Support of cancer patients' spiritual needs and associations with medical care costs at the end of life

Chaplaincy and outpatient cancer care in a faith-based health system: lessons learned when imbedding two full time chaplain positions in a cancer institute with a faith-based heritage

There is interest in chaplains devoted to outpatient cancer care, informed by a growing body of research as well as recommendations of accreditors. Simultaneously, a growing share of U.S. healthcare is faith-based and possesses a foundational interest in religious/spiritual (R/S) care due to institutional culture. In that milieu, few articles describe how religious organizational cultures influence the creation and implementation of FTEs intended to meet the evidence-based recommendations of accreditors. This is a lacuna, given that board certified chaplains are measured on their ability to integrate spiritual care into the life and service of their institutions. In response, this article describes the creation and implementation of two chaplain positions devoted to a group of outpatient cancer clinics in a large Catholic healthcare system. This includes lessons learned when navigating R/S aspects of organizational cultures while implementing and executing chaplain practice to meet accreditor recommendations.

Unmet spiritual needs in palliative care: psychometrics of a screening checklist

BACKGROUND

While studies in palliative care use measures of spirituality and religious belief, there have been few validation studies of a screening tool that identifies unmet spiritual needs.

METHODS

A multidisciplinary research team developed and examined the usefulness, reliability and validity of a 17-item Spiritual Concerns Checklist (SCC) as a screening tool for unmet spiritual needs. A cohort of patients recruited from three palliative care services in Sydney and Melbourne, Australia completed anonymous questionnaires. Factor structure and item response theory were used to examine its properties; concurrent validity employed the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp-12).

RESULTS

Among 261 patients, while only 15% directly sought spiritual care, nearly 62% identified at least one spiritual concern. Existential needs (fear of the dying process 32%; loss of control 31%), regret (20%), need for forgiveness (17%), guilt (13%), loss of hope (13%) and meaning (15%) were prominent concerns. Eleven concerns were present for more than 10% of the participants and 25% of religiously orientated participants expressed >4 concerns. The 17-item SCC was unidimensional, with satisfactory reliability. Concurrent validity was evident in the reduced sense of meaning and peace on the FACIT-Sp-12.

CONCLUSION

This preliminary Rasch analysis of the newly developed SCC has demonstrated its usefulness, reliability and validity. Our findings encourage refinement and ongoing development of the SCC with further investigation of its psychometric properties in varying populations.

What makes the palliative care initial encounter meaningful? A descriptive study with patients with cancer, family carers and palliative care professionals

BACKGROUND

The palliative care initial encounter can have a positive impact on the quality of life of patients and family carers if it proves to be a meaningful experience. A better understanding of what makes the encounter meaningful would reinforce the provision of person-centred, quality palliative care.

AIM

To explore the expectations that patients with cancer, family carers and palliative care professionals have of this initial encounter.

DESIGN

Qualitative descriptive study with content analysis of transcripts from 60 semi-structured interviews.

SETTING/PARTICIPANTS

Twenty patients with cancer, 20 family carers and 20 palliative care professionals from 10 institutions across Spain.

RESULTS

Four themes were developed from the analysis of interviews: (1) the initial encounter as an opportunity to understand what palliative care entails; (2) individualised care; (3) professional commitment to the patient and family carers: present and future; and (4) acknowledgement.

CONCLUSION

The initial encounter becomes meaningful when it facilitates a shared understanding of what palliative care entails and acknowledgement of the needs and/or roles of patients with cancer, family carers and professionals. Further studies are required to explore how a perception of acknowledgement may best be fostered in the initial encounter.

Cost considerations for implementing dignity therapy in palliative care: Insights and implications

OBJECTIVES

Despite the clinical use of dignity therapy (DT) to enhance end-of-life experiences and promote an increased sense of meaning and purpose, little is known about the cost in practice settings. The aim is to examine the costs of implementing DT, including transcriptions, editing of legacy document, and dignity-therapists' time for interviews/patient's validation.

