- Relation of Religion and Spirituality to Adjustment, Quality of Life, and Health Indices
- Screening and Assessment of Spiritual Concerns
- Modes of Intervention
- Increasing Personal Awareness in Health Care Providers
- Issues to Consider
- Additional Resources
- Current Clinical Trials
- Changes to This Summary (07 / 03 / 2014)
- Questions or Comments About This Summary
- About This PDQ Summary
- Get More Information From NCI
Spirituality in Cancer Care (PDQ®): Supportive care - Health Professional Information [NCI]
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Spirituality in Cancer Care
National surveys consistently support the idea that religion and spirituality are important to most individuals in the general population. More than 90% of adults express a belief in God, and slightly more than 70% of individuals surveyed identified religion as one of the most important influences in their lives. Yet even widely held beliefs, such as survival of the soul after death or a belief in miracles, vary substantially by gender, education, and ethnicity.
Research indicates that both patients and family caregivers [3,4] commonly rely on spirituality and religion to help them deal with serious physical illnesses, expressing a desire to have specific spiritual and religious needs and concerns acknowledged or addressed by medical staff; these needs, although widespread, may take different forms between and within cultural and religious traditions.[5,6,7]
A survey of hospital inpatients found that 77% of patients reported that physicians should take patients' spiritual needs into consideration, and 37% wanted physicians to address religious beliefs more frequently. A large survey of cancer outpatients in New York City found that a slight majority felt it was appropriate for a physician to inquire about their religious beliefs and spiritual needs, although only 1% reported that this had occurred. Those who reported that spiritual needs were not being met gave lower ratings to quality of care (P < .01) and reported lower satisfaction with care (P < .01). A pilot study of 14 African American men with a history of prostate cancer found that most had discussed spirituality and religious beliefs with their physicians; they expressed a desire for their doctors and clergy to be in contact with each other.
Sixty-one percent of 57 inpatients with advanced cancer receiving end-of-life care in a hospital supported by the Catholic archdiocese reported spiritual distress when interviewed by hospital chaplains. Intensity of spiritual distress correlated with self-reports of depression but not with physical pain or with perceived severity of illness. Another study  of advanced cancer patients (N = 230) in New England and Texas assessed their spiritual needs. Almost half (47%) reported that their spiritual needs were not being met by a religious community, and 72% reported that these needs were not supported by the medical system. When such support existed, it was positively related to improved quality of life. Furthermore, having spiritual issues addressed by the medical care team had more impact on increasing the use of hospice and decreasing aggressive end-of-life measures than did pastoral counseling.
This summary will review the following topics:
- How religion and spirituality can be usefully conceptualized within the medical setting.
- The empirical evidence for the importance of religious and spiritual factors in adjustment to illness in general and to cancer in particular, throughout the course of illness and at the end of life, for both patients and family caregivers.
- The range of assessment approaches that may be useful in a clinical environment.
- Various models for management and intervention.
- Resources for clinical care.
Paying attention to the religious or spiritual beliefs of seriously ill patients has a long tradition within inpatient medical environments. Addressing such issues has been viewed as the domain of hospital chaplains or a patient's own religious leader. In this context, systematic assessment has usually been limited to identifying a patient's religious preference; responsibility for management of apparent spiritual distress has been focused on referring patients to the chaplain service.[13,14,15] Although health care providers may address such concerns themselves, they are generally very ambivalent about doing so, and there has been relatively little systematic investigation addressing the physician's role. These issues, however, are being increasingly addressed in medical training. Acknowledging the role of all health care professionals in spirituality, a multidisciplinary group from one cancer center developed a four-stage model that allows health care professionals to deliver spiritual care consistent with their knowledge, skills, and actions at one of four skill levels.
Interest in and recognition of the function of religious and spiritual coping in adjustment to serious illness, including cancer, has been growing.[19,20,21,22,23] New ways to assess and address religious and spiritual concerns as part of overall quality of life are being developed and tested. Limited data support the possibility that spiritual coping is one of the most powerful means by which patients draw on their own resources to deal with a serious illness such as cancer; however, patients and their family-member caregivers may be reluctant to raise religious and spiritual concerns with their professional health care providers.[24,25,26] Increased spiritual well-being in a seriously ill population may be linked with lower anxiety about death, but greater religious involvement may also be linked to an increased likelihood of desire for extreme measures at the end of life. Given the importance of religion and spirituality to patients, integrating systematic assessment of such needs into medical care, including outpatient care, is crucial. The development of better assessment tools will make it easier to discern which aspects of religious and spiritual coping may be important in a particular patient's adjustment to illness.
