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February 2012, Volume 16, Number 1
Article
The Challenge of Existential Issues in Acute Care: Nursing
Considerations for the Patient With a New Diagnosis of
Lung Cancer
Rebecca H. Lehto, PhD, RN, OCN®
A new diagnosis of lung
cancer is a highly threatening experience that raises personally relevant
existential issues and brings death-related thoughts and concerns to mind.
Those issues can be very disturbing to patients, leading to distress and
potentially to a lowered quality of life. The purpose of this article is to
present to the practicing oncology nurse the types of existential and
death-related concerns that patients with a new diagnosis of lung cancer may
have. In addition, the article identifies practical strategies and resources
for oncology nurses who can help patients accept and manage the normal but
often distressing responses to a life-threatening diagnosis.
Cancer is an alienating and existential experience. I
know of no other common disease that immediately causes so much fear, anxiety,
depression, confusion, and sense of impending disaster in a patient or his or
her significant others as when they hear the word cancer for the first time (Krelstein, 2010, p. 657).
—Murray Krelstein, patient
Lung cancer is the leading
cause of cancer death and the second most common cancer among men and women in
the United States (Siegal, Ward, Brawley, & Jemal, 2011). A new diagnosis of this life-threatening
disease has a broad impact on a person’s emotional, cognitive, social,
spiritual, and physical well-being (Hill, Muers,
Connolly, & Round, 2003; Rolke, Bakke, & Gallefoss, 2008). Although lung cancer carries an overall
very poor prognosis, little attention has been given to understanding and
addressing existential concerns among newly diagnosed patients (Lehto & Therrien, 2010). That
problem is particularly relevant as it relates to individuals who are facing
early-stage disease, a group that is growing with longer anticipated survival
secondary to the earlier detection and access to improved treatment
methodologies (Molina, Yang, Cassivi, Schild, & Adiel, 2008). The
purpose of this article is twofold: to present to the practicing oncology nurse
the types of existential and/or death concerns that patients with a new
diagnosis of lung cancer may have, and to identify practical strategies and
resources for oncology nurses who help patients accept and manage the normal
but often distressing responses to a life-threatening diagnosis.
Background
The term existential is defined as “of or relating to existence” in various
dictionary sources. The term has been more fully developed in philosophical and
psychological schools of thought that focus on the condition of human
existence. Of primary concern to existential scholars and researchers is an individual’s actions, personal responsibilities,
pursuit of life meaning and purpose, and overarching human concepts of personal
freedom, alienation, making sense of suffering and death, regret, and choice (Yalom, 1980). Existential concerns, which arise while
actively wrestling with the knowledge and potential imminence of personal
death, are normal and common and can be a significant source of distress among
individuals facing a life-threatening diagnosis regardless of the type of
illness and the cultural background of the person (Henoch & Danielson,
2009; LeMay & Wilson, 2008; Leung & Esplan, 2010). Existential issues can be evoked by physical
and psychological concerns, and surface when self-identity is threatened
(Henoch & Danielson, 2009). How people resolve existential issues will
differ individually, with some people finding solace in spiritual and religious
sources, while others do not (Udo, Melin-Johansson, & Danielson, 2010; Yalom,
1980).
Clinical focus on existential
and death-related concerns in individuals with cancer largely stem from
palliative care and have been aimed at assisting patients with a terminal
diagnosis manage psychological and physical symptoms at the end of life (Breitbart, Gibson, Poppito, &
Berg, 2004; Fitzsimmons et al., 2007). Individuals in medical-surgical
environments who are facing life-threatening illness often feel alone with
their issues, and healthcare providers who are uncomfortable addressing
end-of-life and death-related issues contribute to this alienation (Fitzsimmons
et al., 2007). LeMay and Wilson (2008) identified
that individuals who have difficulty finding meaning and purpose in their lives
have regrets and concerns about the past, possess anticipatory death concerns,
have higher religious worry, and are more likely to experience existential
distress, a condition characterized by despair that may heighten desire for
death and even contribute to suicidal ideation. However, people who overcome
existential challenges may experience end of life as a time of enhanced
relationships with loved ones, a deepening sense of self, and heightened
psychological growth (LeMay
& Wilson, 2008).