METHODS

Analysis of a prior six-site, randomized controlled trial with a stepped-wedge design and chaplains or nurses delivering the DT.

RESULTS

The mean cost per transcript was $84.30 (SD = 24.0), and the mean time required for transcription was 52.3 minutes (SD = 14.7). Chaplain interviews were more expensive and longer than nurse interviews. The mean cost and time required for transcription varied across the study sites. The typical total cost for each DT protocol was $331-$356.

SIGNIFICANCE OF RESULTS

DT implementation costs varied by provider type and study site. The study's findings will be useful for translating DT in clinical practice and future research.

The Perception of Spirituality and Its Assessment among Those with Different Health Statuses in Saudi Arabia

This study compares the perception of spirituality among individuals with different health statuses. It also describes the spiritual services and religious support in the healthcare system that are recommended by the community. A cross-sectional comparative study was conducted in Riyadh during the year 2021. A face-to-face questionnaire was used to obtain data from seriously ill inpatients (N = 132), chronically ill outpatients (N = 202), and healthy individuals (N = 283), which is an assessment tool designed by the investigators to meet the purpose of the study. This study was conducted in two tertiary hospitals and in the community. Participants were randomly selected using a stratified random sampling technique. The study was performed on 635 participants. A significant number of the participants agreed that the provision of spiritual services has a positive effect on patient condition. The rural population had a higher mean value on limiting the concept of spirituality to religious aspects. There is a clear tendency from all categories toward religious services. The majority of the participants support the provision of psychological services, especially if it is provided by specialized and expert spiritual care providers. The positive perception of participants about spiritual care has been reflected on the tendency toward providing spiritual services. The provision of spiritual care in healthcare systems is expected to be a necessity and not a luxury.

Spiritual Care within Dietetic Practice: A Systematic Literature Review

Registered dietitians assess, diagnose and treat nutritional problems. Although integral to healthcare, their role in spiritual care is unknown. We conducted a systematic review of spiritual needs and spiritual care in nutrition and dietetic practice. Subject Headings and keywords were used to search Medline, CINAHL, PsycINFO and AMED for studies exploring spiritual care and nutrition or dietetic practice. From 1433 records, 13 studies were included. Medium quality evidence showed unmet spiritual needs among dietetic patients suffering from cancer, COPD, heart failure and diabetes. Unmet needs occurred in patients from a variety of ethnicities, religions and none. However, dietitians were only involved in spiritual care regarding nutrition and hydration at the end of life. Integrating spiritual screening and sign-posting within dietetic practice is prudent, but clinical trials are needed to evaluate its effectiveness.

A Statement on the Role and Qualifications of Health Care Chaplains for Research and Quality

CONTEXT

This statement fills a significant gap in the efforts to demonstrate outcomes of the chaplaincy role in health care and to provide direction for quality measurement related to spiritual care as a key domain of serious illness care.

OBJECTIVES

The objective of this project was to develop the first major consensus statement on the role and qualifications of health care chaplains in the Unites States.

METHODS

The statement was developed by a diverse panel of highly regarded professional chaplains and nonchaplain stakeholders.

RESULTS

The document provides guidance to chaplains and other spiritual care stakeholders as they further integrate spiritual care in health care and conduct research and quality improvement efforts to strengthen the evidence base for practice. The consensus statement is in Fig. 1 and available at https://www.spiritualcareassociation.org/role-of-the-chaplain-guidance.html.

CONCLUSION

This statement can potentially drive the standardization and alignment of all phases of health care chaplaincy preparation and practice.

Relationship Between Religion/Spirituality and the Aggressiveness of Cancer Care: A Scoping Review

CONTEXT

Religiosity/spirituality/religious-spiritual coping (RS) are resources used by cancer patients with cancer to help cope with the disease and may influence the preference and receipt of end-of-life (EOL) treatment.

OBJECTIVES

To examine the relationship between RS and the EOL care preferred or received by cancer patients.

