Defining And Analysing The Concept Of Hope Philosophy Essay

Defining And Analysing The Concept Of Hope Philosophy Essay 1. DEFINITION: Define your phenomenon. In this section make it clear how you know it when you see it and what it is not. Concept analysis papers can be helpful in writing this section. Be certain to include a variety of viewpoints/definitions (nursing and/or others such as psychology) and do not use only Tabers or other dictionary definitions. Make certain you clearly identify the nursing perspective/definition including standard language (NANDA) Hope can be used as both a noun and a verb. When being used as a noun, hope is defined as a feeling that what one desires will happen, the thing hoped for, a cause of hope, a person or thing that gives hope to others or that others have hope, the ground for expecting something/promise (World Book Dictionary 1976) When used as a verb, Hope is defined in Websters New Collegiate Dictionary (1986) as trust, reliance, desire accompanied by expectation or belief fulfillment Hope has also been defined as an ambiguous or uncertain anticipation of something desired (Green 1977), a desire accompanied by expectation (Frank 1968) and a positive expectation in a studied situation which goes beyond the visible fact (Mennmger 1959) Stotland (1969) expanded the definition of hope to include a degree of expectation when he defined hope as expectation greater than zero of achieving a goal Hope has also been defined m active terms as a response of the creature to the Infinite Being (Marcel 1962), a con fident leap mto the future (Alfaro 1970) and a psychic commitment to life (Fromm 1968) Other definitions mdude a sense of the possible (Lynch 1965), a conviction that a good future is possible (Smith 1983) and a stage of being, an inner readmess, intense, but not yet spent activeness (Fromm 1968) Implicit withm these definitions are two attributes (a) the desu-e for some good, and (b) the ability to look to the future with expectation (McGee 1984) From these definitions and attnbutes, a tentative definition of hope can be proposed hope is an antiapation, accompanied by desire and expectation, of a positive possible future Antonym Hope has been contrasted with its antonym hopeless The term hopeless means to be without hope, and the term hopelessness means the condition or state of bemg without hope {World Book Dtdionary 1976) Two more terms which come from the same Latm root speare are despair and desperation, and are defined as bemg without hope Desperation suggests a state of strong mental anguish or feeimgs of discomfort Other defirutions that reflect hopelessness ^ e a sense of the impossible (Lynch 1965), negative expectations about the future (Stotland 1969) and inaction m the face of threat (Lazarus 1966) A review of the antonyms suggest that bemg without hope has both a cognitive and behavioural component HOPE AS A PROCESS Impliat withm vanous statements is the idea that hope mvolves an active process The theme of antiapation is 1457 C Stephenson reflected in the definition of hope as a process, an adventure, a gomg fcwward with confidence (Mennmger 1959) Hope IS also characterized as an openness (Molhnan 1967), a creahve expectation (Bloch 1970) and a set of dispositions (Macquame 1978) Conceptually, hope involves an active interaction of a persons thoughts, feelings, action and relationships (Dufault Martocchi 1985, Hickey 1986, Miller 1983) For example, if a person has hopeful thoughts, that person will feel hopeful and ocf in a hopeful manner toward self and others The thinking component of this process of hof>e involves visualizing something not yet existing Macquame 1978) Typically the individual identifies an object of hope, which can include a goal, solution, relief, a relationship or anything meaningful to the person (Dufault Martocchi 1985) After the identification of the object, the calcii lation of probability or estimation of certain outcomes is made by the person (Marcel 1972, Mishel 1984) In addition, the person searches for dues to provide the grounding for hope This grounding can be based on realistic or unrealistic expectations, but as long as the individual believes that a foundation is present upon which hope rests assurance will be felt (Wnght Shontz 1968) Reality grounding methods may include considenng the environmental conditions and assets available, seeking confirmation firom others, and comparing self with others Interpretation of these clues will depend on the persons past expenences and the valuation of self as confident and competent (McGee 1984) ^notion Although no single emotion has been assoaated with hope, a positive feeling state usually exists Typical descnptions of this state include feeling good, uplifted, inspired, cared for and loved (Lynch 1965, Marcel 1962, Miller 1983) Hope has also been assoaated with a feeling of confidence diluted b y a degree of uncertamty Engel (1963) suggested that hope moves the person away from self-reliance and toward seeking support from others The behavioural component of the hoping process is reflected m the idea that hope seems to be a prerequisite to coping and adaptation (Rideout Montemuro 1986) Beliefs about ones abilities and antiapated responses to ones efforts go togethCT