Received: 13 December 2020

DOI: 10.1002/pon.5666

REVIEW
- -
Revised: 16 February 2021 Accepted: 19 February 2021

Psychological resilience among palliative patients with

advanced cancer: A systematic review of definitions and
associated factors

Jerrald Lau1,2 | Athena Ming‐Gui Khoo1 | Andy Hau‐Yan Ho3,4,5 | Ker‐Kan Tan1

1
Yong Loo Lin School of Medicine, National
University of Singapore, Singapore
2
Saw Swee Hock School of Public Health,
National University of Singapore, Singapore
3
School of Social Sciences, Nanyang
Technological University, Singapore
4
Lee Kong Chian School of Medicine, Nanyang
Technological University, Singapore
5
Palliative Care Centre for Excellence in
Research and Education, Singapore
Correspondence
Ker‐Kan TAN, Division of Colorectal Surgery,
University Surgical Cluster, National
University Health System, 1E Kent Ridge Road
119228, Singapore.
Email: surtkk@nus.edu.sg
Funding information
Singapore Population Health Improvement
Centre (SPHERiC)
Abstract
Objective: The palliative journey can be emotionally stressful for both patients with
advanced cancer and their families. Psychological resilience is crucial in aiding with
patients' adaptation and post‐traumatic growth. The aim of this systematic review
was to critically examine the definitions of psychological resilience and its associ-
ated factors in palliative patients with advanced cancer.
Methods: Four databases were systematically searched from inception to August
2020. Both qualitative and quantitative studies that examined factors associated
with psychological resilience in a sample of patients with advanced cancer under-
going palliative care were included.
Results: A total of 15 studies met the criteria, of which 10 were qualitative and five
were quantitative. Nine studies included a definition of psychological resilience,
from which five common themes of buffering, adaptation, resources, recovery, and
growth were derived. The quantitative studies found association between resilience
and hope, independence, social support, fatigue, emotional distress, and coping
strategies. The qualitative studies reported additional sources of resilience such as
spirituality, social support, prior experience dealing with illness and life adversity,
meaning‐making, reconciling with life's finiteness, acceptance of illness, control,
determination, positive attitude, dignity, engagement with palliative care and quality
of life being supported by palliative care.
Conclusions: More research is needed for developing an overarching definition
of psychological resilience in palliative advanced cancer patients that acknowl-
edges and appreciates the contextual sensitivity of this concept among different
cultural groups. Further studies are also needed to examine a holistic range of bio‐
psycho‐socio‐spiritual factors associated with psychological resilience among these
patients and their families.

KEYWORDS
advanced cancer, palliative care, psychosocial outcomes, psychological resilience, systematic
review

Psycho‐Oncology. 2021;30:1029–1040. wileyonlinelibrary.com/journal/pon © 2021 John Wiley & Sons Ltd.