METHODS

This review protocol is registered on (International Prospective Register of Systematic Review, CRD42021251833) and follows the recommendations of the preferred reporting items for systematic reviews and meta-analyses checklist. Embase, Proquest, PubMed, Scopus, and Web of Science databases were consulted. Google Scholar was consulted for additional publications and gray literature. Quantitative studies including adults with any cancer type/stage were eligible. The paper selection was performed by two independent reviewers; the methodological quality was measured using the Newcastle Ottawa scale.

RESULTS

Seventeen studies were included in the review. In general, RS is related to the preference or receipt of aggressive EOL care and with less advance care planning. Spiritual care by the medical team is related to higher referral to hospice and less aggressive care; in contrast, high spiritual support from religious communities is associated with less hospice and more aggressive care. Religious denominations influenced health care preferences, as Catholics were less likely to sign a do-not-resuscitate order and Buddhists or Taoists received more aggressive interventions at the EOL. Most studies (70%) were of high quality according to the Newcastle Ottawa scale.

CONCLUSION

RS is associated with more aggressive EOL treatments, as well as with lower rates of ACP in cancer patients. On the other hand, spiritual care provided by the medical team seems to be associated with less aggressive EOL care.

Assessing the Impact of Provider Training and Perceived Barriers on the Provision of Spiritual Care: a Mixed Methods Study

The current study evaluated formal training around spiritual care for healthcare providers and the relationships between that training, perceived barriers to spiritual care, and frequency of inquiry around spiritual topics. A mixed methods explanatory sequential design was used. Quantitative methods included an online survey administered to providers at The Ohio State University Comprehensive Cancer Center. Main and interactive effects of formal training and barriers to spiritual care on frequency of inquiry around spiritual topics were assessed with two-way ANOVA. Qualitative follow-up explored provider strategies to engage spiritual topics. Among 340 quantitative participants, most were female (82.1%) or White (82.6%) with over one-half identifying as religious (57.5%). The majority were nurses (64.7%) and less than 10% of all providers (n = 26) indicated formal training around spiritual care. There were main effects on frequency of inquiry around spiritual topics for providers who indicated "personal discomfort" as a barrier (p < 0.001), but not formal training (p = 0.526). Providers who indicated "personal discomfort" as a barrier inquired about spirituality less frequently, regardless of receiving formal training (M = 8.0, SD = 1.41) or not (M = 8.76, SD = 2.96). There were no interactive effects between training and "may offend patients" or "personal discomfort" (p = 0.258 and 0.125, respectively). Qualitative analysis revealed four strategies with direct and indirect approaches: (1) permission-giving, (2) self-awareness/use-of-self, (3) formal assessment, and (4) informal assessment. Training for providers should emphasize self-awareness to address intrapersonal barriers to improve the frequency and quality of spiritual care for cancer patients.

The predictors of spiritual dryness among Iranian cancer patients during the COVID-19 pandemic

Background

Spiritual struggles affect the wellbeing of religious people. Among them are strugglers with God which is perceived as non-responsive and distant. These perceptions were so far analyzed predominantly in Western societies with a Christian background, but not in Muslims from Iran. The aim of this study was to determine the predictors of spiritual dryness among cancer patients in Iran during the COVID-19 pandemic.

Methods

Cross-sectional study with standardized questionnaires (i.e., Spiritual Dryness Scale, WHO-5, BMLSS-10, Awe/Gratitude Scale) among 490 cancer patients (mean age 49.50 ± 14.92 years) referring to the selected educational hospitals in Tehran (the capital of Iran), who were selected through convenience sampling and based on the inclusion criteria, enrolled between December 2020-May 2021. Data analysis was done using SPSS software version 26 and the statistical methods including calculating the mean and the standard deviation, correlation coefficients, as well as regression analysis.

