THE MEDICAL USES OF HOPE
William
M. Buchholz, MD
"Hope
is the thing with Feathers
That perches in the soul and sings the tune without the words
And never stops at all."
(Emily Dickinson)
Too
frequently patients will complain, "The doctor gave me no HOPE,"
as if it were a sample or prescription that should have been offered
along with the rest of the treatment. If HOPE were a medicine and
listed like other drugs in the PDR, the entree might look like this.
Clinical
Pharmacology:
HOPE
is a naturally occurring substance created by an individuals ability
to project himself into the future and imagine something better
than what exists in the present. It serves as a co-factor for most
purposeful behavior and is necessary for coping with fluctuating
feelings of despair, depression, fear, anxiety and uncertainty.
HOPE
has three components: The individual hoping; the projection into
the future (expectation); and the object, event, or state desired.
Individuals
experiencing HOPE vary with respect to the density and binding constants
of HOPE Receptors. There is both up- and down- regulation of receptors
depending on the danger of the circumstances , the individual's
sense of vulnerability, and the support system available. Certain
individuals have a pathological need for HOPE and are susceptible
to False HOPE.
Expectation,
comprised of the subunits Credibility and Attainability, is conveniently
measured as a vector having units of distance and difficulty (X,Y).
Even if there is a strong belief that a goal is possible (Credibility),
if the individual perceives it to be too difficult to attain, or
that it is impossible to project himself into the future, Expectation
will be low. Both intellectual and emotional Expectancies must be
above threshold levels for HOPE to be effective.
The
Object Desired is the most visible aspect of HOPE and may be expressed
concretely or implied, (e.g. "I hope the surgery will cure the cancer.
I hope everything turns out all right.") The strength of HOPE often
depends on the meaning or importance (Preciousness) of the Object.
Pharmacokinetics:
After
administration either verbally or visually HOPE enters cortical
and thalamic pathways where it is processed for Credibility and
Attainability. If receptors are blocked by depression, anxiety,
or distraction there is no binding and HOPE dissipates immediately.
Depending on the number and avidity of open receptors, there is
an immediate effect that has a half life of minutes to hours. Longer
effects require repeated administration. Both sensitivity and tachyphalaxis
can develop depending on how often the Desired Event occurs or does
not occur.
Indications:
HOPE
is indicated in the treatment of HOPE Deficiency, Depression, Anxiety
and to increase Motivation and Compliance with treatment. It is
useful in relieving fear, pessimism, and a sense of vulnerability.
It increases energy and courage in all individuals, resulting in
greater likelihood of difficult goals being accomplished.
HOPE
should be given at the initial diagnosis of a potentially fatal
disease, at any recurrence and when the disease is terminal. It
should also be used when dealing with chronic "benign" diseases
such as arthritis, diabetes and hypertension. It should be given
whenever despair is anticipated.
HOPE
Deficiency (Hopelessness) is a state of despair characterized by
the inability to anticipate any positive outcome. Patients are generally
unable to act decisively, make decisions, have meaningful relationships
or experience joy or meaning. They are described as having "given
up." The Will to Live is diminished in proportion to the degree
of hopelessness.
Contraindications:
There
are no known contraindications for giving HOPE.
Mechanism
of Action:
Depression
is characterized by the inability to imagine anything different
from the present. HOPE, because of the component of Expectation,
relieves the inability to project into the future. HOPE allows such
individuals to create a possible future, thereby relieving the onus
of living in the present. The anticipation of pleasure relieves
pessimism.
Anxiety,
characterized by a sense of loss of control, is alleviated by predicting
a desirable future event, thereby providing an anchor for the individual
in the midst of free-floating anxiety. The sense of aloneness is
relieved by anticipating allies or help. Fear, which consists of
projecting into the future an undesirable event (helplessness, pain,
etc.) is redirected by the expectancy of a positive rather than
negative outcome. Motivation to accomplish goals and compliance
with medical treatment are increased by a sense that the goal is
attainable.
Warnings:
False
HOPE is the intentional or inadvertent creation of the expectancy
that a low probability outcome is likely. It is a violation of medical
ethics to intentionally deceive a patient for the purposes of manipulating
their behavior. Physicians and nurses generally try to avoid any
appearance of False HOPE and may generate False Despair instead.
Certain individuals, because of a high need for HOPE based on the
seriousness of their condition or their premorbid personality characteristics,
are prone to misinterpret information given and develop False HOPE
or False Despair even when none is intended. Patients generally
use False HOPE to diminish the full emotional impact of an intolerable
situation.