Usually hope, plus self-efficacy, will lead to effechve copmg However, if a person is unable to acbeve a sense of control or belief in ones own abihty, this control may be relinquished to a health professional or therapist for a penod of time (Hinds Martm 1988, Simtix 1983) The relationship component of the hopmg process is stressed by Lynch (1965). He states that hope is an intenor sense that there is help on the outside The process of hope IS really an mward appropriation from other people, God (higher being), or some other living thing (Dufault Martocchi 1985, Miller 1983, Vaillot 1970) According to Macquame (1978), hope becomes trust within a relationship, and a bond is made between the persons in exchanging and shanng of hope In studies reported by Campbell (1987) and Owen (1989), individuals who were hopeful were descnbed as active, energehc and able to set goals In contrast, persons who were ho peless were descnbed as inactive, apathetic and unable to set goab In studying cases of sudden death, Engel (1963) noted a failure in the coping mechanism which he called the giving-up given-up complex Individuals who had given up demonstrated certain common charactenstics which included feelings of incompetence and being out of control, feeling at the end of their tether, a loss of gratification fi-om roles, a sense of disruption m continuity with the past and fiiture, and the recall of previous helpless situations This failure of coping could be called loss of hope HOPE AS A THEORY Stotland (1969) proposed a theory of hope that incorporates the active process of hope and cfefines hope as an expectation greater than zero of achieving a goal Hopefulness refers to high expectation and hopeless refers to low expectation Stotland states that the greater the perceived expectation of goal attainment, the more likely the organism is to achieve the goal He also states that the greater the antiapation of havmg the hoped for object, the greater would be the attention to, thinking about and action toward getting the object The perceived importance of the goal to the person and the probability of attaining the desired goal are both important Meaning in life The presence of hope has been equated with mearung and value in life (Frankl 1959, Hickey 1986, Travelbee 1971, Vaillot 1970, Watson 1979) Aitei World War H, Victor Fimikl (1959) wrote about his expenences in a concentration camp He observed that individuals who had hope were able to endure very dilibailt physical cuui e motional crcumstances However, when a person lost h c ^ , he or ^ The concefi of hope In studying people with suiadal behaviours, Jourard (1970) also found that a person lived as long as hfe had meaning This theme was also discussed by Travelbee (1971) m her theory of nursing as an interactive process Travelbee defined hope as a future orientation m which one looks forward to a time when life will be more meaningful She implied that, without hope, one cannot be spintually or emotionally healthy ASSOCIATED WITH NURSING In nursing literature, the term liope is connected with nursing activities cind role obligation According to Roberts (1978), fostering hope is one aspect of the professional nurses role In fact, nurses have been identified as sources of hope and have been admonished to inspire hope (VaiUot 1970) In a study reported by OMalley Menke (1988), patients perceived nurses who were kind, supportive of the patient, and conveyed confidence in the treatment as promoting hope Watson (1979) states that the instillation of faith-hope is involved in the canng and curative processes However, the author does not define this faith-hope Antecedents and consequences The antecedents to hope are not clearly understood If hope IS a trait of the person, it is always present and a necessary part of hfe (Fromm 1968) However, the state of hope or the process of hoping seems to imply that there can be levels of hope withm a person Marcel (1962) states that hope IS a response to captivity, tnal or entrapment For Marcel, hope anses oul of despair and the more a person expenences confinement the more the person experiences hope A cnsis has been suggested as an antecedent to hope (Oufault i 1985, Komer 1970, McGree 1984, Nowotny 1989) The crisis could include loss, a life atening situation, a hardship or a change A difficult decision or a challenge could also be an antecedent to hope (Nowotny 1989) However, in this vmters opinion, the antecedent to hope could be anythmg that would be significant to the person since hope is uniquely related to the individuals life expenences The consequences or outcome of hope can be a new perspective (Boros 1970) For examp le, hope seems to energize, empower and strengthen the person (Lynch 1965, Vaillot 1970) People who have seen their hopes fulfilled, descnbe themselves as invigorated, full of purpose, renewed, calm, and encouraged (Hmds 1988, Stanley 1978) Conceptual attributes and a tentative definition Definitions and contextual usage of the word hope have been presented However, the term wish (a synonym) needs to be mentioned m relation to hof>e To hope and to wish may be very similar, m fact wishing may be part of hoping However, a wish is not hope m the fullest sense Usually with a wish there is little personal commitment