Results

The overall experience of spiritual dryness was perceived regularly in 10.2% of Iranian cancer patients, sometimes in 22.9%, rarely in 22.9%, and never in 43.3%. The mean ± SD was 25.66 ± 5.04, and the scores ranged from 10 to 55. A higher score means greater spiritual dryness. The strongest predictors of spiritual dryness were praying activities Furthermore, the perception of burden due to the pandemic was positively correlated with spiritual dryness. Moreover, each 1 unit increase in its score changed the spiritual dryness score by 0.2 units. The regression of spirituality-related indicators, demographic-clinical variables, and health-related behaviors accounted for 21, 6, and 4% of the total SDS variance, respectively. These findings show that with an increase in praying, performing daily prayers, and the indicators related to spirituality, spiritual dryness will decrease. Most patients were able to cope with these phases often or even regularly, while 31.1% were never or rarely only able to cope.

Conclusion

The results of this study showed that in times of crisis, cancer patients' faith and confidence in God could be challenged. It is not the disease itself which seems to be associated with this form of crisis, but their religious practices. Therefore, it is necessary to support these patients during their struggle, especially as spirituality is one of the best approaches to cope with the disease.

Religion/Spirituality Curriculum in US Osteopathic Medical Schools: A Survey

OBJECTIVE

Several articles have been published on the relationship between religion, spirituality, and health during the past 2 decades. Corresponding to this, professional medical organizations such as the Association of American Medical Colleges and the National Board of Osteopathic Medical Examiners have created competencies for medical students that include being able to understand how a patient's religious/spiritual beliefs may affect their health. It is not, however, certain how and to what extent medical schools implement religion/spirituality in medicine training into their curriculum. Our objective in this study was to quantify and assess the implementation of religion/spirituality in medicine curricula at US osteopathic medical schools.

METHODS

In early 2021, an electronic survey was sent to individuals in curriculum positions at all US osteopathic medical school main and branch locations. The survey consisted of questions regarding the presence or absence of curriculum on religion/spirituality in medicine at their school, and, if it was present, what it consisted of.

RESULTS

Ten institutions responded to the survey, with the majority (80%) stating they did not have religion/spirituality curriculum at their institution.

CONCLUSIONS

Based on the current evidence, there may be a downward trend in osteopathic medical schools providing formal education on religion/spirituality in medicine.

Digital Competencies for Nurses: Tools for Responding to Spiritual Care Needs

Users show a growing interest in expanding the implementation of digital tools as a support of technical and management issues in healthcare. This medical care has focused on telemedicine but does not include the recognition of needs as an important part of patient-centred healthcare. Nurses interact with patients at critical times in their life journeys, including birth and death, which are historical events linked with religious beliefs. Furthermore, large migration flows have led to multicultural societies in which religion and spirituality are experienced in distinct ways by different people. Finally, most healthcare professionals lack the proper skills to handle the spiritual needs of their patients, especially for core and digital competences. This article shows the results of qualitative research applying as a research tool an open-ended questionnaire, which allows detecting the educational needs for nurses’ interventions aimed at providing spiritual support to their patients using digital tools. The results obtained reveal that nurses need education and training on fundamental spiritual concepts and digital competencies to meet the multiple demands of their patients’ spiritual needs. Finally, we present an open digital educational proposal for the development of competencies for nurses and other health professionals to provide spiritual care with the support of digital tools.

Hospital chaplains' communication with patients: Characteristics, functions and potential benefits

OBJECTIVE

Hospital chaplains communicate with patients concerning spirituality/religion, but many aspects of their interactions have received little attention.

METHODS

Telephone qualitative interviews of ~1 h each were conducted with chaplains and analyzed, drawing on grounded theory.

RESULTS

We interviewed 21 U.S. chaplains. Chaplains have relatively unique characteristics, having relatively more time to spend with patients, and less rigid and less medicalized agendas, while gaining respect/trust as religious figures. Chaplains can thus provide several critical beneficial functions - e.g., obtaining key information from patients/families that can help with decision-making and with diagnosis and treatment, and conveying medical providers' points of view to patients/families. Consequently, chaplains can serve as mediators between patients/families and providers; and also overcome staff biases and "labelling" of patients, and pursue or encourage psychological interventions, in part because psychotherapists are often unavailable.

