1. Harpham, Wendy S. MD

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"If there is hope, have hope."


I developed that aphorism because in survivorship people talk about hope all the time. But hope has many different meanings. And problems can arise if patients confuse the various meanings.

WENDY S. HARPHAM, MD... - Click to enlarge in new windowWENDY S. HARPHAM, MD. WENDY S. HARPHAM, MD, is an internist, cancer survivor, and author. Her books include

Since the aphorism first popped into my head, my take on it has evolved as I've continued exploring philosophical ideas about hope. Given clinicians' vital-and unique-role in patients' hope, let's take a closer look.


The aphorism uses the key word, hope, twice. But the second time, hope has a different meaning. In the opening phrase hope means "a possibility," such as when clinicians say "There is hope of remission" or "There is hope this treatment will relieve your pain." After the comma, "hope" refers to an emotion, specifically the pleasant feeling linked to a belief that the desired outcome could happen.


For now I'll leave it to philosophers to parse the distinctions between having hope, feeling hope, possessing hope, and other such phrases. In the aphorism, what matters is that the second hope is fundamentally different from hope as possibility, because it taps into subjective human experiences and feelings.


The comma is more than a rhetorical device. It serves as a syntactic break that separates "is hope" from "have hope," prompting patients to distinguish between the two different ideas.


The comma also functions like a speed bump, encouraging patients to slow down and first reflect on the intellectual concept of hope as a statistical possibility before dealing with any personal issues that involve emotions.


Hope as objective possibility provides a useful starting point because, for one thing, it's easier to talk about statistics than feelings. For another, thinking about hope as a fixed clinical fact may help patients lay seeds for nurturing the feeling of hope, a malleable emotion that directs them to action.


Imagine patients who are hopeless about cure, pain relief, or reaching a forthcoming milestone. Feeling no hope, they may conclude there is no hope-and thus see no reason to do anything to help their situation. Hopelessness leads to paralysis.


Family members and friends may try to convince them otherwise, insisting "There is hope." But to no avail. Like quarreling spouses, patients dismiss legitimate arguments, hearing only the emotions behind their loved ones' words.


Not so if their physicians say the same thing. Since the initial visit, patients have looked to their physicians for an expert and objective assessment of their prognosis (i.e., what they can expect) and the best possible outcome for them (i.e., what they can hope for). Patients have trusted their physicians to base all such assessments on what modern science and technology can reveal and forecast.


At the very least, patients who hear their physicians say "There is hope" know that their physicians believe the goal under discussion is possible for them. At best, the authority behind that professional determination enables patients to begin believing in that possibility themselves.


That's nice. For some patients, a newfound belief in the objective possibility causes a shift in perception that opens the floodgates to feeling hope. But for others that same belief only budges the door to hopeful feelings, especially if the odds are long for achieving the desired outcome.


A weakness of the aphorism is this: Visually separating the first idea of hope from the second is a low-lying, gracefully curved comma. Its size and simplicity belie the dense complexity of the relationship between hope as possibility and the emotion we call hope.


Patients can believe there is hope, yet not have hope. As if that were not challenging enough, the path to hope is highly individual and rarely linear or predictable.


Where does that leave clinicians? If there is hope for some clinical endpoint, what can clinicians say or do to help patients have hope for that outcome?


Ironically, the aphorism designed to assist in that quest led me to scrap my past approach as too clinical. Too narrow. You see, some philosophers suggest that the emotion we call hope helps people live. Not hope for this or hope for that. Simply hope.


In the care of patients who feel no hope, maybe we need to step back and look for ways to help them feel hope-a positive feeling about a future good that can happen. Clinicians may need to plumb for a meaningful possibility that resonates with an individual and stirs feelings of hope. Maybe it's hope of physical comfort. Or of making the best decisions. Or of dealing with the challenges gracefully. Maybe it's the nebulous hope that, somehow, tomorrow can be a better day.


Hope feels good. But hope is not good if it unwittingly leads patients to decisions and actions that, in the end, hurt them and go against their life values. It's not good if, for example, unwavering hope of recovery hinders dying patients from having candid conversations and taking advantage of timely end-of-life care. The emotion we call hope is healing only when it helps patients get good care and live as fully as possible.


"If there is hope, have hope" is not a solution to hopelessness. It's a tool for talking about hope in ways that help patients...


* Distinguish hope as statistical possibility from the feeling of hope;


* Appreciate the fundamental human need to feel hope;


* Avoid dangerous hopes; and


* Invest in healthy hopes, whatever they might be.



Clinicians use the science and art of medicine to help patients understand the different meanings of hope so they can find hope. Patients need hope. Because where there is hope, there is life.