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Professor and Director of PhD Program Christine E. Lynn College of Nursing
Florida Atlantic University
BS Biology: Lebanon Valley College
BSN Thomas Jefferson University
MScN University of Toronto
PhD University of South Carolina
Post-Doc-John A. Hartford Foundation Building Academic Geriatric Nursing
Nursing Interventions Classification (NIC
Nursing Theory Guided Research, Practice, and Education
Unitary Caring Nursing Science
Rogers Science of Unitary Human Beings
Dispiritedness and Mild Depression in Later Life
Testing Written Emotional Expression to enhance Meaning-Making
Howard K. Butcher
Nursing Science Quarterly, ISSN: 08943184, eISSN: 15527409, Pages: 148-159, Published: April 2022 SAGE Publications
All phenomenological research, including descriptive phenomenological methods, are theory based. The knowledge in a discipline is built using discipline-specific methods. The purpose of this article is to develop and describe the processes of a mode of inquiry specific to caring in nursing theories housed within the unitary caring paradigm. Morgan’s practical framework examining ontological-epistemological-methodological linkages was used to develop the unitary-caring hermeneutic phenomenological research method The method is specific to conducting hermeneutic phenomenological research within Watson’s unitary caring science and Smith’s theory of unitary caring. The method includes a process of linking and interpreting themes generated from the textual analysis of participant descriptions of the caring phenomena to concepts in the specific unitary caring theory that informs the researcher’s a priori theoretical perspective to develop a theoretical understanding of the experience and contribute to the development of unitary caring nursing science.
Seham Alselami and Howard K. Butcher
Nursing Science Quarterly, ISSN: 08943184, eISSN: 15527409, Pages: 191-202, Published: April 2022 SAGE Publications
The aim of this study was to gain a deeper understanding of the experience of Saudi informal family caregivers of hospitalized patients who have experienced a stroke. In-depth, face-to-face, semistructured interviews of five family caregivers using open-ended questions were conducted in a major hospital in Saudi Arabia. The interviews were recorded, transcribed verbatim, and analyzed using the unitary-caring hermeneutic phenomenological research method. Data analysis revealed six major essences that were synthesized into one statement reflecting the essence of caring for a family member with a stroke in Saudi Arabia: Living with the uncertainty of ambiguity amid feeling distressed with worries and fears replete with unfulfilled desires while yearning for compassionate caring and overcoming uncertainties through connections and faith honoring abiding commitments. As a means to transform the findings into theory and language of the nursing discipline, the essences were then interpreted within the theory of unitary caring.
Pilar Lozano, Howard K. Butcher, Cecilia Serrano, Aurelio Carrasco, Carolina Lagares, Pilar Lusilla, and Cristina O'Ferral
International Journal of Nursing Knowledge, ISSN: 20473087, eISSN: 20473095, Pages: 240-252, Published: October 2021 Wiley
INTRODUCTION Low adherence to treatment is a common problem in the care of patients with severe mental illnesses. Motivational interviewing is a directive, client-centered counseling therapeutic approach designed to elicit behavior change by helping clients to explore and resolve ambivalence. Nurses use motivational interviewing, although it has not been defined from a nursing perspective nor with nursing language. Thus, nursing research on the use of these techniques is being carried out, supported by their effectiveness in many health problems. The development of motivational interviewing as a standardized nursing intervention for inclusion in the Nursing Interventions Classification (NIC) may promote its use by mental health nurses in their daily work and thus improve the quality of care. OBJECTIVES To validate a proposed motivational interviewing nursing intervention for inclusion in the NIC. MATERIALS AND METHODS We followed the validation methodology of the NIC of the Iowa and the Intervention Normalization for Nursing Practice projects. The study comprised theoretical (scientific and expert validation) and empirical (terminological and clinical validation) phases. RESULTS There is ample evidence supporting the efficiency of the motivational interviewing to improve the therapeutic adherence of people with severe mental illness. The group of experts agreed on the label name "motivational interviewing" for the NIC based on the modified model by Miller & Röllnick (2015), which includes 28 associated activities through the phases of engaging, focusing, evoking, and planning. Development of the NANDA International and the Nursing Outcomes Classification nursing language was completed. Knowledge and drug attitude improved in the motivational intervention group. CONCLUSIONS We validated the nursing intervention motivational interviewing for inclusion in the NIC that will help improve therapeutic adherence. The intervention may be used for other behavioral changes.