Of equal importance is the consideration of how and when to address religion and spirituality with patients and the best ways to do so in different medical environments.[29,30,31] Although addressing spiritual concerns is often considered an end-of-life issue, such concerns may arise at any time after diagnosis. Acknowledging the importance of these concerns and addressing them, even briefly, at diagnosis may facilitate better adjustment throughout the course of treatment and create a context for richer dialogue later in the illness. One study of 118 patients seen in follow-up by one of four oncologists suggests that a semistructured inquiry into spiritual concerns related to coping with cancer is well accepted by patients and oncologists and is associated with positive perceptions of care and well-being.
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.
Specific religious beliefs and practices should be distinguished from the idea of a universal capacity for spiritual and religious experiences. Although this distinction may not be salient or important on a personal basis, it is important conceptually for understanding various aspects of evaluation and the role of different beliefs, practices, and experiences in coping with cancer.
The most useful general distinction to make in this context is between religion and spirituality. There is no general agreement on definitions of either term, but there is general agreement on the usefulness of this distinction. A number of reviews address matters of definition.[1,2,3] Religion can be viewed as a specific set of beliefs and practices associated with a recognized religion or denomination. Spirituality is generally recognized as encompassing experiential aspects, whether related to engaging in religious practices or to acknowledging a general sense of peace and connectedness. The concept of spirituality is found in all cultures and is often considered to encompass a search for ultimate meaning through religion or other paths. Within health care, concerns about spiritual or religious well-being have sometimes been viewed as an aspect of complementary and alternative medicine (CAM), but this perception may be more characteristic of providers than of patients. In one study, virtually no patients but about 20% of providers said that CAM services were sought to assist with spiritual or religious issues. Religion is highly culturally determined; spirituality is considered a universal human capacity, usually—but not necessarily—associated with and expressed in religious practice. Most individuals consider themselves both spiritual and religious; some may consider themselves religious but not spiritual. Others, including some atheists (people who do not believe in the existence of God) or agnostics (people who believe that God cannot be shown to exist), may consider themselves spiritual but not religious. In a sample of 369 representative cancer outpatients in New York City (33% minority), while only 6% identified themselves as agnostic or atheist, only 29% attended religious services weekly; 66% represented themselves as spiritual but not religious.
One effort to characterize individuals by types of spiritual and religious experience  identified the following three groups, using cluster analytic techniques:
|1.||Religious individuals who highly value religious faith, spiritual well-being, and the meaning of life.|
|2.||Existential individuals who highly value spiritual well-being but not religious faith.|
|3.||Nonspiritual individuals who have little value for religiousness, spirituality, or a sense of the meaning of life.|
Individuals in the third group were far more distressed about their illness and were experiencing worse adjustment. There is as yet no consensus on the number or types of underlying dimensions of spirituality or religious engagement.
From the prospective of both the research and clinical literature on the relationships between religion, spirituality, and health, it is important to consider how these concepts are defined and used by investigators and authors. Much of the epidemiological literature that has indicated a relationship between religion and health has been based on definitions of religious involvement such as membership in a religious group or frequency of church attendance. Somewhat more complex is assessing specific beliefs or religious practices such as belief in God, frequency of prayer, or reading religious material. Individuals may engage in such practices or believe in God without necessarily attending church services. Terminology also carries certain connotations; the term religiosity, for example, has a history of implying fervor and perhaps undue investment in particular religious practices or beliefs. Religiousness may be a more neutral way to refer to the dimension of religious practice.
Spirituality and spiritual well-being are more challenging to define. Some definitions limit spirituality to mean profound mystical experiences; however, in considerations of effects on health and psychological well-being, the more helpful definitions focus on accessible feelings, such as a sense of inner peace, existential meaning, and purpose in life, or awe when walking in nature. For the purposes of this discussion, it is assumed that there is a continuum of meaningful spiritual experiences, from the common and accessible to the extraordinary and transformative. Both type and intensity of experience may vary. Other aspects of spirituality that have been identified by those working with medical patients include a sense of meaning and peace, a sense of faith, and a sense of connectedness to others or to God. Low levels of these experiences may be associated with poorer coping (refer to the Relation of Religion and Spirituality to Adjustment, Quality of Life, and Health Indices section).
The definition of acute spiritual distress must be considered separately. Spiritual distress may result from the belief that cancer reflects punishment by God or may accompany a preoccupation with the question "Why me?" A cancer patient may also suffer a loss of faith. Although many individuals may have such thoughts at some time following diagnosis, only a few individuals become obsessed with these thoughts or score high on a general measure of religious and spiritual distress (such as the Negative subscale of the Religious Coping Scale [the RCOPE–Negative]). High levels of spiritual distress may contribute to poorer health and psychosocial outcomes.[9,10] The tools for measuring these dimensions are described in the Screening and Assessment of Spiritual Concerns section.