False
Despair is the intentional or inadvertent discrediting of any probability
that a desired outcome is possible. In order to avoid any suggestion
of False HOPE some medical professionals will purposely lower patient
expectations to avoid any chance of disappointment. Patients likewise
may avoid the disappointment of unrealized hopes by purposefully
keeping their expectations low, feeling it is safer to expect the
worst. It is a violation of compassion and the Hippocratic oath
to purposely withhold HOPE of a low but finite probability outcome
from those patients who desire it. It may be pointed out that even
under the bleakest of circumstances there are some survivors.
Usage
in Pregnancy and Children: HOPE is safe during Pregnancy. It passes
into the breast milk and is known to be safe for infants. HOPE may
be used in pediatric patients, adjusting language but not dosage
according to age.
Adverse
Reactions:
Adverse
reactions occur when physicians or nurses, out of a desire to please
the patient, try to appear more powerful than they are and manipulate
patient behavior by substituting False HOPE for True or Realistic
HOPE. Patients likewise may distort ethically administered True
HOPE out of an inability to cope with reality. False HOPE leads
to persistent denial of reality and poor judgment. It causes 1)
persistent goal oriented behavior toward an unobtainable goal; 2)
distraction from necessary activities; and 3) delay in resolving
emotional issues. There are no adverse effects of True HOPE.
Overdosage:
Individual's
capacities for HOPE vary considerably. Excess True HOPE is very
rare. More common is the medical personnel's assessment that the
patient's estimate of outcomes is "unrealistic." Conflict arises
when the patient's need for HOPE differs from the nurse's or physician's.
If overdosage is suspected, however, the patient must be assessed
carefully and the consequences of acute HOPE Deficiency considered.
Acute HOPE Deficiency may precipitate sudden depression and increased
anxiety. Withdrawal of HOPE must be done slowly and gently.
Withdrawal:
If
it is determined that the patient is using False HOPE and suffering
one or more of the above mentioned adverse reactions and the danger
of the continued False HOPE state is greater than precipitating
Acute HOPE Deficiency, the patient may be withdrawn carefully. Efforts
should be made to substitute another goal for the previous unobtainable
one, preserving the positive expectancy while the goal is shifted.
This may be done more easily if it is recognized that the patient
is actually in a HOPE Deficiency state of fear and depression.
Dosage
and Administration:
Dosage
and duration of treatment must be individualized. The only limit
on maximum dosage is the patient's ability to receive and the professional's
ability to administer HOPE at an appropriate rate.
HOPE
must be administered in a form compatible with the patient's receptor
system. Patients with a predominance of Factual HOPE Receptors are
best given HOPE in the form of facts and statistics, phrasing them
according to "the glass is half full" philosophy. For patients with
a predominance of Emotional HOPE Receptors manifesting symptoms
of anxiety and depression, HOPE should be administered in a form
that can be digested emotionally. "Living proof" stories about other
patients who have done well in similar circumstances are more easily
accepted and can be applied directly to emotional wounds.
At
the time of diagnosis. Because excessive information may block receptor
sites for HOPE, patient's needs should be determined before either
Information or HOPE is given. Open ended questions such as "What
have you been told?" or "What do you think is the matter?" will
elicit responses that indicate primary needs for Information (intellectual)
or encouragement (emotional). Information should be given in amounts
that will not overwhelm the patient's ability to incorporate it.
Such overload increases the distortion of the Information and produces
either anxiety or numbness. Unless specific actions based on this
Information must be taken immediately, attending to emotional needs
by giving HOPE first before Information will create a more credible
physician-patient or nurse-patient relationship.
During
therapy. HOPE is easily administered with technical interventions.
Patient HOPE may exceed the professional's HOPE. If HOPE is necessary
for the patient to cope and there is no contraindication (see False
HOPE above), then HOPE should be maintained as long as possible.
When
"nothing else can be done." This is the most critical situation
in which HOPE must be administered. Both medical personnel and patients
must shift the object of HOPE to something that is more credibly
obtainable, maintaining a positive expectancy while changing goals.
Generally it is possible to offer HOPE for comfort. It is always
possible to offer the commitment to be there for patients as they
die. Often that is enough.
How
Supplied:
There
is no standard dose. Individual patient needs and individual personnel
styles determine how HOPE should be given. Listening carefully to
both verbal and non-verbal communication will often suggest the
best preparation of HOPE to use. Sometimes it is pointing out that
even though the chances are slender, there is at least a chance.
Sometimes it is just being there, with a gentle smile and a promise
not to abandon the patient. Sometimes the greatest challenge is
keeping a sufficient supply on hand for the personnel dispensing
it.
©Buchholz
1997 All rights Reserved
Reprinted
from JAMA, May 2, 1990--Vol 263, No 17, p2357-8
|
Acrobat version