- 1029
1030
- LAU
1 | BACKGROUND
Psychological resilience has been broadly defined as the ability to
adapt to stressors, bouncing back from adversities and life crises,
and resume normal psychosocial functioning soon after adverse
1
events. In a meta‐analysis of physically ill individuals, resilience
was associated with a number of internal (e.g., self‐efficacy, hope,
optimism and acceptance) and external (e.g., coping strategies and
perceived social support) psychological factors, as well as a range of
behavioural and health‐related factors such as lifestyle, exercise,
2
illness perception and adherence to treatment. These factors were
also found to contribute to post‐traumatic growth in patients with
3
life‐threatening diseases. In cancer patients particularly, additional
predictors of psychological resilience include spiritual wellbeing and
demographic characteristics such as age, gender, income and marital
status.4–6
Understanding the factors that are associated with psycho-
logical resilience can serve to inform supportive interventions
that aim to maintain and uplift resilience and wellbeing among
palliative patients, their family carers and professional caregivers
even in the face of mortality. 7–9
In fact, patients undergoing
palliative treatment are known to experience a wide range of
distress in multiple life domains,10 but psychological resilience
has the potential to act as a protective factor in reliving such
distress. Specifically, psychological resilience has been observed
to associate with higher levels of hope, perceived social support,
lower levels of fatigue during early stages of radiation therapy,
symptom control, and spirituality; these outcomes are in turn
associated with better psychological outcomes and quality of
life.11–14
While research relating to psychological resilience in cancer
patients in general is slowly growing, the current body of literature
lacks a critical focus on advanced cancer patients undergoing
palliative care. For example, a recent systematic review reveals
that social support, self‐efficacy, emotional distress and hope are
some of the key factors found to predict resilience, yet the review
was based solely on women with breast cancer while its scope did
not uncover how factors relating to resilience may be moderated
by disease staging as well as curative versus non‐curative intent
for treatment. 15
This is an important gap in knowledge because
patients' experience of resilience for each stage of cancer—from
diagnosis and treatment to survivorship or palliation—has been
shown to vary.16 Indeed, for non‐curative patients, the end‐of‐life
experience is known to be marked by its own set of unique needs
and challenges for cancer patients as they struggle between hoping
for a cure, denying their prognosis, upholding dignity, and
accepting their mortality.17,18 The current systemic review aims to
fill this knowledge gap by developing a comprehensive under-
standing and critical summary on: (1) How psychological resilience
has been defined within the context of the palliative literature for
patients with advanced cancer; and (2) What factors are associated
with psychological resilience in palliative patients with advanced
cancer.
ET AL.
2 | METHODS
2.1 | Pre‐registration of review
A record of the present review has been registered under the
PROSPERO international prospective register of systematic reviews
(CRD42020204231).
2.2 | Search strategy
We conducted a systematic search of four databases (PubMed,
CINAHL, Scopus, and PsycINFO) from database inception to August
2020. The search strategy was compiled through a preliminary search
of the Medical Subject Headings (MeSH) database for terms relevant
to ‘psychological resilience’, ‘palliative care’, and ‘cancer’. As we were
interested primarily in psychological resilience in advanced cancer
patients undergoing palliative care rather than caregivers' perspec-
tives, we elected to specifically exclude ‘caregiver’ and its associated
terms from the search. An example of the search strategy (utilised for
PubMed) is as follows:
(“Resilience, Psychological” [Mesh] OR “Adaptation,
Psychological” [Mesh]) AND (“Palliative Care” [Mesh]
OR “Palliative Medicine” [Mesh] OR “Terminal Care”
[Mesh] OR “Terminally Ill” [Mesh] OR “Hospice Care”
[Mesh]) AND (“Neoplasms” [Mesh]) NOT (“Caregivers”
[Mesh])
For databases that were incompatible with MeSH search oper-
ators, all entry terms within each relevant subject heading were
manually included as search terms.
2.3 | Study inclusion and exclusion criteria
Both quantitative and qualitative studies were included if they (I)
included patients with advanced cancerundergoing palliative care in the
sample, (II) included psychological resilience and its associated MeSH
entry terms as a variable of interest, and (III) examined characteristics,
factors, and/or constructs associated with psychological resilience.
Studies were excluded if they (I) did not collect primary data (e.g.,
commentary, review or meta‐analysis), (II) were not published in En-
glish, or (III) were grey literature (i.e., not peer‐reviewed).
2.4 | Study selection, data extraction, and analysis
One co‐author (Athena Ming‐Gui Khoo) applied the appropriate
search strategy to each of the four databases and extracted the
resultant records. Duplicate records were identified and removed
using EndNote X8.19 A preliminary screening of each record's title
and abstract for relevance to the aims of the review was conducted
LAU ET AL.
by two co‐authors (Athena Ming‐Gui Khoo and Jerrald Lau). Full
texts of the relevant records were then independently reviewed by
the two co‐authors (Athena Ming‐Gui Khoo and Jerrald Lau) based
on the aforementioned inclusion and exclusion criteria. Disagree-
ments on study inclusion were resolved through discussion and
mutual agreement among all co‐authors. Quality appraisal of the
studies included in the final sample was performed by two co‐authors
(Athena Ming‐Gui Khoo and Jerrald Lau) using the relevant Joanna
Briggs Institute (JBI) critical appraisal tools.20
Data extraction for the final sample of included studies was
performed by two co‐authors (Athena Ming‐Gui Khoo and Jerrald
Lau) using a standardised data extraction form. Specifically, study
characteristics such as country where the research was conducted,
study design and methodology, as well as sample characteristics were
extracted. Moreover, data pertinent to the aims of this review, con-
sisting of how the study defined psychological resilience, instruments
used to measure psychological resilience (where relevant), factors
associated with psychological resilience, and key findings as reported
by each study were also extracted.
An inductive thematic synthesis was further performed to
identify common themes among the various studies' definitions of
resilience. The verbatim definitions of resilience found in each article
were first compiled into a table. Two co‐authors (Athena Ming‐Gui
Khoo and Jerrald Lau) then coded the definitions independently
before discussing and comparing codes identified. Categorisation of
codes and naming of the resultant inductive themes were confirmed
via mutual agreement among all co‐authors.
F I G U R E 1 Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow chart illustrating search strategy used to
identify eligible studies for inclusion
- 1031
3 | RESULTS
The search yielded a total of 1172 records (725 from PubMed, 156
from CINAHL, 124 from Scopus, and 167 from PsycINFO), of which
174 were detected as duplicates and removed. The remaining 998
records underwent preliminary screening of titles and abstracts. Of
these, 259 records were deemed relevant for further full text review,
which yielded a sample of 12 studies. An additional three relevant
studies were included through hand‐searching the reference lists of
these 12 included studies, for a final review sample of 15 studies. A
flow diagram of the study selection process can be found in Figure 1.
3.1 | Descriptive characteristics of the included
studies
The 15 included studies comprised some 781 patients with advanced
cancer from nine countries (Table 1). Of these, 10 articles (66.7%)
utilised a qualitative study design consisting primarily of in‐depth
interviews. The other five articles examined resilience quantitatively,
with four utilising a cross‐sectional design and the final article being a
single‐blind randomised controlled trial. Per the inclusion criteria, all
study samples included patients with advanced cancer undergoing
palliative care; for studies whose samples also involved patients un-
dergoing curative treatment, only findings pertinent to the non‐cura-
tive, palliative subsample were extracted for analysis. Eight (53.3%)
studies recruited patients with a range of cancers, while four studies
1032
- LAU ET AL.

TABLE 1 Descriptive characteristics of the included studies

Characteristics n (%) Characteristics n (%)

Study design Year of publication

Cross‐sectional 4 (27) 2020 2 (13)

Qualitative 10 (67) 2017 1 (7)

Randomised controlled trial 1 (7) 2016 4 (72)

2015 2 (13)

Journal 2013 4 (27)

Supportive Care in Cancer 2 (13) 2007 1 (7)

Palliative & Supportive Care 2 (13) 2002 1 (7)

Journal of Cancer Research and 1 (7)

Clinical Oncology Country

BMC Palliative Care 1 (7) United States 3 (20)

BMJ Open Respiratory Research 1 (7) Canada 1 (7)

Age and Ageing 1 (7) Norway 4 (27)

Palliative Medicine 1 (72) Brazil 1 (7)

Health: An Interdisciplinary 1 (7) Australia 2 (13)

Journal for the Social Study of Hong Kong 1 (7)

Health, Illness and Medicine India 1 (7)

Cancer Nursing 1 (7) Korea 1 (7)

Indian Journal of Palliative Care 1 (7) Germany 1 (7)

Journal of Palliative Care 1 (7)

The American Journal of 1 (7) Sample size

Hospice & Palliative Care < 50 8 (53)

Social Science & Medicine 1 (7) 50–99 5 (33)

100–149 0 (0)

Tumour group included in sample 150–199 1 (7)

Mixed 8 (53) 200–250 1 (7)

Colorectal cancer 2 (13)

Lung cancer 2 (13)

Not specified 3 (20)

focused on colorectal (n = 2, 13.3%) and lung (n = 2, 13.3%) cancers
respectively. The remaining three studies (20.0%) did not specify the
type of cancer(s). The majority (n = 11, 73.3%) of the studies included
were conducted in countries with predominantly western populations.
All but two of the studies were published within the last decade.
3.2 | Definitions and measurements of
psychological resilience
Nine of the 15 studies included definitions of psychological resilience
within the manuscript. These definitions were relatively heteroge-
nous across studies, although we identified and summarised five
common themes that were used to characterise psychological resil-
ience (Table 2). These were (I) Buffering, which describes resilience as
being able to prevent or reduce the negative impact of stressors; (II)
Adaptation, in which resilience involves the ability to adapt to
adversities or life events (i.e., stressors), (III) Resources, which
describes resilience as the use of the individual's psychosocial
resources to deal with stressors; (IV) Recovery, which involves a
return to the state that the individual was in before encountering the
stressor; and (V) Growth, which consists of positive biopsychosocial
development and/or benefits to the individual's well‐being.
In term of psychometric tools, resilience was quantitatively
measured using the Connor‐Davidson Resilience Scale (CDRS) in
three studies,11,21,22 the Bharathiar University Resilience Scale
LAU ET AL.
- 1033