Mayra Cristina Luz Pádua Guimarães, Juliana Chaves Coelho, Giovanio Vieira da Silva, Luciano Ferreira Drager, Rita de Cassia Gengo e Silva Butcher, Howard K Butcher, and Angela Maria Geraldo Pierin
Patient Preference and Adherence, eISSN: 1177889X, Pages: 2749-2761, Published: 2021 Informa UK Limited
Objective To evaluate and identify variables associated with the control of hypertension and adherence to antihypertensive drug treatment in a group of patients with hypertension monitored in a specialized, highly complex outpatient service. Methods A prospective, cross-sectional study was carried out in the hypertension unit of a tertiary teaching hospital. Patients diagnosed with hypertensive aged 18 years and over and accompanied for at least six months were included in the study. Patients with secondary hypertension and pregnant women were excluded. The sample consisted of 253 patients. Adherence/concordance to antihypertensive treatment was assessed using the Morisky Green Levine Scale. Blood pressure control was set for values less than 140/90 mmHg. Variables with p≤0.20 in univariate analysis were included in multiple logistic regression. The level of significance adopted was p ≤0.05. Results Most of patients were white, married and women, with a mean age of 65 (13.3) years old, low income, and education levels. Blood pressure control and adherence were observed in 69.2% and 90.1% of the patients, respectively. Variables that were independently associated with blood pressure control were (OR, odds ratio; CI, 95% confidence interval): married marital status (OR 2.3; CI 1.34–4.28), use of calcium channel blockers (OR 0.4; CI 0.19–0.92) and number of prescribed antihypertensive drugs (OR 0.78; CI 0.66–0.92). Adherence was not associated with any of the variables studied. Conclusion There was a high frequency of patients with satisfactory adherence to antihypertensive drug treatment. Blood pressure control was less frequent and was associated with social and treatment-related factors.
Howard Karl Butcher
Journal of Gerontological Nursing, ISSN: 00989134, Pages: 7-8, Published: March 2020 SLACK, Inc.
Alba Lúcia Bottura Leite de Barros, Viviane Martins da Silva, Rosimere Ferreira Santana, Agueda Maria Ruiz Zimmer Cavalcante, Allyne Fortes Vitor, Amália de Fatima Lucena, Anamaria Alves Napoleão, Camila Takao Lopes, Cândida Caniçali Primo, Elenice Valentim Carmona, Erika Christiane Marocco Duran, Howard Karl Butcher, Juliana de Lima Lopes, Leidy Johanna Rueda Díaz, Marcia Regina Cubas, Marcos Antônio Gomes Brandão, Marcos Venícios de Oliveira Lopes, Maria Miriam Lima da Nóbrega, Miriam de Abreu Almeida, Priscilla Alfradique de Souza, Rita de Cassia Gengo e Silva Butcher, Rodrigo Jensen, Rudval Souza da Silva, Sheila Coelho Ramalho Vasconcelos Morais, Tania Couto Machado Chianca, and Vinicius Batista Santos
Revista brasileira de enfermagem, ISSN: 00347167, Pages: e20200798, Published: 2020 FapUNIFESP (SciELO)
ABSTRACT Objective: to describe the theoretical construction process of nursing process support documents in COVID-19 care scenarios. Methods: an experience report of the joint activity of the Brazilian Nursing Process Research Network (Rede de Pesquisa em Processo de Enfermagem) composed of Higher Education and Health Institution researchers in Brazil. Results: five instruments were organized collectively, involving the elements of nursing practice (nursing diagnoses, outcomes and interventions) in assistance for community; for patients (with suspected or mild, moderate, and critical COVID-19 and residents in Nursing Homes); for nursing workers’ health support, also subsidizing registration and documentation during the COVID-19 pandemic. Final considerations: valuing the phenomena manifested by families/communities, patients and health professionals is essential for early detection, intervention, and prevention of diseases.