Less attention has been given
to the existential-related concerns that individuals facing a new diagnosis of
a life-threatening disease (e.g., lung cancer) may have in the acute care
treatment setting. That lack of attention is puzzling given the ubiquity of
such concerns that surface when people are told that they have cancer (Leung
& Esplan, 2010; Weisman & Worden, 1976–1977).
However, psychological symptoms such as anxiety and depression are well
documented in individuals newly diagnosed with cancer (Jacobsen & Jim,
2008; Osborn, Demoncada, & Feuerstein, 2006;
Stanton, 2006). In addition, subsets of patients with cancer are shown to
persist with psychological difficulties long into the survivorship spectrum
(Stanton, 2006). In a large sample of patients with cancer (N = 4,496),
psychological distress rates were 35% (n = 1,578) for the overall group and 43%
(n = 273) for the subset of patients with lung cancer (N = 629) (Zabora, BrintzenhofeSzoc, Curbow, Hooker, & Piantadosi,
2001). In that study, psychological distress was defined more broadly and
included a global measure of anxiety, depression, somaticization,
and hostility parameters (Zabora et al., 2001).
Interventions for psychological distress (e.g., anxiety, depression) are
multifaceted. Mental health referrals can be made, and treatment may include
psychotherapy or pharmacotherapy. Types of psychotherapy used for patients with
cancer to manage psychological distress include cognitive-behavioral–type
treatments that focus on altering thought patterns that are maladaptive and
contribute to emotional distress, professional counseling, psychoeducational
treatments, cancer support groups, and problem-solving therapies (Jacobsen
& Jim, 2008; Osborn et al., 2006). In addition, complementary and
alternative therapies such as guided imagery, relaxation training, mindfulness
meditation, and music therapy have become increasingly popular for managing
symptoms, including psychological distress in patients with cancer (Molassiotis et al., 2006; Wells et al., 2007). One
limitation of the research that has examined the efficacy of mental health
interventions in cancer is that the studies have been conducted primarily in
women with breast cancer (Stanton, 2006). In a systematic review of treatments
used for improving well-being and life quality for patients with lung cancer,
the interventions that were successful permitted the patient to develop a
therapeutic and empathic alliance with the health provider (Thompson, Solà, & Subirana, 2005). As
noted in other studies, interventions during the early postdiagnostic
phase of lung cancer focused on coping skills and treatment management, whereas
the patients in the terminal phase of illness received existential-oriented
intervention (Thompson et al., 2005).
Importantly, individuals with
cancer who present with psychological distress often have underlying death
anxiety and may engage in behaviors such as seeking information that distracts
focus from existential-related concerns (Yalom, 1980,
2008). In addition, healthcare providers who have death-related anxiety
themselves can be reluctant to discuss existential or death-related concerns
with patients and their families (Deffner & Bell,
2005). Clinicians may want to avoid the burden of emotional involvement in a
fast-paced health environment that does not support or may even trivialize the
importance of building human relationships (Leung & Esplan,
2010). Therefore, time constraints may limit availability and amount of
exposure with patients, both of which are necessary to build trusting
therapeutic alliances. Patients may expect nurses or their physicians to take
the initiative in discussing their deep fears and concerns, whereas the
providers (particularly in the acute care setting) may be focused on disease
treatment and management (Leung & Esplan, 2010).
However, individuals may experience difficulties focusing attention on
treatment-related information if they are consumed by emotional topics such as
how much time they have left or how their loved ones will manage when they are
gone. Therefore, despite the inherent barriers that are established based on
health environment and patient-provider communication factors, it remains
essential that nurses are comfortable in assessing for and discussing
existential concerns following diagnosis and
during early treatment for lung cancer.
Methods
Death concerns were gleaned
from semistructured interview content derived from 73
men and women recruited from the Veterans Administration Health System and a
regional cancer center, both in the midwestern United
States, who had a new diagnosis of non-small cell lung cancer and who were preparing for treatment. The institutional review board
and research development committees at the respective institutions approved all
study procedures. The major research findings from the study are reported in Lehto and Therrien (2010). The
majority of the individuals (n = 66, 90%) had either stage I or II disease, and
seven (10%) had stage IIIa disease. The participants
all were adults aged 21 years or older (—X age = 64.98, SD = 9.28, range =
47–83) with a mean education of 12.74 years (SD = 2.28, range = 8–20).
