There are very few studies about being a family member of a person with lung or gastrointestinal cancer, two of the most common causes of death in Europe [17
]. The findings in this study bring into focus the challenges confronting family members when one in the family has been diagnosed with advanced cancer. The family members live in a state of insecurity, unsure as to when indeed the frightening possibility will become reality. They cannot escape the feeling that this occasion is coming nearer with each day that passes. In the back of their minds, they prepare themselves for a frightening lonely life without their loved one, knowing that they are going to be left alone in grief but without the slightest idea when
. Such fear of the future has been previously described in the literature [21
In this study, the caregiving burden for family members was not particularly onerous in terms of time because the advanced cancer was in its early stage. Nevertheless, they had to handle life that changed after diagnosis and the overwhelming threat of death hanging over the sick person. How the family members in this study managed is summarized by the theme Striving to be prepared for the painful
, which expresses the function of the seven underlying sub-themes or strategies. In a study performed by Persson and Sundin [3
], the significant others were found to be 'Striving to function oneself' as best they could in everyday life whilst also attempting to visualize what the future held in store through 'Managing perceived threats'. This was confirmed by our own findings. In that same study, the significant others were found to be in an altered relationship with their next of kin, on the one hand closely attached to the sick person, and on the other hand more distanced with feelings of being in an unequal relationship [3
]. The finding regarding an altered relationship with the sick person was not found in this study. These different findings may be explained by the fact that in the earlier study, the elapsed time after diagnosis was six months compared with about two months in our study. It is plausible that living longer with a person who has advanced cancer means larger inequality in the relationship because of an increased amount of caregiving by the family member.
The family members in our study had the strength to make things easier in everyday life. A similar strategy was reported previously and expressed as 'make the best of it' [22
]. This means to not give up, be strong, look ahead, and do the things that can be done and solve practical problems. In Adelbratt and Strang's study [23
], family members in the early stage of the illness were preparing practical things for the funeral and planning to travel with friends. A husband started to practice cooking so he could manage this task when his wife died. These previous findings, as well as the sub-theme in our study 'Making things easier in everyday life', relates to problem-focused coping. Problem-focused coping is concerned with handling the source of stress, dealing directly with the situation. This type of coping is more often related to successful outcomes [24
] compared to emotion-focused coping. Emotion-focused coping is concerned with handling emotions associated with stressful situations, (i.e. relieving the feeling of stress without actually having to change the situation) [14
]. However, longitudinal and experimental studies have documented the adaptive potential of emotional-approach coping in the context of several types of stressors, including breast cancer and chronic pain [25
]. In our study, only 'Making things easier in everyday life' can be classified as problem-focused. The other sub-themes are emotion-focused.
The strategy 'Banishing thoughts about the approaching loss' revealed that family members experience the situation as highly emotionally stressful and have to manage it by distancing. This strategy is similar to findings in a previous study by Benkel and colleagues [26
] indicating that family members fully understand that cancer is a serious and incurable disease that is leading to the patient's death. However, because the date of death is unknown, they hide this information deep in their hearts so they can live as if death is far off in the future. This makes it possible, despite the insight, to deal with the patient as a living person instead of a dying one. The strategy 'Thinking that the death is far off in the future' in this previous study as well as 'Banishing thoughts about the approaching loss' in our study are in contrast to the concept of denial, a psychological defence mechanism in which the person does not acknowledge the existing reality and suppresses thoughts of it [26
'Living in the present' gives the family members a feeling that the catastrophe is ahead of them and not happening right now. They take one day at a time. Benkel and colleagues [26
] showed that family members strive to maintain as normal a life as possible during the palliative stage, keeping to their usual routines and activities. In the findings of other studies, housekeeping, cooking and other practical activities were more prominent than in our study findings [26
'Adjusting to the sick person's situation' includes the family members' sympathy for the sick person and their wish to be accessible every day to provide support. Milberg and Strang [29
] found that family members do everything they can for the sick person in everyday life in palliative home care, supported by the sharing caring staff. Caring for the sick person with support from the staff gives the family member a feeling of greater togetherness and a deeper understanding of the sick person's everyday activities [29
]. In our study, the family members' interview narratives showed that they wanted to be close to the sick person, spending all the time they could with their loved one. Goldzweig and colleagues  reported that middle age and older males tend to have more support from females than vice versa [30
]. In our study, nearly half of the family members were female and married to a male patient. The family members as well as patients were older adults. Perhaps the findings in our study were influenced by gender and age given that married older male patients have been shown to receive more support than married female patients.