M. Lindell Joseph, Heather Bair, Michele Williams, Diane L. Huber, Sue Moorhead, Kirsten Hanrahan, Howard Butcher, and Nai-Ching Chi
Nursing Outlook, ISSN: 00296554, Pages: 596-604, Published: September - October 2019 Elsevier BV
BACKGROUND An innovation scholarly interest group used the Jobs to Be Done Theory from the business literature to provide insight into the solution-focused progress that nurses are trying to make in challenging situations. PURPOSE This article presents a theoretical framework for understanding the progress nurses are trying to make through health care innovations across both practice and academic environments. METHOD This was a qualitative descriptive study using directed content analysis. We used the Jobs to Be Done Theory to guide the development of the semistructured questionnaire and the interpretation of findings. FINDINGS A theoretical framework of nursing innovations was derived to summarize and visually display the pathways and linkages of challenges, innovations, and impact domains of nursing innovations. Situations and opportunities arise within the context of interconnectedness and can lead to health care innovations in care delivery, patient care interventions, role transitions, research and translational methods, communication and collaboration, technology and data, teaching methods, and processes to improve care. DISCUSSION This theoretical framework offers insight into the dynamic interactions of academic-practice partnerships for innovation. Workplace situations are interconnected and can result in needed innovations designed to impact care delivery.
Joel Olayiwola Faronbi, Howard K. Butcher, and Adenike Ayobola Olaogun
Journal of Gerontological Nursing, ISSN: 00989134, Pages: 39-46, Published: 1 January 2019 SLACK, Inc.
Family members play key roles in the care of older adults with chronic illness. However, little is known about the negative consequences of caregiving in Sub-Sahara Africa. The current study examined the influence of caregivers' burden and coping ability on the health-related quality of life of caregivers of older adults with chronic illness. An exploratory sequential mixed methods study was conducted among 16 family members. Findings showed that caregivers experienced severe burden, coped moderately with the burden, and had poor quality of life. Furthermore, directed content analysis of the in-depth interviews uncovered six major themes: (a) Being Pulled in Opposite Directions, (b) Experiencing Poor Health, (c) Receiving Support From Family and Friends, (d) Turning to God for Help, (e) Seeking Relief for Aching Bodies, and (f) Seeking Remedies for Sleeplessness. The current findings may have implications for designing programs that aim to improve the well-being of caregivers. [Journal of Gerontological Nursing, 45(1), 39-46.].
Howard K. Butcher and Todd N. Ingram
Journal of Gerontological Nursing, ISSN: 00989134, Pages: 20-32, Published: 1 November 2018 SLACK, Inc.
Suicide is a tragic, traumatic loss, and one of the most emotionally devastating events families, friends, and communities experience. Suicide claims more than 800,000 lives every year, and some of the highest rates of suicide in the United States and globally are among older adults. The purpose of this evidence-based guideline is to help health care providers recognize those at risk for suicide and recommend appropriate and effective secondary suicide prevention interventions. The information in this guideline is intended for health care providers who work in a variety of settings, including hospitals, nursing homes, rehabilitation centers, out-patient clinics, mental health clinics, home health care, and other long-term care facilities. Assessment and preventive treatment strategies were derived by exhaustive literature review and synthesis of the current evidence on secondary prevention of late-life suicide across practice settings. [Journal of Gerontological Nursing, 44(11), 20-32.].
Noreen Frisch, Howard K. Butcher, Diana Campbell, and Dickon Weir-Hughes
Journal of Holistic Nursing, ISSN: 08980101, eISSN: 15525724, Pages: 210-217, Published: 1 September 2018 SAGE Publications
As part of a study of a larger study of self-identified holistic nurses, researchers asked nurses to describe practice situations where energy-based modalities (EBMs) were used. Four hundred and twenty-four nurses responded by writing free-text responses on an online survey tool. The participants were highly educated and very experienced with 42% holding graduate degrees and 77% having over 21 years of practice. Conventional content analysis revealed four themes: EMBs are 1) caring modalities used to treat a wide range of identified nursing concerns; 2) implemented across the life span and to facilitate life transitions; 3) support care for the treatment of specific medical conditions; and 4) Use of EBMs transcend labels of ‘conditions’ and are used within a holistic framework. The fourth theme reveals a shared vision of nursing work such that the modality becomes secondary and the need to address the ‘whole’ at an energetic level emerges as the primary focus of holistic nursing.
Jeanette M. Daly and Howard K. Butcher
Journal of Gerontological Nursing, ISSN: 00989134, Pages: 21-30, Published: 1 July 2018 SLACK, Inc.