TABLE 2 Definitions of psychological resilience in the included studies

Study Definition Key terms

Chochinov et al. (2002) ‘Resilience or fighting spirit refers to the mental determination that some patients Buffering, growth
exercise to overcome their illness‐related concerns or to optimise their quality
of life’

Dong et al. (2016) Did not define

Haug et al. (2015) ‘Clark and colleagues (2011, p. 53) suggest a process‐oriented framework called the Resources, Buffering, Growth
“resilience repertoire,” understood as a “supply of skills and resources” in older
people. These can be applied to reduce the negative consequences of difficult
events. In some cases, this activation can even lead to positive growth and
development’

Haug et al. (2016) ‘Resilience is approached as a set of behaviours regulating maintenance and Buffering, Recovery, Growth,
recovery to previous levels after loss of functioning’. ‘Resilience is involved in Resources
the dynamic between losses and gains, in close interaction with the available
cultural resources’.

Hjorth et al. (2020) Did not define

Ho et al. (2013) ‘Resilience/fighting spirit refers to patients' ability to rally against their illness‐ Buffering, Growth
related concerns for enhancing their sense of well‐being and optimising their
quality of life’.

Lau et al. (2020) ‘Resilience is defined as the process of harnessing resources to sustain physical and Resources, Buffering
emotional well‐being during and after any stressor’.

MacArtney et al. (2015) Did not define

Min et al. (2013) ‘Resilience has been defined as the dynamic capacity of individuals to successfully Buffering, Recovery
maintain or regain their mental health in the face of significant life adversities or
risks’.

Rohde et al. (2017) Did not define

Sachs et al. (2013) Did not define

Solano et al. (2016) ‘Personal resilience is a construct associated with the ability to adapt when Adaptation, Growth
challenged by stressors or adversities, or to strive despite the difficulty of an
experienced circumstance’.

Somasundaram et al. ‘Resilience is the ability to recover quickly from disruptions in functioning that Recovery
(2016) result from stress appraisals and to return to the previous level of functioning’.

Strauss et al. (2007) ‘Resilience was defined within developmental psychology as a variety of Resources, Buffering
psychological resources providing power of resistance when a person faces
critical life situations or demands’.

Wise et al. (2013) Did not define

(BURS) in one study,12 and the Resilience Scale (RS) in one study.13
Several differences were observed when comparing the theoretical
constructs and domains of resilience among the three instruments
adopted in the quantitative studies. The CDRS and RS were noted to
broadly share two common constructs (‘personal competence’ and
‘acceptance of change’ in the RS; corresponding to ‘personal
competence, high standards, and tenacity’ and ‘positive acceptance of
change, and secure relationships’—Factors 1 and 3 respectively in the
CDRS), which—in addition to the CDRS's ‘trust in one's instincts,
tolerance of negative affect, strengthening effects of stress’ (Factor
2)—show similarities with the identified themes of Adaptation and
Buffering.23,24 However, both scales also included constructs of
resilience that were heterogenous, including ‘self‐reliance’, ‘balance’
24
and ‘determination’ in the RS, as well as ‘control’ and ‘spiritual in-
fluence’ (Factors 4 and 5) in the CDRS.23
Our analysis on the BURS was inconclusive, owing to the scant
literature validating and utilising the instrument in palliative cancer
populations. While there is literature listing the seven domains
covered by the BURS,25 no description or definitions of each domain
were provided. Based on this limitation, therefore, we postulate that
the domain of ‘duration taken to get back to normalcy’ shows simi-
larities to the identified theme of Recovery, while the domains of
‘reaction to negative events’, ‘response to risk factors in life’, and
‘openness to experience and flexibility’ appear relevant to Adaption.
The domain of ‘hope/confidence in coping with future’ appears to be a
form of psychological Resource. Lastly, the domains of ‘perception of
effectofpast negativeevents’ and‘defining ‘problems’’could berelevant
to Adaption and Resource. Nonetheless, without enough published
literature explicating and validating the various domains comprising the
BURS, this analysis should be interpreted with caution.
1034
- LAU
3.3 | Factors associated with psychological
resilience: Quantitative studies
Two studies examined bivariate correlations between psychological
resilience and other factors (Table 3). Solano and colleagues found
that resilience was directly correlated with hope and independence
while inversely correlated with depression,11 while Somasundaram
and colleagues reported that resilience was directly correlated
with social support while inversely correlated with hopelessness
11,12
among advanced cancer patients. Psychological resilience was
also analysed as an antecedent/predictor of health outcomes in
two studies, whereby higher resilience was found to be associated
with lower fatigue during the initial phase of palliative radio-
therapy,13 and with lower emotional distress.22 Only one study
examined psychological resilience as an outcome of interest. Lau
and colleagues' randomised controlled trial (RCT) found that pa-
tients who underwent an intervention that promoted positive
coping strategies on stress management, goal setting and cognitive
restructuring experienced significantly higher resilience scores
21
compared to those in the control group.
3.4 | Factors associated with psychological
resilience: Qualitative studies
The 10 qualitative studies in the present review explored palliative
patients' perspectives on their sources of resilience as they live with
advanced cancer (Table 4). Spirituality,26–28 social support from
friends and family,27–29 and prior experience dealing with illness and
life adversity30–32 were the most common sources. Meaning‐making
(or positive reframing),30,33 reconciling with life's finiteness (by
focusing on past experiences and the present with a positive orien-
tation towards a limited future),28,31 acceptance of illness,28,29 and a
sense of control and determination26 were also commonly cited
sources of psychological resilience in palliative patients. Other
possible sources of resilience included having a positive attitude,26
hope,31 dignity,34 engagement with palliative care,26 and quality of
life being supported by palliative care.29 Only one study35 also looked
at psychological resilience as a source instead, suggesting that it
enhances or contributes to a sense of dignity in palliative patients
with advanced cancer.
3.5 | Quality appraisal of the included studies
Corresponding to the respective study designs, the JBI critical
11–13,22
appraisal checklists for analytical cross sectional (four studies),
26–35
qualitative research (10 studies), and randomised controlled
trials (one study)21 were utilised. Appraisal scores were calculated as
a proportion of the number of items each study fulfilled on its
respective checklist, after excluding non‐applicable items. In general,
all the included studies in our final sample demonstrated high
appraisal scores ranging from 70%–100%.
ET AL.
4 | DISCUSSION
To our knowledge, this is the first systematic review to explore how
psychological resilience has been defined and examined within the
palliative literature for patients with advanced cancer. Despite
growing importance in recognising the role of resilience in promoting
more favourable biopsychosocial outcomes during a cancer patient's
diagnosis and treatment journey,36 our review found only 15 studies
that examined psychological resilience within the psycho‐oncology
literature.. With the exception of two studies,13,35 all the other
studies in our sample were published within the past decade, which
further highlights the paucity of resilience‐related research in the
advanced cancer palliative care domain.
While psychological resilience was found to be loosely defined
and relatively heterogenous, the available definitions shared common
themes with most included studies highlighting the role of resilience
in helping reduce or prevent the negative psychosocial impact and
existential distress brought on by advanced illness, death and
dying.13,21,22,30,33,34 Additionally, these five defining themes of psy-
chological resilience as identified by this research fit closely with the
most general understanding of resilience, in that it is intrinsically a
response to adverse life events and a means by which individuals
positively adapt to these circumstances,37,38 with little contextual
sensitivity to palliative care. Nonetheless, considerable heterogeneity
was also found when comparing these common themes to the
established constructs from validated quantitative scales that mea-
sure psychological resilience. As studies have cautioned that resil-
ience must be defined in a way that is relevant to both the
sociocultural and environmental context in which the individual is
situated,39 our findings suggest that it may be timely for the palliative
and advanced cancer research community to begin a holistic mixed‐
methods approach of working towards a homogenous definition of
psychological resilience that is, firstly, more contextually sensitive to
advanced cancer patients undergoing palliation, as well as relevant to
the unique factors identified as essential to support one's resilience.
Moreover, studies with quantitative methodologies were the mi-
nority in our sample. Higher resilience was found to be associated with
better physiological (i.e., fatigue) and psychosocial (i.e., emotional
distress, hope, social support) outcomes in four studies.11–13,22 This is
cautiously consistent with the wider literature on psychological resil-
ience in cancer patients, which has been found to associate with
improvedmental health, quality of life, and even survivaloutcomes.40–42
There was a distinct absence of longitudinal studies in our review which
is significant for two reasons. First, aside from age and stage of cancer at
diagnosis, psychological resilience in cancer patients (in general) has
been shown to vary over the treatment process and patient's lifespan,43
but it remains to be seen how these trends occur among palliative
advanced cancer patients. Second, while resilience was observed to
correlate with the aforementioned patient‐reported outcomes, the lack
of prospective designs precludes causal associations.
The 10 qualitative studies in our sample examined how palliative
patients with advanced cancer developed a sense of resilience. The
most common findings of spirituality and support from loved ones as
TABLE 3 Descriptive summary of key findings from included quantitative studies
LAU