Relation of Religion and Spirituality to Adjustment, Quality of Life, and Health Indices
Religion and spirituality have been shown to be significantly associated with measures of adjustment and with the management of symptoms in cancer patients. Religious and spiritual coping have been associated with lower levels of patient discomfort as well as reduced hostility, anxiety, and social isolation in cancer patients [1,2,3,4] and in family caregivers. Specific characteristics of strong religious beliefs, including hope, optimism, freedom from regret, and life satisfaction, have also been associated with improved adjustment in individuals diagnosed with cancer.[6,7]
Type of religious coping may influence quality of life. In a multi-institutional cross-sectional study of 170 patients with advanced cancer, more use of positive religious coping methods (such as benevolent religious appraisals) was associated with better overall quality of life and higher scores on the existential and support domains of the McGill Quality of Life Questionnaire. In contrast, more use of negative religious coping methods (such as anger at God) was related to poorer overall quality of life and lower scores on the existential and psychological domains.[8,9] A study of 95 cancer patients diagnosed within the past 5 years found that spirituality was associated with less distress and better quality of life regardless of perceived life threat, with existential well-being but not religious well-being as the major contributor.
Spiritual well-being, particularly a sense of meaning and peace, is significantly associated with an ability of cancer patients to continue to enjoy life despite high levels of pain or fatigue. Spiritual well-being and depression are inversely related.[12,13] Higher levels of a sense of inner meaning and peace have also been associated with lower levels of depression, whereas measures of religiousness were unrelated to depression.
This relationship has been specifically demonstrated in the cancer setting. In a cross-sectional survey of 85 hospice patients with cancer, there was a negative correlation between anxiety and depression (as measured by the Hospital Anxiety and Depression Scale) and overall spiritual well-being (as measured by the Spiritual Well-Being Scale) (P < .0001). There was also a negative correlation between the existential well-being scores and the anxiety and depression scores but not with the religious well-being score (P < .001). These patterns were also found in a large study of indigent prostate cancer survivors; the patterns were consistent across ethnicity and metastatic status.
In a large (N = 418) study of breast cancer patients, a higher level of meaning and peace was associated with a decline in depression over 12 months, whereas higher religiousness predicted an increase in depression, particularly if meaning/peace was lower.[Level of evidence: II] A second study with mixed gender/mixed cancer survivors (N = 165) found similar patterns. In both studies, high levels of religiousness were linked to increases in perceived cancer-related growth.[Level of evidence: II] In a convenience sample, 222 low-income men with prostate cancer were surveyed about spirituality and health-related quality of life. Low scores in spirituality, as measured by the peace/meaning and faith subscale of the Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp), were associated with significantly worse physical and mental health than were high scores in spirituality.
A large national survey of 361 paired U.S. survivors and caregivers (caregivers included spouses and adult children) found that for both survivors and caregivers, the peace factor of the FACIT-Sp was strongly related to mental health but negligibly or not at all related to physical well-being. The faith factor ("religiousness") was unrelated to physical or mental well-being. Fifty-two percent of the survivors in this survey were women. These findings support the value of the FACIT-Sp in separating people's religious involvement from their sense of spiritual well-being and that it is this sense of spiritual well-being that seems to be most related to psychological adjustment.
Another large national survey study of female family caregivers (N = 252; 89% white) identified that higher levels of spirituality, as measured by the FACIT-Sp, were associated with much less psychological distress (measured by the Pearlin Stress Scale). Participants with higher levels of spirituality actually had improved well-being even as caregiving stress increased, while those with lower levels of spirituality showed the opposite pattern, suggesting a strong stress-buffering effect of spiritual well-being. This finding reinforces the need to identify low spiritual well-being when assessing the coping capacity of family caregivers as well as patients.
One author  found that cancer survivors who had drawn on spiritual resources reported substantial personal growth as a function of dealing with the trauma of cancer. This was also found in a survey study of 100 well-educated, mostly married/partnered white women with early-stage breast cancer, recruited for the study from an Internet Web site, in which increasing levels of spiritual struggle were related to poorer emotional adjustment, though not to other aspects of cancer-related quality of life. Using path analytic techniques, a study of women with breast cancer found that at both prediagnosis and 6 months postsurgery, holding negative images of God was the strongest predictor of emotional distress and lower social well-being. However, longitudinal analyses failed to find sustained effects for baseline positive or negative attitudes toward God at either 6 or 12 months. One possible explanation for these findings is that such attitudes are somewhat unstable during a period of uncertainty (e.g., at prediagnosis).