or investment, and if it comes true there is an element of surpnse With hope there is usually a pwrsonal investment and the fulfilment does not bnng a surpnse, but a calmness, reassurance or sense of encouragement (Green 1977, Miller 1983) Four attributes In analysmg the definitions and contextual usage of the word hope, at least four attnbutes have been identified 1 The object of hope is meaningful to the person, 2 Hope IS a process involving thoughts, feelmgs, behaviours and relationships, 3 There is an element of antiapahon, 4 There is a positive future onentation, which is grounded in the present and linked with the past These attnbutes can be used to answer the corKeptual question What is hope? Hope can be defined as a process of anticipation that involves the interaction of thinkmg, acting, feeling and relating, and is directed toward a future fulfilment that is personally meaningful CONCLUSION The concept of hope has been analysed through the use of common definitions and contextual usage fiom the literature In addition, attnbutes, antecedents and consequences of hope have been identified and a definition of hope has been proposed Qanficahon of the concept of hope has implications for nursmg and health care delivery Nurses are m a unique position to interact with individuals and family members m a holistic manner Assessment of personal health care needs could include gathermg data on hope fi-om the mdividual as well as from the familys perspective Data on hope could serve as a cruaal foundation for assessing quality of life in general In addition, interventions could be designed to strengthen the hoping process without givmg false reassurance Further research Further study could be done on the behavKMirs of Iwalth personnel and sigruficant others that impact the hoping 1459 C Stephenson process Although these thoughts may not be applicable to every individual, study of the concept of hope contnbutes to the knowledge base necessary for quality nursmg care for al] people Abstract Hope has been described in theoretical terms for many years but the recognition of the importance of hope within the practice of nursing is a more recent phenomenon. Despite the recent growth of references to hope within contemporary nursing literature, it is reasonable to suggest that there remain gaps in the substantive knowledge base and that there appears to be room for both additional research and further discursive literature. Accordingly, this series of six articles will explore the nature of hope, review the existing theoretical and empirical work in several discrete areas of nursing, and provide case studies to illustrate the role that hope plays in clinical situations. This article focuses on the origins, background and definitions of hope. The next article will examine hope within mental health nursing, and further articles will focus on hope within palliative care nursing, hope in gerontological nursing and hope in critical and acute care nursing. Hope is defined as to cherish a desire with expectation of fulfillment; trust, reliance(Websters New Collegiate Dictionary, 1973). Hope enables realistic appraisal of an event and the identification of options (Morse Dobemeck, 1995; Wang, 2000); has a causal effect upon many biopsychosocial and spiritual factors (Wang); mobilizes energy (Rusteon, 2000); has a dynamic quality in that it waxes and wanes (Morse Dobemeck; Parse, 2000); coexists with no hope (Parse); incorporates a bracing for negative outcomes (Morse Dobemeck); promotes a determination to endure (Morse Dobemeck); is future focused, facilitates a positive outlook (Herth, 1992); encompasses a measure of control (Parse, 2000; Wang); facilitates transcendence (Hasse, Britt, Coward, Leidy, Perm, 1992); and provides comfort (Hinds, 1999).Frankl (1963) writes that hope is basic to life and loss of hope can precipitate death. Without hope, persons despair and lose the interest or energy to cope or endure (Levine, 1989). Events that Elicit Hope: Wished for object Dilemma Crisis Qualities of Hope: Universal yet unique to each individual Dynamic in its presence Enabling Outcomes of Hope: Resilience Transcendence Positive psychologically, spiritually, physiologically Psychology Hope begins with thoughts (cognitions) (Benson, 1996). Bums (1980) writes thatthoughts are the manner in which you view things, your perceptions, mental attitudes,beliefs, and what you say to yourself about your perceptions. Bums further assertsthat thoughts influence emotions and behavior. Experiences are first processedthrough the brain and given a meaning before an emotional response is elicited(Bums; Meier, Minirth, Wichem, 1982). Clinical psychologists, Alfred Ellis (1970)and Aaron Beck (1970), developed therapy models based on the premise thatinterpretations of situations and events influence emotion with corresponding actionsand behaviors (Fortinash Holoday-Worret, 1996). Ellis and Beck purport thatbeliefs and values are formed from experiences, scripting by significant others, andones inherited temperament and this in tum determines the interpretation of andreaction to situation or events (Fortinash Holloday-Worret). Religion: Faith communities have traditionally referred to God as the Ultimate Hope. Numerousverses in the Holy