Study and
ET AL.

country Purpose and design of study Sample characteristics Resilience scale(s) used Key findings Key terms

Min et al. To examine the relationship between N = 152 (Stage I–III: n = 71; Stage IV: Connor‐Davidson Resilience Scale; Resilience predicts emotional Emotional distress
(2013) emotional distress and resilience n = 81) Hospital Anxiety Depression distress in a negative direction
in cancer patients Age: Mean of distressed Scale
group = 52.6, mean of non‐
distress group = 50.8

Korea Cross‐sectional Gender: Female (67), male (85)

Type of cancer: Not specified

Lau et al. (2020) To examine how the Promoting
Resilience in Stress management
United States (PRISM) program compares to
the usual care in terms of
participant's resilience, hope,
benefit‐finding, quality of life and
distress scoresRandomised
controlled trial
N = 92 (Stage I–III: n = 68; Stage IV: Connor‐Davidson Resilience Scale;
n = 24)Age: 12–25Gender: hope Scale; Benefit and Burden
Female (40), male (52)Type of Scale for Children; Pediatric
cancer: Mixed cancer Quality of Life Generic Short‐
Form; Kessler‐6 Psychological
Distress Scale
Those assigned to PRISM Coping strategies
intervention show significantly
higher resilience scores
compared to those who went
through usual care intervention.
PRISM aims to teach coping skills
such as stress management, goal
setting and cognitive
restructuring.

Solano et al. To examine the relationship between N = 44 (Stage IV: n = 44) Connor‐Davidson Resilience Scale; Resilience was positively correlated HopeIndependenceEmotional
(2016) personal resilience, hope and Herth hope Index; Barthel Index; to hope even after adjustment distress
other predictors of hope in visual‐numeric pain scale; visual‐ for gender, age and depression.
Age: 29–86 (mean = 56)
patients with advanced numeric scale for experienced Resilience was also positively
cancerCross‐sectional suffering; two‐item screening for correlated to independence and
depression negatively correlated to
Brazil Gender: Female (16), male (28)
depression.
Type of cancer: Colorectal cancer

Somasundaram To examine the relationship between N = 60 (Stage I–III: n = 30; Stage IV: Bharathiar University Resilience Resilience is positively correlated Social supportHope
et al. (2016) resilience, hopelessness, and n = 30) Scale; Multidimensional Scale of with social support while
social support in curative and Perceived Social Support; Beck negatively correlated with
Age: 18–65 (mean = 40)
palliative cancer patientsCross‐ hopelessness Scale hopelessness
India sectional Gender: Female (38), male (22)

Type of cancer: Not specified

Strauss et al. To examine if resilience influences
(2007) fatigue in cancer patients during
the beginning and at the end of
radiotherapyCross‐sectional
Germany
N = 239 (Stage I–III: n = 99, Stage IV: The Resilience Scale; Resilience predicts fatigue scores Fatigue
n = 45) Multidimensional Fatigue (negative relationship) only
Inventory; Short Form (12) during initial stage of
Age: 25–85 (mean = 61.5)
health Survey radiotherapy
Gender: Female (162), male (77)