Engaging in prayer is often cited as an adaptive tool, but qualitative research  found that for about one third of cancer patients interviewed, concerns about how to pray effectively or the questions raised about the effectiveness of prayer also caused inner conflict and mild distress. In a study of reported use of spiritual healing and prayer by a sample of 123 patients hospitalized on a palliative care unit, 26.8% reported having used spiritual healing and prayer for curative purposes, 35% for improving survival, and 36.6% for improving symptoms (note: these percentages overlap). Higher levels of faith on the FACIT-Sp were associated with greater use of complementary and alternative medicine techniques in general and with interest in future use, whereas the level of meaning/peace was not. The study also looked at the general use of complementary therapies. A useful discussion of how prayer is used by cancer patients and how clinicians might conceptualize prayer has been published.
Ethnicity and spirituality were investigated in a qualitative study of 161 breast cancer survivors. In individual interviews, most participants (83%) spoke about some aspect of their spirituality. Seven themes were identified: "God as a Comforting Presence," "Questioning Faith," "Anger at God," "Spiritual Transformation of Self and Attitude Towards Others/Recognition of Own Mortality," "Deepening of Faith," "Acceptance," and "Prayer by Self." A higher percentage of African Americans, Latinas, and persons identified as Christians were more likely to feel comforted by God than were other groups.
Positive religious involvement and spirituality appear to be associated with better health and longer life expectancy, even after controlling for other variables such as health behaviors and social support, as shown in one meta-analysis. Although little of this research is specific to cancer patients, one study of 230 patients with advanced cancer (expected prognosis <1 year) investigated a variety of associations between religiousness and spiritual support. Most study participants (88%) considered religion either very important (68%) or somewhat important (20%); more African Americans and Hispanics than whites reported religion to be very important. Spiritual support by religious communities or the medical system was associated with better patient quality of life. Age was not associated with religiousness. At the time of recruitment to participate in the study, increasing self-reported distress was associated with increasing religiousness, and private religious or spiritual activities were performed by a larger percentage of patients after their diagnosis (61%) than before (47%). Regarding spiritual support, 38% reported that their spiritual needs were supported by a religious community "to a large extent or completely," while 47% reported receiving support from a religious community "to a small extent or not at all." Finally, religiousness was also associated with the end-of-life treatment preference of "wanting all measures taken to extend life." Another study  found that helper and cytotoxic T-cell counts were higher among women with metastatic breast cancer who reported greater importance of spirituality. Other investigators  found that attendance at religious services was associated with better immune system functioning. Other research [32,33] suggests that religious distress negatively affects health status. These associations, however, have been criticized as weak and inconsistent.
Several randomized trials with cancer patients have suggested that group support interventions benefit survival.[35,36] These studies must be interpreted cautiously, however. First, the treatments focused on general psychotherapeutic issues and psychosocial support. Although spiritually relevant issues undoubtedly arose in these settings, they were not the focus of the groups. Second, there has been difficulty replicating these effects.
Screening and Assessment of Spiritual Concerns
- Waiting for the patient to bring up spiritual concerns.
- Requesting that the patient complete a paper-and-pencil assessment.
- Having the physician do a spiritual inquiry or assessment by indicating his or her openness to a discussion.
These approaches have different potential value and limitations. Patients may express reluctance to bring up spiritual issues, noting that they would prefer to wait for the provider to broach the subject. Standardized assessment tools vary, have generally been designed for research purposes, and need to be reviewed and utilized appropriately by the provider. Physicians, unless trained specifically to address such issues, may feel uncomfortable raising spiritual concerns with patients. However, an increasing number of models are becoming available for physician use and training.
Numerous assessment tools are pertinent to performing a religious and spiritual assessment. Table 1 summarizes a selection of assessment tools. Several factors should be considered before choosing an assessment tool:
- Focus of the evaluation (religious practice or spiritual well-being/distress).
- Purpose of the assessment (e.g., screening for distress vs. evaluation of all patients as part of care).
- Modality of the assessment (interview or questionnaire).
- Feasibility of the assessment (staff and patient burden).
The line between assessment and intervention is blurred, and simply inquiring about an area such as religious or spiritual coping may be experienced by the patient as an opening for further exploration and validation of the importance of this experience. Evidence suggests that such an inquiry will be experienced as intrusive and distressing by only a very small proportion of patients. Key assessment approaches are briefly reviewed below; pertinent characteristics are summarized in Table 1.
Standardized Assessment Measures
One of several paper-and-pencil measures can be given to patients to assess religious and spiritual needs. These measures have the advantage of being self-administered; however, they were mostly designed as research tools, and their role for clinical assessment purposes is not as well understood. These measures may be helpful in opening up the area for exploration and for ascertaining basic levels of religious engagement or spiritual well-being (or spiritual distress). Most also assume a belief in God and therefore may seem inappropriate for an atheist or agnostic patient, who may still be spiritually oriented. All of the measures have undergone varying degrees of psychometric development, and most are being used in investigations of the relationship between religion or spirituality, health indices, and adjustment to illness.