Bible speak to hope and the human condition. Matthews (1999)refers to hope as a means of transcending or rising above lifes difficulties. Religiouspractices and rituals such as prayer, singing hymns, Bible reading and study, churchattendance maintain connection to a Higher Power and foster hope that goodness,emotional comfort, and/or peace of mind will prevail (Peale, 1990; Graham, 1991;Matthews). Koenig (1999) concludes religious belief can manifest psychologically byreplacing despair with hope and physically by affecting the immune system responseand lowering blood pressure. Thus, hope is viewed as an attribute linked withbiopsychosocial and spiritual factors (Wang, 2000). Medicine: Research by Benson (1996) provides strong empirical support conceming the powe of beliefs and thoughts on physiological outcomes within the body. Benson (1996) proposes that hope has considerable influence physically and emotionally. Hope is elicited and nurtured with memories and thoughts of happy times and wellness (Benson). There is a placebo effect in that there is a positive correlation with increased hope and relief of certain symptoms (Benson). Nursing:Parse (2000) writes that hope is enmeshed with health and life quality, is ersal, and a way of living with imagine possibilities in each day. Parse also notes that a hope-no hope quality is always present. Other insights derived from Parses work are that hope is derived from memories, is influenced by interpersonal relationships, romotes a moving forward, offers new insights and purpose; and that hopeful persons ponder situations realistically, and consider options and consequences (Parse, 2000). Dufault and Martocchio (1995) identify six interrelated dimensions of hope: cognitive (thoughts), affective (feelings), behavioral (actions), affiliative (relationships with others and a Higher Power), temporal (future-oriented, influenced by present and past), and contextual (circumstances that occasion hope). Antecedents to hope include relationships with others including a Higher Power, positive personal attributes, ptimism, and an ability to use thoughts to mitigate perceived threats (Haase, Britt, ard, Leidy, Penn, 1992). Hope moves a person to action directed at providing a vel of comfort or attainment of hoped for objects (Dufault Martocchio, 1995). Systematizing the Observations The development of nursing knowledge and interventions involve understandmg human responses and needs The human response of hope was identified as a concept m need of further danficahon The purpose of this paper was to review definitions and contextual usage of the word hope from the hterature and answer the conceptual question What is hopef Literature from theology, philosophy, psychology and nursing was reviewed for contextual usage of the word hope In the hterature, hope was viewed as part of human development, a process, a theory and a source of meaning in life In addition, antecendents, attributes and outcomes of hope were identified from the literature that contnbuted to a clearer understanding of the concept When the world says, Give up, Hope whispers, Try it one more time. (Unknown, 2010) The definition of hope and hopelessness differs from person to person. In Scripture, according to the Hebrew and Greek words, hope is an indication of certainty. (Keathley) Tabers dictionary defines hope as, The expectation that something desired will occur. One of the bases of professional health care is encouraging and supporting the presence of hope while providing accurate information and realistic reassurance. (Hope, Hopelessness, 2009) Hope and hopelessness all depend on your expectations and goals. Without them hope would cease to be. On the contrary, hopelessness is despair; loss of faith on the possibility of a positive outcome. (Hope, Hopelessness, 2009) Although hopelessness can lead depression, desperation, or antisocial behaviors, hopelessness is a feeling that many people experience without the ill effects. Hopelessness is a common human response, and can be overcome. THEORY Chinese perspective According to Landrum (1993), while the early Chinese believed that human destiny depended on the gods, they also recognized the value of human virtue. Their four basic human qualities love, righteousness, propriety and wisdom are developed through moral training and social education. Chinese culture has a strong sense of optimism because human nature is considered to be essentially good. No specific reference to the origin of hope or the role that it has is made. However, one could speculate that optimism is an expression of hope, albeit couched in different terminology. East Indian perspective Landrum (1993) asserts that an East Indian perspective is concerned with the notions of the subjective nature of humans, the value of knowing oneself, the links between the supreme inward reality of spirit and the outward reality of matter. This perspective sees the universe as being in a meaningful and constant state of flux, that yet, paradoxically, provides order. To survive one must act. No specific reference to the origin of hope or the role that it has is made. Ancient Greek perspective When describing the ancient Greek perspective, Landrum (1993) suggests that the early ancient Greeks regarded