'Distracting themselves by being with others' concerns the finding that friends and co-workers offer support to the family members, enabling them to be with others and think of something else for a short while [1
]. Such support has been indicated in previous studies [32
'Shielding the family and bearing their grief' means that the family members shield their family from the disease and poor prognosis. They think it best to protect the children from suffering by holding back information and understating the gravity of the situation. In a study by Fletcher and colleagues [35
], family members were worried about their family's well-being, especially the children [35
]. They felt pressured by the possibility that their children might face the same illness or that their children might need more emotional support than they were receiving. In addition, in our study the family member managed worries about their family by protecting the children from distress and bearing the grief themselves. The fact that there are not many studies showing that family members shield the others in the family and bear their grief can perhaps be explained by the fact that in recent years research has increasingly adopted the perspective of those who provide care rather than that of the close family.
'Setting hopes on the future' was the strategy least frequently mentioned by the family members in the interviews. One possible explanation for this is that the cancer diagnosis was received 2-3 months ago, and some family members could have still been in shock or not yet adjusted to the new reality of the person's having advanced cancer. Previous research on hope has usually been directed towards the terminal stage of cancer. It has focused mainly on the significance of hope from the patient's perspective as a way to manage terminal illness through acknowledgement, acceptance and struggle. There are two overarching themes of hope commonly described in the literature: 'living with hope' (reconciliation with life and death) and 'hoping for something' (hope of being cured) [36
]. The findings in the present study indicate that the family members were indeed 'hoping for something'. This is a reasonable result in view of the fact that all of the sick persons were undergoing cytostatic treatment. The few studies concerning hope in family members show inconsistent findings regarding the influence of age on the existence of hope [36
]. Prognostic uncertainty and the continued hope of survival harboured by family members can make it difficult to decide the proper time to stop active therapy and initiate palliation [37
The findings in this study, for instance, that family members mostly give emotional support to the sick person reflect the early stage of advanced cancer. This must be borne in mind when interpreting these findings, especially in view of the fact that previous studies have, with few exceptions, concerned a later stage of palliative or terminal care. One weakness with regard to the transferability of the findings is the small proportion of male participants (20%). The nurses who inquired about participation were both males and females. However, 13 of the 20 patients were male, and all of them except one chose a female family member. Four of the 7 female patients were mothers, and 3 of them chose a daughter. The design of the study stipulated that the family member be chosen by the sick person, which might be one reason for the low proportion of men among family members. This needs to be kept in mind when comparing the findings in this study with findings in previous research.
The achievement of credibility in the inductive approach for qualitative content analysis implies careful and comprehensive interpretation at every stage of the research process [20
]. This includes an appraisal of the authors regarding whether the data reach enough saturation and credibility. The family members appreciated being able to talk about their situation, and the interviews were characterized by richness of narrations. The duration of the interviews was on average 75 minutes. However, some of the family members were preoccupied with their experienced distress and had difficulty finding words for how they managed the situation. In these cases, several follow-up questions were needed to obtain comprehensive descriptions. The design applied followed the basic principles of latent content analysis, which means that there was a systematic coding into sub-themes and then integration into a theme [20
]. The construction of the concepts was derived from the in-depth analysis and constant comparison of parts within the perspective of an emerging wholeness. To attain greater rigour, the analysis by the first author (CS) was scrutinized at each step by the other two authors (GA, BH), both of whom are experienced in latent content analysis. The findings were discussed until agreement was reached.