Elder abuse occurs in all practice settings and presents in various forms. The purpose of the current evidence-based practice guideline is to facilitate health care professionals' assessment of older adults in domestic and institutional settings who are at risk for elder abuse, and to recommend interventions to reduce the incidence of mistreatment. Limited research has been conducted on interventions to prevent or reduce elder abuse. Research is available on the prevalence of elder abuse and indicators of individuals who may be more susceptible to harm. The current article summarizes prevalence and risk factors for elder abuse, instruments available to assess individuals at risk for or victims of abuse, and potential interventions to prevent or reduce elder abuse. [Journal of Gerontological Nursing, 44(7), 21-30.].
Patricia Finch Guthrie, Shelley Rayborn, and Howard K. Butcher
Journal of Gerontological Nursing, ISSN: 00989134, Pages: 14-24, Published: 1 February 2018 SLACK, Inc.
Delirium is a common cause of morbidity and mortality in hospitalized older adults often superimposed on dementia. Older patients with delirium are more likely than other populations to develop hospital-acquired infections, pressure ulcers, and immobility and nutritional issues, as well as to have increased health care costs, longer hospital stays, and long-term care following discharge. Interventions that prevent or mitigate the effects of delirium while promoting recovery are essential for caring for hospitalized older patients. This article is a summary of an evidence-based guideline that includes a framework for addressing delirium that focuses on predisposing and precipitating factors for delirium. In addition, the guideline includes evidence-based assessment and intervention principles, along with a review of reliable and valid assessment instruments. The guideline also identifies measurable outcomes for managing delirium and a quality improvement approach for improving outcomes. [Journal of Gerontological Nursing, 44(2), 14-24.].
Deborah Shields, Ann Fuller, Marci Resnicoff, Howard K. Butcher, and Noreen Frisch
Journal of Holistic Nursing, ISSN: 08980101, eISSN: 15525724, Pages: 352-368, Published: 1 December 2017 SAGE Publications
The human energy field (HEF) as a phenomenon of interest across disciplines has gained increased attention over the 20th and 21st centuries. However, a concern has arisen that there is a lack of evidence to support the concept of the HEF as a phenomenon of interest to professional nurses and nursing practice. Using Chinn and Kramer’s method of creating conceptual meaning, a concept analysis was conducted for the purpose of developing a conceptual definition of HEF. A systematic review of the literature using the CINAHL database yielded a total of 81 articles and text sources that were determined to be relevant to the concept analysis. The HEF is defined as a luminous field of energy that comprises a person, extends beyond the physical body, and is in a continuous mutual process with the environmental energy field. It is a vital energy that is a continuous whole and is recognized by its unique pattern; it is dynamic, creative, nonlinear, unpredictable, and flows in lower and higher frequencies. The balanced HEF is characterized by flow, rhythm, symmetry, and gentle vibration.
Cheryl Kruschke and Howard K. Butcher
Journal of Gerontological Nursing, ISSN: 00989134, Pages: 15-21, Published: 1 November 2017 SLACK, Inc.
Falls are a major cause of injury and death annually for millions of individuals 65 and older. Older adults are at risk for falls for a variety of reasons regardless of where they live. Falls are defined as any sudden drop from one surface to a lower surface. The purpose of this fall prevention evidence-based practice guideline is to describe strategies that can identify individuals at risk for falls. A 10-step protocol including screening for falls, comprehensive fall assessment, gait and balance screening when necessary, and an individualized fall intervention program addressing specific fall risks is presented. Reassessing fall risk and fall prevention programs will ensure a proactive approach to reducing falls in the aging population. [Journal of Gerontological Nursing, 43(11), 15-21.].
Renan Alves Silva, Geórgia Alcântara Alencar Melo, Joselany Áfio Caetano, Marcos Venícios Oliveira Lopes, Howard Karl Butcher, and Viviane Martins da Silva
Revista gaucha de enfermagem, ISSN: 01026933, Pages: e65768, Published: 6 July 2017 FapUNIFESP (SciELO)
RESUMO Objetivo Analisar a acurácia do diagnóstico “Disposição para melhora da Esperança” em pacientes renais crônicos. Método Estudo transversal com 62 pacientes em clínica de hemodiálise entre agosto a novembro de 2015. Utilizou-se a Escala de Esperança de Herth para a construção das definições das características definidoras da North American Nursing Diagnosis Association International. Analisaram-se medidas de sensibilidade, especificidade, valor preditivo, razão de verossimilhança e odds ratio das características definidoras do diagnóstico. Resultados 82,22% apresentaram o diagnóstico. Verificou-se que as características definidoras “Expressa desejo de intensificar a coerência entre expectativas e desejos” e “Expressa o desejo de reforçar a resolução de problemas para alcançar as metas” aumentou em onze e cinco vezes, respectivamente, a chance de possuírem o diagnóstico. Conclusão “Expressa desejo de intensificar a coerência entre expectativas e desejos” e “Expressa o desejo de reforçar a resolução de problemas para alcançar as metas” apresentaram boas medidas de acurácia.