Type of cancer: Mixed cancer

-
1035
TABLE 4 Descriptive summary of key findings from included qualitative studies
1036
-

Study and
country Purpose and design of study Sample characteristics Key findings Key terms

Chochinov et al. To determine how dying patients understand and N = 50 Resilience, or fighting spirit, enhances one's Dignity
(2002) define the term dignity, and what sense of dignity
experiences or issue supported or
Age: 37–90 (mean = 69)
undermined their personal sense of dignity
Canada Gender: Female (27), male (23)

Type of cancer: Mixed cancer, terminal

Dong et al. To qualitative examine the experience and N = 58 Resilience was positively associated with the PersonalitySpiritualityPalliative
(2016) perception of advanced cancer patients with adoption of a positive attitude, participating care
multiple symptoms in oncology and palliative with palliative care, spiritual faith, sense of
Age: mean = 67
care setting control, determination, personifying the
Australia Gender: Female (43), male (15) cancer

Type of cancer: Mixed cancer at advanced stage

Haug et al. To understand how patients with incurable N = 21 Resilience was associated with life history, in the Meaning‐making
(2015) cancer experience daily living while they sense that it allows the development of
receive palliative care personal narratives and identity, thus
Age: 70–88 (mean = 76)
becoming a resource one can draw from.
Norway Gender: Female (9), male (12) Resilience is also associated with meaning in
life, such as with relationships, activities of
Type of cancer: Mixed cancer, incurable
normal daily life and existential meaning‐
making

Haug et al. To understand how older people with incurable
(2016) cancer and receiving palliative care
experience the existential meaning‐making
function in their daily living
Norway
N = 21 Resilience was positively associated with Meaning‐makingPrior
existential meaning‐making, developing experience dealing with
narratives, previous life experiences and the illness and life adversity
Age: 70–75
cultural context
Gender: Female (9), male (12)
Type of cancer: Mixed cancer, incurable

Hjorth et al. To explore the topics patients discussed during N = 51Age: 41–86 (mean = 69.4)Gender: Female Resilience was positively associated with having Prior experience dealing with
(2020) conversations about advanced care planning, (11), male (40)Type of cancer: Lung cancer previous experiences with illness and disease, illness and life
Norway and to assess the acceptability and feasibility and related lung diseases, at palliative care be it personally or through a relative. It is also adversityReconciling with
of advanced care planning in patients, stage associated with focusing on the present or life's finiteness
relatives, and clinicians talking to others about their past.

Ho et al. (2013) To explore how the concept of living and dying
with dignity is understood in Chinese
context, as well as to examine how the
Hong Kong Dignity model can be generalised to older
terminal Hong Kong patients.
N = 16
Age: 61–92 (mean = 77.7)
Gender: Female (10), male (6)
Type of cancer: Mixed cancer, stage IV
Resilience was associated with dignity Dignity
conversing repertoire, which is the idea that
the impact of death is buffered by one's
personal worldviews that protects an
individual's sense of dignity.
LAU
ET AL.
TABLE 4 (Continued)
LAU

Study and
ET AL.

country Purpose and design of study Sample characteristics Key findings Key terms

MacArtney To explore experiences shaped by acceptance N = 40 Resilience is positively associated with Acceptance of illness
et al. (2015) and resilience, and to highlight how they acceptance, social support, relational
facilitate and restrict possibilities for people consequences and whether an individual's
Age: 30–91 (mean = 68) Social support
at end‐of‐life stage. palliative care emphasis on quality of life
Australia Gender: Female (22), Male (18)

Type of cancer: 86% diagnosed with advanced Quality of life being supported by
cancer (type not specified) palliative care

Rohde et al. To examine the spiritual well‐being of colorectal N = 20 Resilience is positively associated with SpiritualitySocial support
(2017) cancer patients who are in the palliative spirituality, social support and closeness with
stage and receiving chemotherapy friends and family
Age: Those with first line chemo (34–75;
mean = 63). Those with second line chemo
(64–75; mean = 69)

Norway Gender: Female (8), male (12)

Type of cancer: Colorectal cancer, palliative

stage

Sachs et al. To explore the relationship between hope and N = 22 Resilience is negatively associated with HopePast experiences
(2013) hopelessness as well as to identify factors hopelessness, and positively associated with
that contributes to the maintenance of hope having overcome mental illness through
and vulnerability to hopelessness Age: 30–80 (mean = 58.5) psychiatric treatment

United States Gender: Female (15), male (7)

