.[14] Likewise, interventions that increased patients general knowledge about their specific disease have been reported to reduce anxiety, distress and help them take a more active part in the decision making process.[24] Interventions by members of the healthcare system designed to teach caregivers proficiency in both the physical and psychological care of patients have been shown to benefit both partners.[33] Interventions that focus on both the patient and the caregiver as a couple have proven more effective in helping adaptation to cancer than those that try to help the patient or caregiver individually, largely due to the inclusion of training in supportive communication, sexual counselling and partner support.[34] Finally, spirituality has been demonstrated to be related to quality of life for caregivers.[35]

Benefits

Not every caregiver experiences only negative consequences from cancer caregiving. For some caregivers, there are personal benefits that stem from caring for their loved one, and the benefits found might help to buffer the negative experiences that caregivers frequently face.[1] The concept of post-traumatic growth is of particular note when discussing the benefits of cancer caregiving, and cancer in general. Post-traumatic growth is a positive psychological growth that occurs as a result of a traumatic incident. Studies have found that within the cancer caregiver population, strong predictors of post-traumatic growth are: less education, being employed, or displaying high avoidance tendencies pre-surgery, and framing coping strategies in a positive style.[36] Furthermore, individuals who engage in religious coping or have high perceived social support are more likely to report post-traumatic growth. Other benefits of caregiving include: an improved sense of self-worth,[2][3][4] increased self-satisfaction,[1][2][3][4] a sense of mastery,[2][4] increased intimacy with their ill loved one,[2] and a sense of meaning.[1][2] Experiencing a loved one's cancer may also cause significant lifestyle changes for caregivers. For instance, caregivers may become more proactive by engaging in health behaviours such as increased exercise, better diets and increased screening.[3][6] However, this finding is not conclusive; some studies report that certain behaviours such as screening tend to decrease amongst caregivers.[3]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 Given B.; Sherwood P. R. (2006). "Family care for the older person with cancer". Seminars in Oncology Nursing 22 (1): 43–50. doi:10.1016/j.soncn.2005.10.006. PMID 16458182. 
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 Haley W. E. (2003a). "The costs of family caregiving: Implications for geriatric oncology". Critical Reviews in Oncology/Hematology 48 (2): 151–158. doi:10.1016/j.critrevonc.2003.04.005. PMID 14607378. 
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.21 3.22 3.23 3.24 3.25 Kim Y.; Given B. A. (2008). "Quality of life of family caregivers of cancer survivors". Cancer 112 (S11): 2556–2568. doi:10.1002/cncr.23449. PMID 18428199. 
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 Nijboer C.; Tempelaar R.; Sanderman R.; Triemstra M.; Spruijt R. J.; van den Bos G. A. (1998). "Cancer and caregiving: The impact on the caregiver's health". Psychooncology 7 (1): 3–13. doi:10.1002/(SICI)1099-1611(199801/02)7:1<3::AID-PON320>3.0.CO;2-5. PMID 9516646. https://pure.rug.nl/ws/files/6654476/Nijboer_1998_Psycho_Oncology.pdf. 
  5. ↑ 5.0 5.1 Adams E.; Boulton M.; Watson E. (2009). "The information needs of partners and family members of cancer patients: A systematic literature review". Patient Education & Counseling 77 (2): 179–186. doi:10.1016/j.pec.2009.03.027. PMID 19406609. https://radar.brookes.ac.uk/radar/items/5b3620e1-3055-00a7-a57f-9689db0161cd/1. 
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 Golant M. H., Natalie V., Mat (2008). "Other cancer survivors": The impact on family and caregivers". Cancer Journal 14 (6): 420–424. doi:10.1097/PPO.0b013e31818d894a. PMID 19060608. 
  7. ↑ Soothill, K., Morris, S. M., Harman, J. C. (2001). Informal carers of cancer patients: what are their unmet psychosocial needs. Health and Social Care in the Community, 9, 464–475.
  8. ↑ Boehmer U.; Clark J. A. (2001). "Married couples' perspectives on prostate cancer diagnosis and treatment decision-making". Psycho-Oncology 10 (2): 147–155. doi:10.1002/pon.504. PMID 11268141. 