Eligibility criteria for the study included that the participants were aged 21
years or older with a new diagnosis of limited-stage non-small cell lung cancer
and able to read and write English to achieve the study requirements. Potential
volunteers were excluded if they had a history of cancer or lung cancer
recurrence; cognitive or psychiatric disorders; history of advanced cardiac,
respiratory, renal, or other disabling medical disease; or current use of
psychoactive medication that could impair study participation.
The semistructured
interview used the Conceptual Content Cognitive Map (3CM)
method to gather data related to the individual’s perceptions and concerns
following a new lung cancer diagnosis during the early pretreatment period. The
3CM is an established procedure used to measure
perceptions and thought contents while providing a mechanism for participants
to explore the important issues in their minds (Kearney & Kaplan, 1997).
Participants are asked to think about and write down important concepts related
to an issue or problem on separate cards, and then to arrange the specified
concepts in a way that makes sense to them. No restrictions are placed on how
many items are listed or how the content is organized. The 3CM
has useful application for examining research problems where less is known
about an individual or group’s perceptions and information is needed to make
decisions and to determine appropriate action plans. The method has established
early construct and concurrent validity (Kearney & Kaplan, 1997). The 3CM provided a method for examining and gaining
understanding of illness perceptions and concerns of the participants who were
facing a new diagnosis of lung cancer. Participants wrote down the important
concepts that came to mind about the cancer diagnosis on note paper. They then
coded the content with positive (+) or negative (–) symbols for affect
associated with the specific content.
The results were quantified
by content analysis and the development of categorical themes that emerged from
the data based on groupings of related statements. Contents were quantified and
qualitatively analyzed for substance. Inter-rater reliability of the coding
scheme was achieved between two nurse scientists who independently analyzed,
summarized, and coded the 3CM content (Lehto & Therrien, 2010).
Types of
Existential Concerns
The focus of the interviews
was aimed at understanding patients’ perceptions and concerns about the illness
experience. Among the patients, death-related issues were cited by 53% (n =
39), existential-oriented future disease fears were cited by 66% (n = 48), and
spiritual-oriented content was identified by 22% (n = 16) of the sample,
demonstrating the importance of such content to individuals facing lung cancer.
The areas of concern included (a) psychological preparation, (b) time left to
live and loss of a productive future, (c) impact of death on loved ones, (d)
behavioral preparation, (e) death acceptance, (f) experiences with others who
have died from cancer, and (g) post-death issues. Existential-oriented future
disease fears included concerns about an uncertain future, the potential for
disability, and the possibility of disease spread. Spiritual-based content
included religious practice and prayer, life purpose, and a sense of a larger
purpose (Lehto & Therrien,
2010).
Death-related anxiety and
existential concerns affect individuals facing cancer who remain physically
healthy, but who are vulnerable because of the nature of the diagnosis, the stressful
hospital environment, the experience of unpredictable circumstances, and
previous death encounters among friends and family. Addressing such concerns
during the early pretreatment phases of illness may assist individuals while
they remain physically healthy to explore their responses to the illness in a
life-enhancing direction (LeMay
& Wilson, 2008).
The Role
of the Nurse: Strategies and Resources
Although existential distress
is not identified as an accepted nursing diagnosis, death anxiety is listed and
specific interventions are cited (Carpenito-Moyet,
2008). However, the identified nursing interventions for death anxiety are
focused on helping people who are facing imminent death. Strategies such as
exploring life stories, relationships, spirituality, advance directives, and
symptom management are identified as appropriate nursing interventions in the
setting. However, having discussions related to existential and death-related
concerns may be uncomfortable for oncology nurses in the acute care setting who
could be concerned that such communication will increase psychological distress
for patients. Therefore, patients who are preparing for or are receiving
treatment for early-stage lung cancer may not have existential and
death-related concerns addressed because the healthcare providers are focused
on curative treatments and disease management. Strategies for nurses are needed
that can offset or reconcile death-related concerns among individuals facing
procedures such as surgical lung resections during acute treatment processes.
By addressing existential issues and death-related concerns early, nurses will
be better able to determine individualized needs for mental health or other
supportive interventions or services.
Interventions to Help Patients With
Specific Areas of Concern
Psychological preparation: Psychological preparation is reflective of actively
coming to grips with the reality of personal death and the awareness that the
treatment might not be effective. Similar to what Janis (1985) termed the “work
of worry” in his seminal work conducted among patients facing surgery,
psychological preparation likely helps facilitate cognitive integration of the
life-threatening illness. Being able to integrate a potentially life-shattering
event such as a diagnosis of lung cancer into one’s life perspective in a way
that makes sense and provides meaning is integral to coping and to ultimate
resolution of the stressor (Frankl, 1985). A first
step involves helping patients to recognize that they are not alone (LeMay & Wilson, 2008).