Type of cancer: Mixed cancer, stage IV

Wise et al. To understand the strategies and the N = 10 Resilience is associated with engaging with life Social support
(2013) psychosocial conditions that influence the such as in the areas of relationships, with
lives of resilient patients with advanced embracing the paradox of facing death yet
Age: 35–82 (mean = 62) Acceptance of illness
cancer living fully, deepening connection with others
United States Gender: Female (3), male (7) and spiritual forces, act on priorities and to Spirituality
reframe time such as acting on long‐deferred
Type of cancer: Lung cancer, stage IV
dreams and to arrange long‐term plans to
ensure surviving spouse's well‐being. Reconciling with life's finiteness
-
1037
1038
- LAU
primary sources of psychological resilience is consistent with both
44,45
the quantitative and qualitative literature. Meaning‐making was
a source of resilience in two studies.30,33 Although prior research has
suggested that this can actually be a stressful process for cancer
patients which potentially results in higher distress, anxiety, and
maladaptive adjustment, meaning‐making has alternately been found
to be useful in promoting a sense of peace and acceptance in both
palliative patients and their caregivers.46–49 Nonetheless, as both
studies were conducted in Norway with only elderly samples, more
work will have to be done to further examine the relationship be-
tween meaning‐making and psychological resilience across palliative
advanced cancer populations. Similarly, the broad range of sources by
which patients derived resilience in our review reinforces the sug-
gestion that may be considerable sociocultural variation,39 and it
remains difficult at present to understand how generalisable these
findings are due to the dearth of palliative cancer literature on psy-
chological resilience; more culturally specific exploratory research
will be necessarily in the near future to help close this gap.
4.1 | Study limitations
As a ‘first look’ into psychological resilience in the palliative literature
for patients with advanced cancer, our review identified several limi-
tations across the sample. Firstly, 10 of the 15 included studies were
qualitative in design and methodology. While qualitative studies have
contributed greatly to the wider body of prior research on resilience by
accounting for sociocultural nuances, a crucial next step for the field
would be to follow‐up on these findings by using quantitative or mixed‐
methodologies to (1) develop and test instruments capable of repre-
sentatively measuring resilience in advanced cancer patients under-
going palliative care, and to (2) further identify factors associated with
resilience in these populations.50,51 Secondly, four of the five quanti-
tative studies in our sample were cross‐sectional in design. As described
earlier, a gap in the literature remains as to how psychological resilience
may interact withpatient‐reported outcomes over time. Lastly, 11of the
15 studies were conducted in countries with typically Western societies
(i.e., USA, Norway, Germany and Australia). As psychological resilience
has been demonstrated to be influenced by societal and cultural con-
texts, even less is known about the experience of palliative advanced
cancer patients outside of these Western populations.
Whilenot strictlyalimitation, ourcritical appraisal ofthe qualitative
studies in the sample found that none of them explicitly addressed
reflexivity in the research. Reflexivity—that is, the researcher having a
self‐awareness of their own assumptions and relationship to the par-
ticipants, the research itself, and the setting—is important in ensuring a
more holistic transparency in the collection and analysis of qualitative
52
data. Considering the highly sociocultural nature of research with
palliative advanced cancer populations, future qualitative studies
should also seek to examine how the authors' own sociodemographic
background and pre‐existing biases could influence patients' sharing
and subsequent interpretation of their subjective experiences.
There are several limitations inherent to our review as well.
While our search terms and strategy were kept deliberately broad in
ET AL.
order to present a representative state of the palliative advanced
cancer literature landscape on psychological resilience, three limita-
tions of our review must be noted. The first was that we only
included studies that were published in English, although it is unlikely
that this could have greatly biased the findings of the review given
that only 11 of the 247 records excluded were due to the language
criterion. Secondly, it is also possible that the search strategy could
have missed studies that examined facets of psychological resilience
but did not explicitly use or define the concept. Nonetheless, we
argue that this reiterates the need for a homogenous, accepted
definition of resilience that is contextually specific to the palliative
cancer literature. Lastly, relating specifically to the quantitative
studies included in this review, we identified factors associated with
psychological resilience based on statistical significance as reported
by these studies. While all studies in this review had high appraisal
scores (suggesting a relatively robust quality of methodological
design and analysis), our interpretation is nonetheless subject to
inherent residual biases—such as different sample sizes and recall/
interviewer limitations—in these studies.
4.2 | Clinical implications
There is increasing clinical interest in understanding the role of
psychological resilience in promoting hope, mental well‐being, and
quality of life in palliative advanced cancer patients.11,12,53 While Lau
and colleagues' RCT represents an early foray into the development
of resilience‐promoting interventions in palliative care, it is likely that
much work remains to be done before targeted strategies can be
adequately developed to meet the needs of these patients.
Perhaps one way to build towards a more homogeneous under-
standing of resilience could be to utilise sequential mixed‐methods
designs with a representative multi‐cultural sample. Qualitatively, such
a method could—for example—use a Delphi approach to generate
consensus on common themes associated with resilience as identified
by the multi‐cultural sample via in‐depth interviews or focus group
discussion. These findings could then be used to build upon existing
sociocultural limitations of the CDRS, RS, or other contemporary in-
struments measuring psychological resilience. Should homogeneity be
found in common factors across cultures, the resultant subscales can be
directly included in these existing instruments, and revalidated across