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 Petrie W.; Logan J.; DeGrasse C. (2001). "Research review of the supportive care needs of spouses of women with breast cancer". Oncology Nursing Forum 28 (10): 1601–1607. PMID 11759307. 
  10. ↑ 10.0 10.1 Jantien Vrijmoet-Wiersma C. M.; van Klink J. M. M.; Kolk A. M.; Koopman H. M.; Ball L. M.; Maarten Egeler R. (2008). "Assessment of Parental Psychological Stress in Pediatric Cancer: A Review". Journal of Pediatric Psychology 33 (7): 694–706. doi:10.1093/jpepsy/jsn007. PMID 18287109. 
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Pitceathly C.; Maguire P. (2003). "The psychological impact of cancer on patients' partners and other key relatives: A review". Eur J Cancer 39 (11): 1517–24. doi:10.1016/s0959-8049(03)00309-5. PMID 12855257. 
  12. ↑ 12.0 12.1 Kitrungroter L.; Cohen M. Z. (2006). "Quality of life of family caregivers of patients with cancer: A literature review". Oncology Nursing Forum 33 (3): 625–632. doi:10.1188/06.onf.625-632. PMID 16676018. 
  13. ↑ Holtslander L. F. (2008). "Caring for bereaved family caregivers: Analyzing the context of care". Clinical Journal of Oncology Nursing 12 (3): 501–506. doi:10.1188/08.cjon.501-506. PMID 18515249. 
  14. ↑ 14.0 14.1 14.2 14.3 Grassi L (2007). "Bereavement in families with relatives dying of cancer". Current Opinion in Supportive and Palliative Care 1 (1): 43–49. doi:10.1097/spc.0b013e32813a3276. PMID 18660724. 
  15. ↑ Garofalo J. P.; Choppala S.; Hamann H. A.; Gjerde J. (2009). "Uncertainty during the transition from cancer patient to survivor". Cancer Nurs 32 (4): E8–E14. doi:10.1097/NCC.0b013e31819f1aab. PMID 19444082. 
  16. ↑ Baravelli C.; Krishnasamy M.; Pezaro C.; Schofield P.; Lotfi-Jam K.; Rogers M.; Milne D.; Aranda S. et al. (2009). "The views of bowel cancer survivors and health care professionals regarding survivorship care plans and post treatment follow up.". Journal of Cancer Survivorship 3 (2): 99–108. doi:10.1007/s11764-009-0086-1. PMID 19415504. 
  17. ↑ Hewitt, M., & Greenfield, S. (2005). From cancer patient to cancer survivors. Lost in transition (). Washington, D.C.: The National Academies Press.
  18. ↑ 18.0 18.1 Schumacher K.; Dodd M.; Paul S. (1993). "The stress process in family caregivers of persons receiving chemotherapy". Research in Nursing and Health 16 (6): 395–404. doi:10.1002/nur.4770160603. PMID 8248566. 
  19. ↑ 19.0 19.1 Hearson B.; McClement S. (2007). "Sleep disturbance in family caregivers of patients with advanced cancer". International Journal of Palliative Nursing 13 (10): 495–501. doi:10.12968/ijpn.2007.13.10.27493. PMID 18073709. 
  20. ↑ Chekryn J (1984). "Cancer recurrence: Personal meaning, communication, and marital adjustment". Cancer Nurs 7 (6): 491–8. doi:10.1097/00002820-198412000-00005. PMID 6568868. 
  21. ↑ Tuinman M. A.; Fleer J.; Sleijfer D. T.; Hoekstra H. J.; Hoekstra-Weebers J. E. (2005). "Marital and sexual satisfaction in testicular cancer survivors and their spouses". Support Care Cancer 13 (7): 540–8. doi:10.1007/s00520-004-0758-3. PMID 15660224. https://pure.rug.nl/ws/files/2887325/Tuinman_2005_Support_Care_Cancer.pdf. 
  22. ↑ Alfano C. M.; Rowland J. H. (2006). "Recovery issues in cancer survivorship: A new challenge for supportive care". Cancer J 12 (5): 432–43. doi:10.1097/00130404-200609000-00012. PMID 17034679. 