- Duke Religious Index (DRI). The DRI (or DUREL) [Level of evidence: II] is short (five items) and has reasonable psychometric properties  examined in cancer patients. It is best used as an indicator of religious involvement rather than spirituality and has low or modest correlations with psychological well-being.
Systems of Belief Inventory (SBI-15R). The SBI-15R [Level of evidence: II] has undergone careful psychometric development and measures two domains:
1. Presence and importance of religious and spiritual beliefs and practices. 2. Value of support from a religious/spiritual community.
The questions are worded well and may provide a good initiation for further discussion and exploration.
- Brief Measure of Religious Coping (RCOPE). The Brief RCOPE [Level of evidence: II] has two dimensions: positive religious coping and negative religious coping, with five items each. The second factor appears to uniquely identify a very important aspect of spiritual adjustment, i.e., the degree to which conflict, self-blame, or anger at God is present for an individual. A longer form of the scale, with additional dimensions, would be suitable for a more comprehensive assessment of religious/spiritual concerns. Psychometric development is high. While high scores in negative religious coping are unusual, they are particularly powerful in predicting poor adjustment to disease.
- Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp). The FACIT-Sp is part of the widely used Functional Assessment of Cancer Therapy (FACT) quality-of-life battery. It was developed with an ethnically diverse cancer population and contains 12 items and 2 factors (faith, and meaning and peace), with good to excellent psychometric properties; although some evidence suggests that inner meaning and inner peace can be identified as two separate factors, such identification does not appear to substantially improve associations with other indicators of well-being. One characteristic of this scale is that the wording of items does not assume a belief in God. Therefore, it can be comfortably completed by an atheist or agnostic, yet it taps into both traditional religiousness dimensions (faith factor) and spiritual dimensions (meaning and peace factor). The meaning and peace factor has been shown to have particularly strong associations with psychological adjustment, in that individuals who score high on this scale are much more likely to report generally enjoying life despite fatigue or pain, are less likely to desire a hastened death at the end of life,[Level of evidence: II] report better disease-specific and psychosocial adjustment,[14,15,16] and report lower levels of helplessness/hopelessness. These associations have been shown to be independent of other indicators of adjustment, supporting the value of adding assessment of this dimension to standard quality-of-life evaluations.[10,16] Total scores on the FACIT-Sp correlated highly over time (27 weeks) with a 10-point linear analogue scale of spiritual well-being in a sample of advanced cancer patients. The linear scale (Spiritual Well-Being Linear Analogue Self-Assessment [SWB LASA]) was worded, "How would you describe your overall spiritual well-being?" and ratings ranged from 0 (as bad as it can be) to 10 (as good as it can be).
- Spiritual Transformation Scale (STS). The STS is a 40-item measure of change in spiritual engagement following cancer diagnosis. It has two subscales: Spiritual Growth (SG) and Spiritual Decline (SD). The SG factor is highly correlated with the Positive RCOPE (r = .71) and the Post-traumatic Growth Inventory (r = .68), while the SD factor is correlated with the Negative RCOPE (r = .56) and the Center for Epidemiologic Studies Depression Scale (CES-D) (r = .40). Analyses show that the STS accounts for additional variance on depression, other measures of adjustment (Positive and Negative Affect Schedule [PANAS]), and the Daily Spiritual Experience Scale. Individuals with later stage cancer (stage III or IV) had higher scores on SG, as did individuals with a recurrence rather than a new diagnosis. Individuals with higher scores on SD were more likely to have not graduated from high school. A unique strength of this scale is that it is specific to change in spirituality since diagnosis; wording on items is also generally appropriate for individuals who identify as spiritual rather than religious. Among the limitations of this scale is that development to date includes mostly observant Christians, with few minorities in the sample.
The following are semistructured interviewing tools designed to facilitate an exploration, by the physician or other health care provider, of religious beliefs and spiritual experiences or issues. The tools take the spiritual history approach and have the advantage of engaging the patient in dialogue, identifying possible areas of concern, and indicating the need for provision of further resources such as referral to a chaplain or support group. These approaches, however, have not been systematically investigated as empirical measures or indices of religiousness or of spiritual well-being or distress.
- The SPIRITual History. The SPIRIT is an acronym for the six domains explored by this tool: S, spiritual belief system; P, personal spirituality; I, integration with a spiritual community; R, ritualized practices and restrictions; I, implications for medical care; T, terminal events planning. The 6 domains are covered by 22 items, which may be covered in as little as 10 or 15 minutes or integrated into general interviewing over several appointments. A strength of this tool is the number of questions pertinent to managing serious illness and to gaining an understanding of how patient religious beliefs may bear on patient care decisions.