CONCLUSION

While past research suggested certain ways how chaplains might benefit hospitals, these professionals can aid these institutions and improve patient care in additional vital, tangible ways.

PRACTICAL IMPLICATIONS

Hospital administrators, chaplaincy departments, doctors, nurses and others should more fully recognize, encourage and facilitate these functions. Targeted improvements in practice and education can help achieve these goals. The findings suggest, too, several specific questions for further investigation.

Protocol for EXICODE: the EXIstential health COhort DEnmark-a register and survey study of adult Danes

INTRODUCTION

We established the EXIstential health COhort DEnmark (EXICODE) to examine how existential and spiritual needs, practices and orientations in a secular culture are linked to health outcomes, illness trajectory and overall cost of care in patients. Substantial literature demonstrates that existential and spiritual well-being has positive effects on health. While people turn to existential and spiritual orientations and practices during ageing, struggle with illness and approaching death, patients with severe illnesses like, for example, cancer similarly experience existential and spiritual needs. These needs are often unmet in secular societies leading to spiritual pain, unnecessary suffering, worse quality of life and higher medical costs of care.

METHODS AND ANALYSIS

EXICODE is a national cohort comprising a 10% random sample of the adult Danish population with individual-level register and survey data. Specific patient subgroups are oversampled to ensure diseased respondents. The questionnaire used in the survey consists of a collection of validated instruments on existential and spiritual constructs suited for secular culture as well as some ad hoc questions compiled in the comprehensive EXICODE Questionnaire.

ETHICS AND DISSEMINATION

The project is registered for legal and GDPR concerns by the University of Southern Denmark, journal number: 10.367. Ethical approval was not required by Danish law since EXICODE collects only interview, survey and register data, but due to institutional best-practice policy an ethical evaluation and approval were nevertheless obtained from the University of Southern Denmark Research Ethics Committee (institutional review board), journal number: 20/39546. The project follows The Danish Code of Conduct for Research Integrity and is carried out in accordance with the Helsinki Declaration. Results will be disseminated widely through publications in peer-reviewed scientific journals, international conferences, patient societies as well as mass and social media.

Preferences for healthcare chaplaincy services among U.S. adults: differences by inpatient and outpatient settings

We examined preferences around spiritual support services delivered by chaplains among U.S. adults in outpatient and inpatient healthcare settings using a cross-sectional national survey of U.S. adults (n = 1,020). For outpatient settings, 5% reported interest in chaplain services, whereas 16% reported interest in inpatient settings. In both settings, a higher perceived value of chaplain services (p < 01) and previous experience with a chaplain (p < .01) were associated with a greater interest in a chaplain consult when adjusting for demographic factors. In both settings, the most desired services were to explore what was most important in the event of a serious illness or injury (46-47%), values related to treatment decisions (43-46%), and connecting to resources for personal strength and resilience (36-39%), whereas exploring more religious concerns was less desirable. There is a need to identify the role of chaplains within the context of healthcare to meet patients' desire for specific services.

Honoring Black Hopes: How to respond when the family is hoping for a miracle

Background: Racial and ethnic disparities in end-of-life healthcare can be reduced by showing physicians how to best respond to a documented underlying cause: African American families’ hopes for a miracle via divine intervention influence their end-of-life medical decisions, like, for example, making them not want to withdraw ventilatory support in cases of poor neurologic prognosis because they are still hoping for God to intervene. 

Methods: Autoethnographic research probing the author’s Spiritual Care experience in this context yields a nuanced, 90-second point-of-care spiritual intervention physicians can use to address the religious aspect of African American families who base end-of-life medical decisions on their hopes for a miracle via divine intervention. Autoethnographic analysis is framed by physician-author, Dr. Jessica Zitter’s documented journey of grappling with this context. The evolution of Dr. Zitter’s responses to miracle-hoping African American families provides a framework for applying autoethnographic analysis to a critical appropriation of the Johns Hopkins “AMEN” communication protocol for families hoping for a miracle. 

