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Within palliative care, hope should also be considered for those who are close to the patients either personally or professionally. Caring for someone close can be very stressful and has been associated with causing psychological and social distress in carers, and therefore with caregiver burden (Kissane et al. 1997; Pitceathly and Ma-guire 2003; Siegel et al. 1991).

In terms of psychological effects on the carer,

Pitceathly and Maguire (2003) found, in their review of the psychological impacts of cancer on patients' partners and other key relatives, that most people can cope with the role of caregiver, but that there are an important few that become highly distressed or develop an affective disorder. Farran et al. (1991) suggested that hope was one of the important factors in supporting the ability of carers to cope with the care-giving role under difficult circumstances.

The importance of hope to families and care-givers alike has been supported in other research (Herth 1993; Hickey 1990), and it is believed that the presence of hope in caregivers can directly impact the sense of hope for those who are ill, suggesting that maintaining hope in family members and caregivers can additionally maintain hope for those who are ill.

This leads to the question of how health professionals can aid in maintaining hope in those who are caring for a person with a terminal illness.

Hope for caregivers in the study by Herth (1993) was defined as "continually unfolding and changing in response to life situations" and as a "dynamic inner power that enables transcendence of the present situation and fosters a positive new awareness of being". In his study of 25 family caregivers, he identified "hope-fostering" strategies to include sustaining relationships, cognitive reframing, time refocusing, attainable expectations, spiritual beliefs, and uplifting energy. Cognitive reframing involved developing a positive outlook on a threatening situation, time refocusing referred to taking a more day-by-day attitude rather than looking too much to the future, attainable expectations described setting attainable goals and being able to redefine their expectations, and uplifting energy referred to learning to balance available energy. He also described threats to maintaining hope, which included isolation, concurrent losses, and poorly controlled symptoms. His results can suggest possible implications for practice, in that efforts should and could be made to aiding those hope-fostering aspects whilst preventing those aspects that are threatening to hope.

It is believed that health professionals such as doctors and nurses can help maintain hope in those who have a terminal illness by "listening carefully to family members, answering their questions, talking with them, and providing useful information" (Duhamel and Dupuis 2003). Treating patients with respect and demonstrating true interest in their physical, psychological, spiritual and emotional health is thought to be a major aspect of bringing comfort and hope to terminally ill patients and their family (Duhamel and Dupuis 2003; Post-White et al. 1996).

In a study of 61 family members of people with terminal cancer, Chapman and Pepler (1998) found that those family members who lacked hope were more likely to experience somatic distress, loss of control, and social isolation. Based on their results they suggest that health professionals (they specify nurses in particular) should be more aware of family members' somatic concerns. They further suggest that "a way of fostering hope, and ultimately health, is to address expressed feelings of anticipatory grief and facilitate coping. Once the grief responses are dealt with, the level of hope would be expected to increase, providing an incentive for constructive coping with loss."

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