- Faith, Importance/Influence, Community, and Address (FICA) Spiritual History.[1,20] FICA is an acronym for Faith, Importance/Influence, Community, and Address, with a set of questions to explore each area (e.g., What is your faith? How important is it? Are you part of a religious community? How would you like me as your provider to address these issues in your care?). Although developed as a spiritual history tool for use in primary care settings, it would lend itself to any patient population. The relative simplicity of the approach has led to its adoption by many medical schools.
Table 1. Assessment of Religion and Spirituality in Cancer Patients
|Tool||Developer||Purpose/ Focus/ Subscale (No.)||Specific to Cancer Patients?||Level of Psychometric Development||Length/ Other Characteristics/ Comments|
|Systems of Belief Inventory (SBI-15R)||Holland et al.||Two factors: Beliefs/experience (10); religious social support (5)||Yes||High||Four items assume belief in God|
|DRI/DUREL||Sherman et al.||Religious involvement (5)||Yes||Moderate|
|FACIT-Sp[10,15]||Brady et al.; Peterman||Two factors: Meaning & peace (8), faith (4)||Yes||High. Limited cross-validation data.||Part of FACT-G quality-of-life battery|
|Brief RCOPE||Pargament et al.||Two factors: Positive coping; negative coping/distress||No||Very High|
|Fetzer Multidimensional Scale||Fetzer||Multiple subscales||No||High. Under development.|
|FICA: Spiritual history||Puchalski et al.||Brief spiritual history||No||Low||MD interview assessment|
|SPIRIT||Maugans||In-depth interview with guided questions||No||Low||MD interview assessment|
|Spiritual Transformation Scale (STS)||Cole et al.||Two factors: Spiritual Growth and Spiritual Decline||Yes||Moderate||Forty items. Unique to assessing change in spiritual experience post–cancer diagnosis.|
Modes of Intervention
Various modes of intervention or assistance might be considered to address the spiritual concerns of patients. These include the following:
- Exploration by the physician or other health care provider within the context of usual medical care.
- Encouragement for the patient to seek assistance from his or her own clergy.
- Formal referral to a hospital chaplain.
- Referral to a religious or faith-based therapist.
- Referral to a range of support groups that are known to address spiritual issues.
Two survey studies [1,2] found that physicians consistently underestimate the degree to which patients want spiritual concerns addressed. An Israeli study found that patients expressed the desire that 18% of a hypothetical 10-minute visit be spent addressing such concerns, while their providers estimated that 12% of the time should be spent in this way. This study also found that while providers perceived that a patient's desire for addressing spiritual concerns related to a broader interest in complementary and alternative medicine (CAM) modalities, patients viewed CAM-related issues and spiritual/religious concerns as quite separate.
A task force  of physicians and end-of-life specialists suggested several guidelines for physicians who wish to respond to patients' spiritual concerns:
- Respect the patient's views and follow the patient's lead.
- Make a connection by listening carefully and acknowledging the patient's concerns, but avoid theological discussions or engaging in specific religious rituals.
- Maintain one's own integrity in relation to one's own religious beliefs and practices.
- Identify common goals for care and medical decisions.
- Mobilize other resources of support for the patient, such as referring the patient to a chaplain or encouraging contact with the patient's own clergy.
Inquiring about religious or spiritual concerns by physicians or other health care professionals may provide valuable and appreciated support to patients. Most cancer patients appear to welcome a dialogue about such concerns, regardless of diagnosis or prognosis. In a large survey of cancer outpatients, between 20% and 35% expressed a desire for religious and spiritual resources, help with talking about finding meaning in life, help with finding hope, talking about death and dying, and finding peace of mind.[Level of evidence: II] It is appropriate to initiate such an inquiry once initial diagnosis and treatment issues have been discussed and considered by the patient (approximately a month after diagnosis or later). In a large, multisite, longitudinal study of patients with advanced cancer,[Level of evidence: II] there was considerable variation in whether spiritual concerns were addressed by medical staff, with about 50% reporting at least some support at three of the settings, in contrast to fewer than 15% reporting some support at the other four settings. Support received from the medical team predicted greater quality of life, greater likelihood of receiving hospice care at the end of life, and for patients who have high levels of religious coping, less aggressive care.