Results: The common instinct of white physicians to remain neutral, holding miracle-hoping African American families at arm’s length, rather than supportively engaging their hopes, is shown to be an intellectual ruse for emotional avoidance. A novel, counterintuitive spiritual intervention for the religious aspect of miracle-hoping African American families is integrated into an existing physician communication protocol for responding to families hoping for a miracle with recommendations for utilization of existing communication technology when necessary. 

Conclusion: Properly addressing the religious dimension of African American families hoping for a miracle may help physicians to increase their therapeutic connection with families, decrease their own stress/burnout levels, and eliminate racial and ethnic disparities in end-of-life healthcare. 

Living experiences of patients with advanced cancer with low socioeconomic status: protocol for a systematic review of qualitative evidence

INTRODUCTION

The number of patients with advanced cancer is rapidly increasing, and the disease burden among those with low socioeconomic status (SES) has accordingly become a global concern. Low SES can adversely impact patients with advanced cancer. The purpose of this systematic review is to shed light on the life experiences of patients with advanced cancer with low SES to help provide targeted and effective strategies to improve their quality of life.

METHODS AND ANALYSIS

We will include the following English databases: Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, PubMed, MEDLINE, Embase, Web of Science, Joanna Briggs Institute (JBI) Database of Systematic Reviews, PsycINFO and OpenGrey, and the following Chinese databases: China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals and Wanfang Data Knowledge Service Platform. A comprehensive search of qualitative studies on the experiences of patients with advanced cancer with low SES will be conducted from the above databases, with no age limit. Quality assessments of the studies will be independently performed by two reviewers using the JBI Critical Assessment Checklist, and any disagreements will be resolved through a discussion with a third reviewer. Relevant data will be extracted using the JBI standardised data extraction tools. The JBI meta-aggregation tool will be used to compare, analyse and summarise the original results. The reliability and credibility of the overall quality of the studies included will be evaluated using the JBI ConQual approach.

ETHICS AND DISSEMINATION

This study is based on existing public literature and therefore does not require a formal ethics review. The results of the study may be presented in peer-reviewed international journals and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42021250423.

Chaplain Care in the Intensive Care Unit at the End of Life: A Qualitative Analysis

Background: The provision of spiritual care is a key component of high-quality patient-centered care, particularly in the intensive care unit (ICU). However, the integration of spiritual care into the care of patients in the ICU is variable, especially at the end of life, which may be due in part to poor or incomplete provider knowledge of the work of chaplains.

Objective: To characterize the care and services provided by chaplains to patients in an ICU at the end of life and/or their families.

Design: A retrospective chart review was performed to identify all patients admitted over a three-month period to an ICU who had visits with a chaplain and an ICU course that ended in death, discharge to a palliative care facility or discharge to hospice.

Subjects/setting: Twenty-five chaplains at a U.S. medical center.

Measurements: Qualitative analysis was performed using directed content analysis on the notes written by the chaplains.

Results: Qualitative analyses of the chaplain notes revealed four broad themes regarding the activities of chaplains in the ICU with respect to patients and families. These were that chaplains provide comfort to patients and family facing the end of life, provide prayers with a variety of purposes, assist in supporting family members through complex medical decision making, and provide connections to appropriate resources.

Conclusions: Chaplains contribute to the care of patients in the ICU through a wide range of activities that demonstrate the unique intermediary and collaborative role chaplains can play within the health care team at the end of life in the ICU.