Paul Arnstein, Keela A. Herr, and Howard K. Butcher
Journal of Gerontological Nursing, ISSN: 00989134, Pages: 20-31, Published: 1 July 2017 SLACK, Inc.
More individuals develop and endure constant or recurring pain in older adulthood. Although 40% of these individuals receive no treatment, many evidence-based treatments are available. Accurate assessment of pain, its impact on functioning, and preventing treatment-related harms lay the foundation of safe, effective pain control. Analgesic agents are often necessary, but require a delicate balance to prevent under-treatment, the unnecessary abandonment of therapy, or exposure to potentially serious adverse effects. Nondrug therapies must be better integrated into the treatment plan to ensure overall safety. Evidence-based approaches help older adults thrive and survive longer despite living with persistent pain. [Journal of Gerontological Nursing, 43(7), 20-31.].
Renan Silva, , Álissan Lima, Natália Barreto, Anna Viana, Howard Butcher, Viviane Martins, , , , , and
Investigacion y Educacion en Enfermeria, ISSN: 01205307, eISSN: 22160280, Pages: 306-319, Published: 2017 Universidad de Antioquia
OBJECTIVES To identify and analyze the concept of the powerlessness in individuals with stroke, according to the NANDA-I Taxonomy. METHODS Concept analysis from online access of four databases using the descriptors: impotence; helplessness, learned; Stroke, depression in languages: Portuguese, English and Spanish. RESULTS The critical attributes of the feeling of powerlessness are: fragility, helplessness, lack of control, and power to achieve the proposed results for recovery and adaptation. Eleven new antecedents were found. It is recommended to reformulate three antecedents present in the taxonomy. Fourteen consequent were found. It is suggested to amend three consequential from the review. CONCLUSIONS With the analysis, a more complete concept of the powerlessness was elaborated allowing clarifying the critical attributes that, in turn, will help the rehabilitating nurse to recognize the signs and symptoms and to strengthen mechanisms of tolerance and resistance to stress.
Howard K. Butcher, Jean K. Gordon, Ji Woon Ko, Yelena Perkhounkova, Jun Young Cho, Andrew Rinner, and Susan Lutgendorf
American Journal of Alzheimer's Disease and other Dementias, ISSN: 15333175, eISSN: 19382731, Pages: 631-642, Published: 1 December 2016 SAGE Publications
This study tested the effect of written emotional expression on the ability to find meaning in caregiving and the effects of finding meaning on emotional state and psychological burden in 91 dementia family caregivers. In a pretest–posttest design, participants were randomly assigned to either an experimental or a comparison group. Experimental caregivers (n = 57) wrote about their deepest thoughts and feelings about caring for a family member with dementia, whereas those in the comparison group (n = 34) wrote about nonemotional topics. Results showed enhanced meaning-making abilities in experimental participants relative to comparison participants, particularly for those who used more positive emotion words. Improved meaning-making ability was in turn associated with psychological benefits at posttest, but experimental participants did not show significantly more benefit than comparison participants. We explore the mediating roles of the meaning-making process as well as some of the background characteristics of the individual caregivers and their caregiving environments.
Howard K. Butcher
Journal of Gerontological Nursing, ISSN: 00989134, Pages: 25-32, Published: 2016 SLACK, Inc.
Evidence-based practice (EBP) is the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making and the achievement of optimal patient outcomes and quality of life. Since 1994, The University of Iowa College of Nursing and its partner, University of Iowa Hospitals and Clinics Department of Nursing Services and Patient Care, has been at the forefront of making gerontological nursing EBP a reality. Every 4 months since 2007, the Journal of Gerontological Nursing (JGN) has published an EBP article focusing on a specific situation or problem associated with the care of older adults based on an EBP guideline developed and published by the University of Iowa College of Nursing. The current article provides background for the development of EBP in general and the specific development, processes, and components of the EBP guidelines published in this section of JGN. [Journal of Gerontological Nursing, 42 (7), 25-32.].