people as individuals who received feelings and ideas from external sources. The soul allowed understanding and consequently direction in life. The mind and body were viewed as separate and several human qualities and physiological responses were explained in relation to mans psyche, with reason regarded as the dominant part of psyche. Reference is made to courage, truth, and temperance and Hippocrates alludes to the positive effects of these qualities and hope, without ever dwelling on or exploring the actual processes of hoping (Barnard, 1995). Christian perspective If hope is considered in terms of the Christian faith then it can be argued that hope has existed almost as long as man has existed. Mans existence began when God created Adam and Eve. Adam knew nothing but contentment, satisfaction and exhilaration and, consequently, his existence can be seen as a hopeful one. He was in a state of contemplation; he lived the beginning of his life in the presence of God and therefore experienced the total absence of despair. Once Adam, through eating forbidden fruit, was alienated from God, the reality of his own demise or annihilation, or permanent separation from God, had to be faced. How does he reconcile his eventual demise and separation from his creator if not but by the action of faith in God (and subsequent redemption) producing a sense of hope that the state of contemplation could be achieved again.For those whom hold Christian beliefs, hope then would seem to be a product of faith (Lynch, 1965), whereby individuals engage in a process where their beliefs in their ultimate salvation, and also their empowerment in the present, are dependent on God. This faith enables the individuals to be hopeful and the hopefulness enables the individual to transcend is/her current difficulty (Lynch, 1965).This is in terms of not only ones eventual redemption, but also a pragmatic sense, in that, despite his fall from grace, Adam eventually achieves his reconciliation with his creator, and enjoys a long and fruitful existence. Existential perspective Existentialism can be regarded as the philosophy of despair, the opposite to hope. However, there is merit in examining hope from an existentialist, philosophical standpoint as some existential literature attempts to explain ho w hope is derived and shares commonalities with the theological perspectives outlined above. The existential philosopher Sartre (1943, cited in Blackham, 1986) claimed that to be truly human is to travel a path towards nihilism (i.e. an extreme form of skepticism maintaining that nothing has a real form ofexistence) to be alone. The more acutely aware of this pointless and isolated existence a man becomes, the more aware hebecomes of the absurdity of his existence. The only outcome of such a perspective is a state of despair. Nietzsche (1938, cited in Rawlins et al, 1993) makes comments which echo the sense of despair that accompanies mans existence when he argues that hope is the worst of evils, for it prolongs the torments of man. If we consider ourselves in a position relative to the progression of linear time (from the dawn of time to the end of time), whilesimultaneously considering ourselves in a position relative to the infinity of the universe, the likely conclusion from suc h a comparison is to view our existence as pointless, minuscule, futile and hopeless. Alternatively, if we view our existence and the world in a finite, more individual, and specific way, the opposite argument becomes apparent. We exist and operate in a finite world, and we can have influence and control over our existence. Indeed, at a micro level each individual potentially makes a difference to the world. Such an existence then can only produce a more hopeful outlook. This view is supported by the contemporary existential philosopher Marcel (1948, cited in Blackham, 1986), who proposed humans achieve being by engaging as fully as possible in life tasks. Such tasks require communication and interaction between people. This existence has endless possibilities and opportunities for personal growth, of increasing human stature by existing in conjunction with other humans. According to Marcel, man has wide horizons that he can move into and influence, as opposed to Sartres view of man as someone who is surrounded by a sea of nothingness. Therefore, if despair is the state of being of Sartres man, then hopefulness (and the potential to be hopeful) is the state of being of Marcels man. Marcel asserted that the human soul, or internal self, exists only by hope, it breathes hope. This view is supported by Blackham (1986) who maintained that the model of all hope is salvation, which means for the Christian, the hope of achieving contemplation and living in the presence of God. Therefore, certain existential philosophers allude to the origins of hope, implying it is implicitly bound up with existence, human spirituality and faith in God. Kiekergaard (cited in Blackham, 1986), did not write directly about hope; however, he elaborated upon the concept of faith (faith in eventual salvation). Faith, he argued, is the antithesis of reason. It is unreasonable to have belief in something that cannot be proved and has no substance. Since hope can spring from this faith, it