more robust samples to ensure internal consistency and construct val-
idity. Conversely, sociocultural differences in conceptualising aspects
or constructs associated with resilience could be developed into sub-
scales that may then be deployed as ‘questionnaire modules’ validated
to specific cultural settings.
5 | CONCLUSIONS
Future studies should seek to examine how psychological resilience is
holistically associated with a broad range of patient bio‐psycho‐
socio‐spiritual characteristics, and whether resilience trends are
predictive of patient‐reported prospective outcomes. Researchers
LAU ET AL.
should also seek to understand how sources of resilience—and the
relationship between resilience and associated factors—differ be-
tween palliative advanced cancer patients from different socio-
demographic or cultural strata. Indeed, much more work is needed to
illuminate the complexities of psychological resilience among pallia-
tive patients with advance cancer, and the findings from this review
can pave the way for the crucial first step towards that goal.
A C K N O WL ED GE M EN T
This work was supported by Singapore Population Health Improve-
ment Centre (SPHERiC) [NMRC/CG/C026/2017_NUHS].
C O N F L IC T O F IN T ER E S T
The authors declare that there is no conflict of interest.
REFERENCES
1. American Psychological Association. The road to resilience. APA.
http://www.apa.org/helpcenter/road‐resilience.aspx. Published 2014.
Accessed Nov 9, 2020.
2. Stewart DE, Yuen T. A systematic review of resilience in the physi-
cally ill. Psychosomatics. 2011;52(3):199‐209. https://doi.org/10.
1016/j.psym.2011.01.036.
3. Barskova T, Oesterreich R. Post‐traumatic growth in people living with
a serious medical condition and its relations to physical and mental
health: a systematic review. Disabil Rehabil. 2009;31(21):1709‐1733.
https://doi.org/10.1080/09638280902738441.
4. Bulkley J, McMullen CK, Hornbrook MC, et al. Spiritual well‐being in
long‐term colorectal cancer survivors with ostomies. Psycho Oncol.
2013;22(11):2513‐2521. https://doi.org/10.1002/pon.3318.
5. Hou WK, Law CC, Yin J, Fu YT. Resource loss, resource gain, and
psychological resilience and dysfunction following cancer diagnosis:
a growth mixture modeling approach. Health Psychol. 2010;29(5):
484‐495. https://doi.org/10.1037/a0020809.
6. Cohen M, Baziliansky S, Beny A. The association of resilience and
age in individuals with colorectal cancer: an exploratory cross‐
sectional study. J Geriatr Oncol. 2014;5(1):33‐39. https://doi.org/10.
1016/j.jgo.2013.07.009.
7. Choo PY, Tan‐Ho G, Dutta O, Patinadan PV, Ho AHY. Reciprocal
dynamics of dignity in end‐of‐life care: a multiperspective system-
atic review of qualitative and mixed methods research. Am J Hosp -
Palliat Care. 2020;37(5):385‐398. https://doi.org/10.1177/1049909
119878860.
8. Tan‐Ho G, Choo PY, Patinadan PV, Low CX, Ho AHY. Blessings or
burdens: an Interpretative Phenomenological Analysis (IPA) study
on the motivations and their impact on end‐of‐life caregiving among
Asian family caregivers. BMC Palliat Care. 2020;19(1):132. https://
doi.org/10.1186/s12904‐020‐00638‐6.
9. Ho AHY, Tan‐Ho G, Ngo TA, et al. A novel mindful‐compassion art
therapy (MCAT) for reducing burnout and promoting resilience for
end‐of‐life care professionals: a waitlist RCT protocol. Trials.
2019;20(1):406. https://doi.org/10.1186/s13063‐019‐3533‐y.
10. Ho AHY, Tan‐Ho G. A good death: resolving the complexity of
mortality. In: Cultural Patterns and Neurocognitive Circuits. Singapore:
World Scientific Publishing; 2016:169‐181. https://doi.org/10.1142/
9789813147492_0009.
11. Solano JP, da Silva AG, Soares IA, Ashmawi HA, Vieira JE. Resilience
and hope during advanced disease: a pilot study with metastatic
colorectal cancer patients. BMC Palliat Care. 2016;15:70. https://doi.
org/10.1186/s12904‐016‐0139‐y.
12. Somasundaram RO, Devamani KA. A comparative study on resilience,
perceived social support and hopelessness among cancer patients
- 1039
treated with curative and palliative care. Indian J Palliat Care.
2016;22(2):135‐140. https://doi.org/10.4103/0973‐1075.179606.
13. Strauss B, Brix C, Fischer S, et al. The influence of resilience on
fatigue in cancer patients undergoing radiation therapy (RT). J Canc
Res Clin Oncol. 2007;133(8):511‐518. https://doi.org/10.1007/
s00432‐007‐0195‐z.
14. Fombuena M, Galiana L, Barreto P, Oliver A, Pascual A, Soto‐Rubio A.
Spirituality in patients with advanced illness: the role of symptom con-
trol, resilience and social network. J Health Psychol. 2016;21(12):
2765‐2774. https://doi.org/10.1177/1359105315586213.
15. Ye ZJ, Peng CH, Zhang HW, et al. A biopsychosocial model of
resilience for breast cancer: a preliminary study in mainland China.
Eur J Oncol Nurs. 2018;36:95‐102. https://doi.org/10.1016/j.ejon.
2018.08.001.
16. Molina Y, Yi JC, Martinez‐Gutierrez J, Reding KW, Yi‐Frazier JP,
Rosenberg AR. Resilience among patients across the cancer con-
tinuum: diverse perspectives. Clin J Oncol Nurs. 2014;18(1):93‐101.
https://doi.org/10.1188/14.CJON.93‐101.
17. Sterba KR, Zapka J, Gore EI, et al. Exploring dimensions of coping in
advanced colorectal cancer: implications for patient‐centered care. J
Psychosoc Oncol. 2013;31(5):517‐539. https://doi.org/10.1080/
07347332.2013.822049.
18. Ho AH, Leung PP, Tse DM, et al. Dignity amidst liminality: healing
within suffering among Chinese terminal cancer patients. Death Stud.
2013;37(10):953‐970. https://doi.org/10.1080/07481187.2012.
703078.
19. EndNote [computer program]. Version EndNote X9. Philadelphia, PA:
Clarivate; 2013.
20. Moola S, Munn Z, Tufanaru C, et al. Chapter 7: systematic reviews of
etiology and risk. In: Aromataris E, Munn Z, eds. Manual for Evidence
Synthesis. JBI; 2020. https://synthesismanual.jbi.global.
21. Lau N, Bradford MC, Steineck A, et al. Examining key sociodemo-
graphic characteristics of adolescents and young adults with cancer:
a post hoc analysis of the Promoting Resilience in Stress Manage-
ment randomized clinical trial. Palliat Med. 2020;34(3):336‐348.
https://doi.org/10.1177/0269216319886215.
22. Min JA, Yoon S, Lee CU, et al. Psychological resilience contributes to
low emotional distress in cancer patients. Support Care Canc. 2013;
21(9):2469‐2476. https://doi.org/10.1007/s00520‐013‐1807‐6.
23. Connor KM, Davidson JR. Development of a new resilience scale:
the connor‐davidson resilience scale (CD‐RISC). Depress Anxiety.
2003;18(2):76‐82. https://doi.org/10.1002/da.10113.
24. Wagnild GM, Young HM. Development and psychometric evaluation
of the resilience scale. J Nurs Meas. 1993;1(2):165‐178. https://www.
ncbi.nlm.nih.gov/pubmed/7850498.Published1993/01/01.
25. Narayanan A, Betts LR. Bullying behaviors and victimization expe-