Resources to help facilitate
that process include the provision of clear and only relevant information,
taking time to listen and to understand the situation from the patient’s point
of view, and tailoring communication in accordance with the patient’s
understanding. Such interventions require that the nurse be sensitive to
developmental, experiential, cultural, and age-related nuances that can lead to
individual variability in how a life-threatening diagnosis is integrated.
Time left to live and loss of a productive future: Patients facing treatment for lung cancer may be
concerned about life expectancy and the anxiety-provoking anticipation of a
limited future. For example, patients may feel sadness and anger about potentially
not having the opportunity to see their grandchildren grow. In addition,
patients may feel grief related to having a life that is not what they hoped.
Facing a new diagnosis of lung cancer is very personal and can be a highly
alienating experience. Patients who lack social support and intimate others in
their lives to confide in may be particularly vulnerable in that regard.
Helping patients access support groups that meet regularly or to find such
resources via health-related social networking computer sites may allow
patients to express feelings, find common bonds, and to find reassurance. In
addition, nurses may be able to assist patients to consider their goals and
values in the context of choosing priorities and using the time that they have
left to live.
Impact of death on loved ones: If a patient is or has been the chief provider of his
or her family, they may have concerns about how death will affect the family.
Patients may be concerned about finding care for pets, for example, and other
tangible and intangible consequences of how death impacts important others. In
addition, patients may feel guilt and personally responsible for the burden
that they are placing on significant others, particularly if they believe that
their disease was self-inflicted by smoking (Lehto,
2004). When patients are worried and anxious about the impact of their disease
on their loved ones, being a supportive, nonjudgmental presence may promote an
atmosphere of freedom where painful concerns can be expressed. Negative emotions
(e.g., anxiety, guilt) can be transformed to sources of meaning that promote
well-being when patients feel comfortable and free to explore their
vulnerabilities (Breitbart et al., 2004).
Behavioral preparation: Behavioral preparation death content refers to active
strategies that the patient can take to make certain that essential life
affairs are in order in case of death. Patients are cognizant that they might
not survive surgery or that the disease might not be cured. Therefore, the
priorities behind behavioral preparation are to offset the financial and legal
burdens on the surviving family. Behavioral preparation strategies include such
things as making funeral and burial arrangements, granting a power of attorney
to act on the patient’s behalf if he or she were not in a position to make
autonomous healthcare or legal decisions, and making or updating wills. Such
activities are concrete action plans for managing an uncertain future and may
increase peace of mind following a new diagnosis of lung cancer. The
development of patient education materials that are easy to read and provide
concrete direction for potential resources can supplement therapeutic
interactions in the context of a trusting relationship. Topics on education
resources may include direction for managing end-of-life affairs such as estate
management and finances, support group location and resources, Internet
resources, self-help references, and resources to assist family members who are
affected by the diagnosis.
Death acceptance: When death acceptance is present at diagnosis, it likely reflects
previous personal contemplation and integration of the reality of death and a
finite existence. Trusting God’s will, maintaining hope, and surrender may
coincide with death acceptance. Patients who accept death may want to discuss
how they are approaching this potentiality. Some patients may find a renewal of
value and even joy in living life when they are comfortable with the reality of
their death (Browall, Melin-Johansson,
Strang, Danielson, & Henoch, 2010).
Experiences with others who have died from cancer: Many patients who are newly diagnosed with lung
cancer have past memories of experiences with friends or family
who previously have died of cancer. Memories arise when the current situation
reminds the patient of former encounters, and can be influential in activating
thoughts and images about death from lung cancer. For the patient who has had
life encounters that were frightening, such as interactions with significant
others who experienced pain or suffering at the end of life, those thoughts can
be particularly anxiety provoking. Building a trusting relationship where the
patient feels comfortable discussing painful memories can be reassuring for the
patient and may bring closure to those fears early in the illness continuum.
Post-death issues: Patients also may consider ideas about an afterlife at the time of a
lung cancer diagnosis. Those thoughts reflect cultural knowledge about death
and perceptions that death is not final. Spirituality content includes
religious practice and prayer, life purpose, and a sense of a larger purpose.