is possible that Kierkegaard would also consider hope for ones salvation to be unreasonable. To illustrate this point further, the authors point out that having hope for future outcomes that do not yet exist can be seen to be a process akin to possessing faith, in that there is often no evidence for peoples hope, especially since not everything people hope for is of a physical state. Thus, by considering Kierkegaards comments regarding believing in something that cannot be proved, similarly, hoping for outcomes that have no evidence to substantiate the focus of the hoping could, according to Kierkegaard, be deemed to be unrea sonable. However, to the person who has hope and who experiences a sense of hopefulness, it is likely to be the most logical, sensible thing. If hope provides one with a sense that one has a future, and also enables one to cope with events in the present, then (if one wishes to preserve ones existence) it is a logical state of being (Hinds, 1984; Raleigh, 1992). A fundamental question for the existentialist philosopher has been the problem of the final destiny of the individual and the issue of the intensity of human existence (Macquarrie, 1972). Life is viewed as more than a biological experience and particular concern is given to the most extreme human experiences such as anguish, despair and confrontation with death (Landrum, 1993). Consequently, the consideration of death involves examining the essence and meanings that people ascribe to their death. Thus, existential analysis of death indicates that understanding the meanings is unlikely to be restricted to the limits of ones p hysical existence and earthly life. Therefore, questions and answers need to consider the possibility of fulfilment beyond death (Macquarrie, 1972). This begs the questions: Where is hope in this scheme of things?. Does hope in the individual project beyond his/her physical existence into the possibility of life after death?. It is likely that if the origin of hope was to enable man to reconcile his alienation from God, then the existential understanding of hope cannot be complete without examining what hope does in terms of fulfillment after death. Pannenberg (1962, cited in Macquarrie, 1972) further described the connection between life after death and hope suggesting: The phenomenology of hope indicates that it belongs to the essence of conscious human existence beyond death. There appears to be a perspective that posits hope as enabling humans to contemplate life after death without entering into utter despair. Hope clearly projects into the spiritual realm of existence (Lynch, 1965; Herth, 1990; Kylma and Vehvilainen- Julkunen, 1997), and this philosophical view of hope supports the thoughts on the origins of hope. If there is no existence after ones physical demise (if, in terms of Christian theology, the universe is Godless), then there is only complete nothingness awaiting each individual, and such a perceptionis the perception of despair. However, if the universe is meaningful (if, in terms of Christian theology, God exists), if the individual is capable of transcending his/her physical existence, then the perception of hope is made possible. By examining the theoretical and empirical literature it becomes evident that attempts have been made to define and understand hope from the 1960s onwards. Lynch (1965) described the spiritual view of hope. Wri ting in the position of a Reverend and as someone who had ministered to many people in times of distress, he suggested that hope comes close to being the very centre of man. Stotland (1969), writing from a psychological perspective, indicated that even though there was an awareness of the role hopefulness plays in everyday life, the subject had not been fully introduced into the mainstream of psychology and psychiatry. Hope in adolescents In the 1980s, studies were conducted to define hope in specific groups (Hinds, 1984; DuFault and Martoocchio, 1985; Owen, 1989) and Miller (1983) carried a review of the relevant literature in order to describe hope (and inspiring hope). Hinds (1984) attempted to define hope in adolescents. She interviewed 25 adolescents, eight of whom were inpatients, and 17 were termed well. While Hinds describes the demographic details of her sample (e.g. age range, sex) she does not state the criteria used to describe an interviewee as well other than that they attended a learning centre for secondary education; in addition, she does not explain how the interviewees were selected. Hinds (1984) then describes using grounded theory methodology and the data reduction technique of Glaser and Strauss (1967) to induce a construct definition of hope, stating hope is the degree to which an adolescent believes that a personal tomorrow exists. Furthermore, Hinds argued that this belief spans four hierarchical levels, from lower to higher levels of believing (Table 2). Unfortunately, Hinds fails to make any statements concerning how she attempted to establish the credibility of her findings. Hope in patients with cancer DuFault and Martoocchio (1985) collected data over a 2-year period from 35 elderly patients with cancer, then collected similar data over a further 2 years from 47 terminally ill patients of various ages. This study i