Mary J. Dyck, Theresa Schwindenhammer, and Howard K. Butcher
Journal of Gerontological Nursing, ISSN: 00989134, Pages: 21-31, Published: 2014 SLACK, Inc.
Heide Christine Bursch and Howard Karl Butcher
Research in Gerontological Nursing, ISSN: 19404921, Pages: 207-215, Published: 2012 SLACK, Inc.
Caring for a person with Alzheimer's disease (AD) challenges family caregivers with existential questions about what is the right thing to do for themselves and their care recipient. This study extracted themes spontaneously occurring in self-disclosure through expressive writing and sheds phenomenological insight into the deepest feelings revealed by caregivers of loved ones with AD. The personal journals of 24 caregivers were analyzed in the framework of Ricoeur's philosophy of ethics based on the concept of personal identity. Caregivers reflected on themes in friendship, self-esteem, authenticity, and capacity to act with the ethical intention to stay present while the care recipient is disappearing. Engaging the text within Ricoeur's ethically sensitive philosophy and methodology illuminated the benefit of writing interventions that allow caregivers to speak about conflicted states regarding their own humanity in the caregiver experience.
Lisa Skemp and Howard Karl Butcher
Journal of gerontological nursing, ISSN: 00989134, Pages: 17-21, Published: January 2012 SLACK, Inc.
Catherine E. Burnette, Sara Sanders, Howard K. Butcher, and Emily Matt Salois
Journal of Ethnic and Cultural Diversity in Social Work, ISSN: 15313204, eISSN: 15313212, Pages: 275-296, Published: October 2011 Informa UK Limited
The historical exploitation experienced by indigenous people in the United States has left a number of negative legacies, including distrust toward research. This distrust poses a barrier to progress made through culturally sensitive research. Given the complex history of research with indigenous groups, the purpose of this descriptive phenomenological study was to illuminate the lived experiences of both indigenous and non-indigenous researchers conducting culturally competent research with indigenous people. Interviews from 13 social science research experts revealed 6 underlying themes about their research with indigenous people, including respect and commitment, mutual trust, affirmation, harmony among multiple worldviews, responsibility, and spiritual/personal growth.
Howard Karl Butcher and Meghan L. McGonigal-Kenney
Research in Gerontological Nursing, ISSN: 19404921, Pages: 148-161, Published: July 2010 SLACK, Inc.
This phenomenological investigation sought to enhance understanding of the experience of dispiritedness by providing a rich and vivid description of the essential structure of the experience in later life. van Manen's hermeneutic-phenomenological method was used to analyze the transcribed texts of 11 individuals who identified themselves as being in "later life" (mean age = 73, age range = 52 to 93) and who participated in phenomenological interviews focusing on describing the experience of dispiritedness. Statements describing the experience of dispiritedness were sorted into 21 thematic categories that were synthesized into 7 essential themes that described the structure of the lived experience of dispiritedness in later life as Arising From Life's Trying Transitions, Feeling Disengaged From Meaning, Experiencing a Restricting Loss of Vigor and Animation, Feeling Forlorn Bewilderment, Moving Between Engagement and Disengagement, Remaining Faithful to Enduring Connections, and Engaging in Day-to-Day Living.
Sara Sanders, Howard K. Butcher, Peggy Swails, and James Power
Death Studies, ISSN: 07481187, eISSN: 10917683, Pages: 521-556, Published: July 2009 Informa UK Limited
The purpose of this study was to investigate how caregivers respond to the end stages of dementia with the assistance from hospice. Data were collected from 27 family caregivers over the course of 10 months, with each caregiver being interviewed up to 4 times during the time that the patient received hospice care. Chart review data were also collected. Four distinct caregiver portraits emerged: (a) disengaged, (b) questioning, (c) all-consumed, and (d) reconciled. Caregivers in each portrait differed in how they responded to the impending death of the care recipient, the disease progression, and hospice care. Recognizing the differences in the ways that caregivers respond to the final stages of the disease will assist hospice and other providers in best meeting the needs of the caregivers.