4. Discussion
chronic illness, hope-promoting, illness, death
CHRONIC ILLNESSES, CHRONIC ILLNESS, DISEASE PROGRESSION
Comparison between the IG and CG suggests that the HPP had a positive effect on hope over time. The most expressive increases were in the levels of total hope and positive interior disposition and expectations, with significant differences in each period. Regarding temporality, trust and interconnection, differences were only significant one month after the intervention. This can be explained by the high level of hope before the HPP, making it difficult to detect large variations immediately after the intervention program. Even so, the increase was significant when compared to the CG (where levels of hope decreased), attesting to the effect of HPP upon the greater sense of temporality, trust and interconnection over time.These results support the active and effective role of nurses in promoting the hope of people with advanced chronic illness [This study was innovative in using a psychosocial supportive hope intervention that differed in terms of dose, composition and the possibility of individualizing the proposed activities. According to Chan et al. [The tested HPP’s design included a greater number of nurse visits in relation to the “Living with Hope Program” [The first HPP session, viewing the film “Living with hope”, may have been crucial in shaping the patients’ positive perception of hope. The use of the video has been an integral part of hope-promoting programs [Participants in the IG had a higher global and physical QoL than those of the CG immediately after the HPP. This difference between groups did not remain over time, although there was an increase in both groups. Disease progression and treatments may have prevented better results. However, considering that the instrument can detect changes in 48 h, these results may indicate the need to reinforce hope-promoting interventions and activities in order to obtain gains in QoL over time [One of the novelties of this study was the evaluation of the program’s ability to promote hope in comfort. So far, the developed programs have not included the relationship between these variables, although comfort is a major goal of care for people with advanced and progressive chronic illnesses in their end-of-life trajectory [In the HPP, the promotion of hope is associated with interventions and activities directed simultaneously toward comfort in the physical, psycho-spiritual, environmental and socio-cultural contexts. In addition to the proposed hope-focused activities, the program includes a relaxation exercise using guided imagery to reinforce the repertoire of coping strategies, self-control and self-confidence. This constitutes a non-pharmacological tool for symptom control using the ability to transcend the situation [The results indicate that HPP brings long-term gains in terms of overall comfort, relief, ease and transcendence, since the evolution was significant for all these states in the patients in the IG one month after the program. The increase in comfort can be partially explained by the increase in hope, as these variables were positively correlated in the study sample. The increase in comfort was most likely related to the relaxation activity using mental images, since this was performed by all participants. Guided imagination has been identified as a non-pharmacological strategy of symptom control capable of facilitating comfort in a hospital environment [Notably, there were significant differences between the experimental and control groups in the state of transcendence. This means that, despite the progression of the illness and the effects of their treatments, HPP enabled people to evolve in the discomfort-comfort continuum, increasing their ability to feel more competent and to plan, control their destiny and solve their problems. In the final phase of life, an increase in transcendental comfort can compensate for successive losses of autonomy and control associated with the experience of illness and the real possibility of death in the short term. The fact that patients were mostly Catholic may have influenced transcendence. Believing in life beyond death and giving meaning to suffering (compared with that of Jesus Christ and other models associated with religion) seems to have been decisive for the perception of hope and may also justify the significant gains in comfort in the psycho-spiritual context [The active involvement of patients in performing the hope-promoting activities proposed in the guide, which was only possible due to their good functional level, may have facilitated the state of greater harmony, satisfaction and calm necessary for efficient performance, leading to greater transcendental comfort [