One trial,[Level of evidence: II] with a sample of 115 mixed-diagnosis patients (54% under active treatment), evaluated a 5-minute semistructured inquiry into spiritual and religious concerns. The four physicians' personal religious backgrounds included two Christians, one Hindu, and one Sikh; 81% of patients were Christian. Unlike the history-oriented interviews noted above, this inquiry was informed by brief patient-centered counseling approaches that view the physician as an important source of empowerment to help patients identify and address personal concerns (see Table 2 below for the content). After 3 weeks, the intervention group had larger reductions in depression, had more improvement in quality of life, and rated their relationship with the physician more favorably. Effects for quality of life remained after statistically adjusting for change in other variables. More improvement was also seen in patients who scored lower in spiritual well-being, as measured by the Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp) at baseline. Acceptability was high, with physicians rating themselves as "comfortable" in providing the intervention during 85% of encounters. Seventy-six percent of patients characterized the inquiry as "somewhat" to "very" useful. Physicians were twice as likely to underestimate the usefulness of the inquiry to patients rather than to overestimate it, in relation to the patient ratings.
The statements in Table 2 may be used to initiate a dialogue between health care provider and patient.
Table 2. Exploring Spiritual/Religious Concerns in Adults With Cancera
|Health Care Provider Inquiry||Question for Patient|
|a Adapted from Kristeller et al.|
|Introduce issue in neutral inquiring manner.||"When dealing with a serious illness, many people draw on religious or spiritual beliefs to help cope. It would be helpful to me to know how you feel about this."|
|Inquire further, adjusting inquiry to patient's initial response.||Positive-Active Faith Response:"What have you found most helpful about your beliefs since your illness?"|
|Neutral-Receptive Response:"How might you draw on your faith or spiritual beliefs to help you?"|
|Spiritually Distressed Response (e.g., expression of anger or guilt):"Many people feel that way…what might help you come to terms with this?"|
|Defensive/Rejecting Response:"It sounds like you're uncomfortable I brought this up. What I'm really interested in is how you are coping…can you tell me about that?"|
|Continue to explore further as indicated.||"I see. Can you tell me more (about…)?"|
|Inquire about ways of finding meaning and a sense of peace.||"Is there some way in which you are able to find a sense of meaning or peace in the midst of this?"|
|Inquire about resources.||"Whom do you have to talk to about this/these concerns?"|
|Offer assistance as appropriate and available.||"Perhaps we can arrange for you to talk to someone/There's a support group I can suggest/There are some reading materials in the waiting room."|
|Bring inquiry to a close.||"I appreciate you discussing these issues with me. May I ask about it again?"|
A common concern is whether to offer to pray with patients. Although one study  found that more than one-half of the patients surveyed expressed a desire to have physicians pray with them, a large proportion did not express this preference. A qualitative study of cancer patients  found that patients were concerned that physicians are too busy, not interested, or even prohibited from discussing religion. At the same time, patients generally wanted their physicians to acknowledge the value of spiritual and religious issues. A suggestion was made that physicians might raise the question of prayer by asking, "Would that comfort you?"
In a study of 70 patients with advanced cancer, 206 oncology physicians, and 115 oncology nurses, all participants were interviewed about their opinions regarding the appropriateness of patient-practitioner prayer in the advanced-cancer setting. Results showed that 71% of advanced-cancer patients, 83% of oncology nurses, and 65% of physicians reported that it is occasionally appropriate for a practitioner to pray with a patient when the request to pray is initiated by the patient. Similarly, 64% of patients, 76% of nurses, and 59% of physicians reported that they consider it appropriate for a religious/spiritual health care practitioner to pray for a patient.
The most important guideline is to remain sensitive to the patient's preference; therefore, asking patients about their beliefs or spiritual concerns in the context of exploring how they are coping in general is the most viable approach in exploring these issues.
Traditional means of providing assistance to patients has generally been through the services of hospital chaplains.[10,11] Hospital chaplains can play a key role in addressing spiritual and religious issues; chaplains are trained to work with a wide range of issues as they arise for medical patients and to be sensitive to the diverse beliefs and concerns that patients may have. Chaplains are generally available in large medical centers, but they may not be available in smaller hospitals on a reliable basis. Chaplains are rarely available in the outpatient settings where most care is now delivered (especially early in the course of cancer treatment, when these issues may first arise). In a large, multisite, longitudinal study of patients with advanced cancer,[Level of evidence: II] only 46% of patients reported receiving pastoral care visits. While these visits were not associated with receipt of end-of-life care (either hospice or aggressive measures), they were associated with better quality of life near death.
Another traditional approach in outpatient settings is having spiritual/religious resources available in waiting rooms. This is relatively easy to do, and many such resources exist; however, a breadth of resources covering all faith backgrounds of patients is highly desirable (refer to the Additional Resources section).
Support groups may provide a setting in which patients may explore spiritual concerns. If spiritual concerns are important to a patient, the health care provider may need to identify whether a locally available group addresses these issues. The published data on the specific effects of support groups on assisting with spiritual concerns is relatively sparse, partly because this aspect of adjustment has not been systematically evaluated. A randomized trial [Level of evidence: I] compared the effects of a mind-body-spirit group to a standard group support program for women with breast cancer. Both groups showed improvement in spiritual well-being, although there were appreciably more differential effects for the mind-body-spirit group in the area of spiritual integration.