riences among adolescent students: the role of resilience. Res Theory
Hum Dev. 2014;175(2):134‐146. https://doi.org/10.1080/00221325.
2013.834290.
26. Dong ST, Butow PN, Tong A, et al. Patients' experiences and perspec-
tives of multiple concurrent symptoms in advanced cancer: a semi‐
structured interview study. Support Care Canc. 2016;24(3):1373‐1386.
https://doi.org/10.1007/s00520‐015‐2913‐4.
27. Rohde G, Kersten C, Vistad I, Mesel T. Spiritual well‐being in
patients with metastatic colorectal cancer receiving noncurative
chemotherapy: a qualitative study. Canc Nurs. 2017;40(3):209‐216.
https://doi.org/10.1097/NCC.0000000000000385.
28. Wise M, Marchand L. Living fully in the shadow of mortal time:
psychosocial assets in advanced cancer. J Palliat Care. 2013 29(2):
76‐82. https://www.ncbi.nlm.nih.gov/pubmed/23923470. Published
2013/08/08.
29. MacArtney JI, Broom A, Kirby E, et al. On resilience and
acceptance in the transition to palliative care at the end of life.
Health. 2015;19(3):263‐279. https://doi.org/10.1177/136345931
4545696.
1040
- LAU
30. Haug SH, Danbolt LJ, Kvigne K, DeMarinis V. Older people with
incurable cancer: existential meaning‐making from a life‐span
perspective. Palliat Support Care. 2016;14(1):20‐32. https://doi.org/
10.1017/S1478951515000644.
31. Hjorth NE, Schaufel MA, Sigurdardottir KR, Haugen DRF. Feasibility
and acceptability of introducing advance care planning on a thoracic
medicine inpatient ward: an exploratory mixed method study. BMJ
Open Respir Res. 2020;7(1). https://doi.org/10.1136/bmjresp‐2019‐
000485.
32. Sachs E, Kolva E, Pessin H, Rosenfeld B, Breitbart W. On sinking and
swimming: the dialectic of hope, hopelessness, and acceptance in
terminal cancer. Am J Hosp Palliat Care. 2013;30(2):121‐127. https://
doi.org/10.1177/1049909112445371.
33. Haug SH, Danbolt LJ, Kvigne K, Demarinis V. How older people with
incurable cancer experience daily living: a qualitative study from
Norway. Palliat Support Care. 2015;13(4):1037‐1048. https://doi.org/
10.1017/S1478951514001011.
34. Ho AH, Chan CL, Leung PP, et al. Living and dying with dignity in
Chinese society: perspectives of older palliative care patients in
Hong Kong. Age Ageing. 2013;42(4):455‐461. https://doi.org/10.
1093/ageing/aft003.
35. Chochinov HM, Hack T, McClement S, Kristjanson L, Harlos M.
Dignity in the terminally ill: a developing empirical model. Soc Sci
Med. 2002;54(3):433‐443. https://doi.org/10.1016/s0277‐9536(01)
00084‐3.
36. Seiler A, Jenewein J. Resilience in cancer patients. Front Psychiatr.
2019;10:208. https://doi.org/10.3389/fpsyt.2019.00208.
37. Luthar SS. Resilience in development: a synthesis of research across
five decades. In: Cicchetti D, Cohen D, eds. Developmental psycho-
pathology: Risk, disorder, and adaptation. New York, NY: Wiley; 2006:
739‐795.
38. Luthar SS, Cicchetti D. The construct of resilience: implications for
interventions and social policies. Dev Psychopathol. 2000;12(4):
857‐885. https://doi.org/10.1017/s0954579400004156.
39. Fletcher D, Sarkar M. Psychological resilience: a review and critique
of definitions, concepts, and theory. Eur Psychol. 2013;18(1):12‐23.
https://doi.org/10.1027/1016‐9040/a000124.
40. Walsh DMJ, Morrison TG, Conway RJ, Rogers E, Sullivan FJ,
Groarke A. A model to predict psychological‐ and health‐related
adjustment in men with prostate cancer: the role of post traumatic
growth, physical post traumatic growth, resilience and mindfulness.
Front Psychol. 2018;9:136. https://doi.org/10.3389/fpsyg.2018.
00136.
41. Wenzel LB, Donnelly JP, Fowler JM, et al. Resilience, reflection, and
residual stress in ovarian cancer survivorship: a gynecologic
oncology group study. Psycho Oncol. 2002;11(2):142‐153. https://
doi.org/10.1002/pon.567.
42. Ye ZJ, Qiu HZ, Li PF, et al. Predicting changes in quality of life and
emotional distress in Chinese patients with lung, gastric, and colon‐
rectal cancer diagnoses: the role of psychological resilience. Psycho
Oncol. 2017;26(6):829‐835. https://doi.org/10.1002/pon.4237.
ET AL.
43. Rowland JH, Baker F. Introduction: resilience of cancer survivors
across the lifespan. Cancer. 2005;104(11 Suppl):2543‐2548. https://
doi.org/10.1002/cncr.21487.
44. Lee V. The existential plight of cancer: meaning making as a concrete
approach to the intangible search for meaning. Support Care Canc.
2008;16(7):779‐785. https://doi.org/10.1007/s00520‐007‐0396‐7.
45. Li MY, Yang YL, Liu L, Wang L. Effects of social support, hope and
resilience on quality of life among Chinese bladder cancer patients: a
cross‐sectional study. Health Qual Life Outcome. 2016;14:73. https://
doi.org/10.1186/s12955‐016‐0481‐z.
46. Wortman CB, Silver RC. The myths of coping with loss revisited. In:
Stroebe MS, Hansson RO, Stroebe W, Schut H, eds. Handbook of
bereavement research: Consequences, coping, and care. Washington,
DC: American Psychological Association; 2001:405‐429. https://doi.
org/10.1037/10436‐017.
47. Kernan WD, Lepore SJ. Searching for and making meaning after
breast cancer: prevalence, patterns, and negative affect. Soc Sci Med.
2009;68(6):1176‐1182. https://doi.org/10.1016/j.socscimed.2008.
12.038.
48. Romanoff BD, Thompson BE. Meaning construction in palliative
care: the use of narrative, ritual, and the expressive arts. Am J Hosp
Palliat Care. 2006;23(4):309‐316. https://doi.org/10.1177/1049909
106290246.
49. Fillion L, Dupuis R, Tremblay I, De Grace GR, Breitbart W. Enhancing
meaning in palliative care practice: a meaning‐centered intervention
to promote job satisfaction. Palliat Support Care. 2006;4(4):333‐344.
https://doi.org/10.1017/s1478951506060445.
50. Ungar M. Qualitative contributions to resilience research. Qual Soc
Work Research and Practice. 2003;2(1):85‐102. https://doi.org/10.
1177/1473325003002001123.
51. Kelle U. Combining qualitative and quantitative methods in research
practice: purposes and advantages. Qual Res Psychol. 2006;3:
293‐311.
52. Korstjens I, Moser A. Series: practical guidance to qualitative
research. Part 4: trustworthiness and publishing. Eur J Gen Pract.
2018;24(1):120‐124. https://doi.org/10.1080/13814788.2017.137
5092.
53. Henry M, Cohen SR, Lee V, et al. The Meaning‐Making intervention
(MMi) appears to increase meaning in life in advanced ovarian
cancer: a randomized controlled pilot study. Psycho Oncol.
2010;19(12):1340‐1347. https://doi.org/10.1002/pon.1764.
How to cite this article: Lau J, Khoo AMG, Ho AHY, Tan KK.
Psychological resilience among palliative patients with
advanced cancer: A systematic review of definitions and
associated factors. Psycho‐Oncology. 2021;30:1029–1040.
https://doi.org/10.1002/pon.5666
Copyright of Psycho-Oncology is the property of John Wiley & Sons, Inc. and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for
individual use.