  23. ↑ 23.0 23.1 Couper J.; Bloch S.; Love A.; Macvean M.; Duchesne G. M.; Kissane D. (2006). "Psychosocial adjustment of women whose partners have prostate cancer". Psycho-Oncology 15 (11): 937–953. doi:10.1002/pon.1031. PMID 16521081. 
  24. ↑ 24.0 24.1 24.2 24.3 24.4 Sinfield P. et al. (2009). "Men's and carers' experiences of care for prostate cancer: a narrative literature review". Health Expectations 12 (3): 301–312. doi:10.1111/j.1369-7625.2009.00546.x. PMID 19754693. 
  25. ↑ 25.0 25.1 25.2 Sherwood P.; Given B.; Given C.; Schiffman R.; Murman D.; Lovely M. (2004). "Caregivers of persons with a brain tumor: a conceptual model". Nursing Inquiry 11 (1): 43–53. doi:10.1111/j.1440-1800.2004.00200.x. PMID 14962346. 
  26. ↑ 26.0 26.1 Hanratty B.; Holland P.; Jacoby A.; Whitehead M. (2007). "Review article: Financial stress and strain associated with terminal cancer a review of the evidence". Palliative Medicine 21 (7): 595–607. doi:10.1177/0269216307082476. PMID 17942498. 
  27. ↑ Hagedoorn M.; Sanderman R.; Bolks H. N.; Tuinstra J.; Coyne J. C. (2008). "Distress in couples coping with cancer: A meta-analysis and critical review of role and gender effects". Psychological Bulletin 134 (1): 1–30. doi:10.1037/0033-2909.134.1.1. PMID 18193993. 
  28. ↑ 28.0 28.1 Given B.; Stommel M.; Collins C.; King S.; Given C. W. (1990). "Responses of elderly spouse caregivers". Research in Nursing & Health 13 (2): 77–85. doi:10.1002/nur.4770130204. PMID 2320760. 
  29. ↑ Given B. A.; Given C. W. (1991). "Family caregiving for the elderly". Annu Rev Nurs Res 9: 77–101. doi:10.1891/0739-6686.9.1.77. PMID 1756094. 
  30. ↑ Baider L.; Koch U.; Esacson R.; Kaplan De-Nour A. (1998). "Prospective study of cancer patients and their spouses: The weakness of marital strength". Psycho-Oncology 7 (1): 49–56. doi:10.1002/(sici)1099-1611(199801/02)7:1<49::aid-pon312>3.0.co;2-z. PMID 9516650. 
  31. ↑ Harden J (2005). "Developmental life stage and couples' experiences with prostate cancer". Cancer Nursing 28 (2): 85–98. doi:10.1097/00002820-200503000-00002. PMID 15815178. 
  32. ↑ Robinson K (1990). "Predictors of burden among wife caregivers". Research and Theory for Nursing Practice 4 (3): 189–203. 
  33. ↑ McCorkle R.; Pasacreta J. V. (2001). "Enhancing caregiver outcomes in palliative care". Cancer Control 8 (1): 36–45. doi:10.1177/107327480100800106. PMID 11252271. 
  34. ↑ Scott J. L.; Halford W. K.; Ward B. G. (2004). "United we stand? The effects of a couple-coping intervention on adjustment to early stage breast or gynaecological cancer". Journal of Consulting and Clinical Psychology 72 (6): 1122–1135. doi:10.1037/0022-006x.72.6.1122. PMID 15612858. 
  35. ↑ Kim, Youngmee; Carver, Charles S.; Spillers, Rachel L.; Crammer, Corinne; Zhou, Eric S. (July 2011). "Individual and dyadic relations between spiritual well-being and quality of life among cancer survivors and their spousal caregivers". Psychooncology 20 (7): 762–770. doi:10.1002/pon.1778. PMID 20878868. 
  36. ↑ http://www.cancerforum.org.au/Issues/2009/November/Forum/Caregivers_of_cancer_survivors_the_state_of_the_field.htm [|permanent dead link|dead link}}]



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