Belief in a positive afterlife and surrender to the unknowable future may
palliate existential concerns (Udo et al., 2010).
Conducting a spiritual assessment can alert the nurse to potential sources of
strength that the patient may use to buttress their existential concerns.
Recommendations for spiritual or religious resources can be made if the patient
desires. However, patients may have negative perceptions and even anger toward
religion. Listening and showing genuine respect for individual differences in
perspective allow the patient both the freedom and permission to work through
issues related to finding personal meaning and purpose for their life.
Future disease fears: Most patients who are newly diagnosed with localized
lung cancer have concerns about the future, the treatment, the possibility of
disability, and the potential that the disease will metastasize. Some
individuals are less able to tolerate uncertainty and, as such, experience much
higher levels of potentially disabling worry in situations that lack structure,
are uncontrollable, and carry potentially threatening outcomes (Dugas, Buhr, & Ladouceur, 2004). Providing reassurance and teaching
concrete cognitive-behavioral strategies to reframe the situation and allay
cognitive distortions may help patients to manage living with uncertainty
(Shearer & Gordon, 2006). Assisting patients to focus their awareness on
the current moment (e.g., through mindfulness practice) also may offset the
worry and anxiety associated with uncertainty. Such interventions teach
patients to identify and to disengage from negative patterns of thinking and to
practice focused awareness and acceptance via meditation and breathing
exercises (Hofmann, Sawyer, Witt, & Oh, 2010; Ledesma
& Kumano, 2009). Relaxation strategies, such as hot baths, massage, yoga,
music, exercise, and journaling to help alleviate anxious arousal also can be
recommended (Shearer & Gordon, 2006).
As Weisman and Worden
(1976–1977) identified in their seminal article on the existential plight in
cancer, confronting personal mortality and managing the accompanying distress
that surfaces from perceptions of powerlessness, regret, disappointment, anxiety,
and life disruption are common and occur in varying levels of severity among
individuals facing a life-threatening diagnosis. Reconciling that painful state
is a process that unfolds over time and at different rates among people (Yalom, 1985). Patients who are experiencing distress about
how their families will manage, who express unresolved grief, and who
demonstrate high levels of negative affect secondary to existential and
death-related concerns are likely to benefit from targeted mental health assistance.
Referral in such cases may offset the risk to the patient of developing serious
depression that could negatively impact long-term adaptation.
More formal strategies that
are grounded in both clinical and empirical research have been applied to help
individuals facing cancer manage existential distress (LeMay & Wilson, 2008). Those strategies often are
implemented in the structure of support group therapy and are aimed at helping
patients who are in the terminal phases of illness. Table
1 contains a listing of five recognized treatments. Such therapies are time
intensive, require an organizational structure, often require a trained
therapist to facilitate, and may be less available for oncology nurses who
maintain a busy practice, particularly in noncomprehensive
cancer center treatment settings. In addition, some of the therapies may not
have systematic testing in groups with lung cancer. For example, cognitive
existential therapy was developed for women with breast cancer (Kissane et al., 2003).
Death
Awareness and Education for Staff
Death awareness and education
have far-reaching importance to oncology nursing practice. Identifying
practical strategies that the oncology nurse can use to help patients accept
and manage such concerns are essential. As direct care providers and as
educators, oncology nurses are on the front lines in terms of assisting
patients with managing difficult thoughts, feelings, and concerns. Importantly,
research has shown that nurses who receive death communication education become
more comfortable with discussion of life and death concerns with patients and
their families (Deffner & Bell, 2005).
Familiarity and comfort may be one factor for why discussions related to
existential issues are more likely to occur in hospice and palliative care
environments compared to acute care environments (Browall
et al., 2010).
Close interpersonal
relationships with patients and families can be burdensome to oncology nurses,
a stressor exacerbated by finance-driven health care, high hospital patient
acuity, shortened length of stays, high rates of nursing turnover, staffing
shortages, and patient and family expectations (Barnard, Street, & Love,
2006). Nurses identified that finding time and a location for private
discussion as well as staff attitudes can be barriers to establishing a
dialogue related to existential issues (Browall et
al., 2010). Such realities are challenging, and nurses working in acute care
environments need to elicit support to ensure that time and space are available
to engage in such discussions (Browall et al., 2010).