A study of 97 lower-income women with breast cancer who were participating in an online support group examined the relationship between a variety of psychosocial outcomes and religious expression (as indicated by the use of religious words such as faith, God, pray, holy, or spirit). Results showed that women who communicated a deeper religiousness in their online writing to others were found to have lower levels of negative emotions, higher levels of perceived health self-efficacy, and higher functional well-being. An exploratory study of a monthly spirituality-based support group program for African American women with breast cancer suggested high levels of satisfaction in a sample that already had high levels of engagement in the religious and spiritual aspects of their lives.[Level of evidence: III]
One author  presents a well-developed model of adjuvant psychological therapy that uses a large group format and addresses both basic coping issues and spiritual concerns and healing, using a combination of group exploration, meditation, prayer, and other spiritually oriented exercises. In a carefully conducted longitudinal qualitative study of 22 patients enrolled in this type of intervention, researchers found that patients who were more psychologically engaged with the issues presented were more likely to survive longer. Other approaches are available but have yet to be systematically evaluated,[18,19] have not explicitly addressed religious and spiritual issues, or have failed to evaluate the effects of the intervention on spiritual well-being.
Other therapies may also support spiritual growth and post-traumatic benefit finding. For example, in a nonrandomized comparison of mindfulness-based stress reduction (n = 60) and a healing arts program (n = 44) in cancer outpatients with a variety of diagnoses, both programs significantly improved facilitation of positive growth in participants, although improvement in spirituality, stress, depression, and anger was significantly larger for the mindfulness-based stress reduction group.[Level of evidence: II]
Increasing Personal Awareness in Health Care Providers
Spirituality, religion, death, and dying may be experienced by many providers as a taboo subject. The meaning of illness and the possibility of death are often difficult to address. The assessment resources noted above may be of value in introducing the topic of spiritual concerns, death, and dying to a patient in a supportive manner. In addition, reading clinical accounts by other health care providers can be very helpful. One such example is a qualitative study utilizing an autoethnographic approach to explore spirituality in members of an interdisciplinary palliative care team. Findings from this work yielded a collective spirituality that emerged from the common goals, values, and belonging shared by team members. Reflections of the participants offer insights into patient care for other health care professionals.
|1.||Sinclair S, Raffin S, Pereira J, et al.: Collective soul: the spirituality of an interdisciplinary palliative care team. Palliat Support Care 4 (1): 13-24, 2006.|
Issues to Consider
Although a considerable number of anecdotal accounts suggest that prayer, meditation, imagery, or other religious activity can have healing power, the empirical evidence is extremely limited and by no means consistent. On the basis of current evidence, it is questionable whether any patient with cancer should be encouraged to seek such resources as a means to healing or to limiting the physical effects of disease. However, the psychological value of support and spiritual well-being is increasingly well documented, and evidence that spiritual distress can have a negative impact on health is growing. Therefore, in exploring these issues with patients or encouraging the use of such resources, health care providers need to frame these resources in terms of self-understanding, clarifying questions of beliefs with an appropriate spiritual or religious leader, or seeking a sense of inner peace or awareness.
|1.||Sloan RP, Bagiella E: Claims about religious involvement and health outcomes. Ann Behav Med 24 (1): 14-21, 2002 Winter.|
- www.spiritualityandhealth.ufl.edu: University of Florida Center for Spirituality and Health. Conducts courses, research projects, and programs that focus on the interface between religious traditions, spirituality, and health.
- smhs.gwu.edu/gwish: The George Washington Institute for Spirituality & Health (GWish). Focuses on medical education in the area of religion, spirituality, and medicine.
- www.massgeneral.org/bhi: Benson-Henry Institute for Mind Body Medicine (BHI) at Massachusetts General Hospital. Provides outpatient medical services, training for health professionals, corporate and school-based programs, women's health services, and affiliation for national and international health care systems.
- www.spiritualityandhealth.duke.edu: Duke University Center for Spirituality, Theology and Health. Conducts interdisciplinary research, scholarship, and education on spirituality, theology, and health.
These reference citations are included for informational purposes only. Their inclusion should not be viewed as an endorsement of the content of the Web sites by the PDQ Cancer Supportive Care Editorial Board or the National Cancer Institute.
Current Clinical Trials
Check NCI's list of cancer clinical trials for U.S. supportive and palliative care trials about spiritual concerns and spiritual therapy that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
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This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about religious and spiritual coping in cancer care. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
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Last Revised: 2014-07-03
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