Oncology nurses also may
personally experience death anxiety as they observe death, pain, and suffering
in their clinical practice; a factor that may impede therapeutic interactions
and discussions with patients about death-related concerns (Deffner
& Bell, 2005; Lehto & Stein, 2009). Oncology
nurses must examine their own thoughts, feelings, and attitudes regarding death
and dying (Westman, Bergenmar,
& Andersson, 2006). Knowledge and acceptance of
death and dying can help decrease existential fears and can help a patient
realize the importance of acknowledging and even preparing for death. Facing
fear and managing disturbing, difficult emotions is challenging. In addition,
by being a listening presence and by making effective connections with patients
who are facing a diagnosis of lung cancer, care providers may find themselves
experiencing similar disturbing emotions (i.e., sadness, fear, and feelings of
attachment and helplessness). Some of those thoughts and emotions may be new
and, therefore, surprising and confusing. Therefore, oncology nurses are first
tasked with needing to recognize and understand how to cope with their own
aversive thoughts and emotions. In that regard, seasoned oncology nurses also
can share strategies that they have found effective to manage emotional sequela with more novice oncology nurses.
Scheduling even a few extra
minutes in the context of a trusting relationship would allow time for the
nurse to assess for existential or death-related concerns as part of the
admission or pretreatment screening process. Existential and death-related
concerns are of significance to the person facing early-stage lung cancer
during the earliest illness phase. According to literature about the general
nature of psychological distress among individuals with a new diagnosis of
cancer (Osborn et al., 2006), nursing’s primary role in the targeted assessment
and discussion of existential and death-related concerns cannot be
underestimated. With many different types of interventions available to help
patients manage a new lung cancer diagnosis, providers have an obligation to
provide the most effective support to address the particular problem. Patients
need to recognize that existential-related concerns are both common and normal,
know that open discussion about such concerns is acceptable, and also perceive
that oncology nurses and acute care team members are willing to confront the
issues. An honest, willing, and receptive attitude among healthcare professionals
to their own personal existential vulnerabilities can facilitate comfort in
having such constructive encounters with patients. When resistance to accepting
the reality of death is faced with compassion and openness, patients facing
lung cancer can benefit from an improved quality of life and self-directed
adaptation.
Information
on End-of-Life Concerns
Many patients with cancer
facing the possibility of impairment or death from their diagnosis confront
issues regarding financial and legal burdens on family members and loved ones.
Strategies such as making funeral and burial plans, granting a power of
attorney, and updating wills all are important aspects at this stage. Resources
related to those concerns are available for healthcare providers and patients
at the following Web sites.
·
American Cancer
Society
www.cancer.org/myacs/Midwest/ProgramsandServices/american-cancer-society-navigator
·
American College
of Physicians
www.acponline.org/patients_families/end_of_life_issues
·
National Cancer
Institute
www.cancer.gov/cancertopics/coping/financial-legal
Implications
for Practice
·
Patients with
newly diagnosed localized lung cancer have existential-related concerns about
an uncertain future, the potential of disease spread, and the possibility of
disability and death.
·
Identifying
strategies that foster resolution of existential and death-related concerns in
the early postdiagnostic period and during the acute
treatment process is essential.
·
Nurses who are
comfortable with listening for and discussing existentially related concerns
during the acute phases of treatment may be in a better position to promote the
patient’s psychological adaptation.
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Journal of Oncology Nursing Associate Editor Mallori Hooker, RN, MSN, NP-C,
AOCNP®, interviews Rebecca H. Lehto, PhD, RN, OCN®,
about her inspiration to share the existential and death concerns of patients
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Rebecca H. Lehto, PhD, RN, OCN®, is an assistant professor in the College
of Nursing at Michigan State University. The author takes full responsibility
for the content of the article. The author received financial support through a
grant from the National Institute of Health (T32 NR0704), administered by the University of Michigan, and
the Mary Margaret Walther Program for Cancer Care Research. The content of this
article has been reviewed by independent peer reviewers to ensure that it is
balanced, objective, and free from commercial bias. No financial relationships
relevant to the content of this article have been disclosed by independent peer
reviewers or editorial staff. Lehto can be reached at
rebecca.lehto@hc.msu.edu, with
copy to editor at CJONEditor@ons.org. (First submission March 2011. Revision submitted April 2011.
Accepted for publication May 7, 2011.)
http://dx.doi.org/10.1188/12.CJON.E1-E8