Spiritual Resources of Family Members of Patients in Palliative Care in Brazil

Although religiosity is a strong feature of Brazilian people, the integration of spirituality in palliative care (PC) has been a challenge for health care professionals. In order to evaluate the spiritual resources used by family members of patients in PC, this work presents the results of the research carried out with 50 family members. The Satisfaction with Life Scale, Centrality of Religiosity Scale, Spiritual/Religious Coping Scale, Religious and Spiritual Struggles Scale, and Attachment to God Inventory were applied. The prevalence of positive spiritual/religious coping was very high (76%) or high (6%). There was a strong correlation between positive spiritual/religious coping and centrality of religiosity (r = 0.805; SD = 0.87). There was a moderate negative correlation between the avoidant attachment to God and centrality of religiosity (r = -0.611; SD = 1.24) and positive spiritual/religious coping (r = -0.575; SD = 1.37). There was a moderate positive correlation between the anxious attachment to God and spiritual struggles (r = 0.515; SD = 0.76) and negative spiritual/religious coping (r = 0.555; SD = 0.616). These results suggest that spiritual/religious resources are present in family members of patients in PC. These resources have been mostly ignored by the multidisciplinary team. Findings provide an evidence base for training health care professionals to better integrate spirituality in PC settings.

Documentation of Assessment of Spiritual Concerns of Adult Advanced Cancer Patients: An Audit in a Hospital-based Specialist Palliative Care Service

OBJECTIVES

Spirituality is a significant dimension of quality palliative care service provision. The purpose of our audit was to assess current practice and improve documentation of spiritual concerns of adult advanced cancer patients in a specialist palliative care (SPC) service in a tertiary care cancer centre.

MATERIALS AND METHODS

In a standard-based audit, we measured the percentage of patient assessment forms with documentation of assessed spiritual concerns at a baseline and reaudit after practice change measures. We set the optimum standard that at least 60% of the case forms would have patients' spiritual concerns recorded. We implemented the following measures - (1) engaging our palliative care staff in team discussions on existing practice and identifying problems and (2) conducting a structured 2 h training module for assessment and documentation of patients' spiritual concerns.

RESULTS

About 70.8% and 93.4% of the patient assessment forms included had documentation of assessed spiritual concerns which is higher than the standard we set at 60% and 90% at baseline and after implementing practice change, respectively. In the reaudit, we found that documentation specific to spirituality and overall psychological assessment improved. We identified that a persisting problem was the lack of recording of spiritual assessment in the patients' follow-up notes.

CONCLUSION

We achieved the benchmark of a standard-based audit on documentation of assessed spiritual concerns of advanced cancer patients in our SPC service. Regular audits in clinical service delivery and documentation should be integrated into quality improvement measures in palliative care.

Considering religion and spirituality in precision medicine

The emerging era of precision medicine (PM) holds great promise for patient care by considering individual, environmental, and lifestyle factors to optimize treatment. Context is centrally important to PM, yet, to date, little attention has been given to the unique context of religion and spirituality (R/S) and their applicability to PM. R/S can support and reinforce health beliefs and behaviors that affect health outcomes. The purpose of this article is to discuss how R/S can be considered in PM at multiple levels of context and recommend strategies for integrating R/S in PM. We conducted a descriptive, integrative literature review of R/S at the individual, institutional, and societal levels, with the aim of focusing on R/S factors with a high level of salience to PM. We discuss the utility of considering R/S in the suitability and uptake of PM prevention and treatment strategies by providing specific examples of how R/S influences health beliefs and practices at each level. We also propose future directions in research and practice to foster greater understanding and integration of R/S to enhance the acceptability and patient responsiveness of PM research approaches and clinical practices. Elucidating the context of R/S and its value to PM can advance efforts toward a more whole-person and patient-centered approach to improve individual and population health.

The Influence of Patient and Provider Religious and Spiritual Beliefs on Treatment Decision Making in the Cancer Care Context

BACKGROUND

Providers often underestimate the influence of patient religious and spiritual (R&S) needs. The current study sought to determine the influence of R&S beliefs on treatment decision making among patients and providers in the context of cancer care.

METHODS

We conducted a systematic review of the literature using web-based search engines and discipline-specific databases. Search terms included a combination of the following Medical Subject Headings and key terms: "cancer,""spirituality,""religion," and "decision making." We used Covidence to screen relevant studies and extracted data into Microsoft Excel.

RESULTS

Among 311 screened studies, 32 met inclusion/exclusion criteria. Most studies evaluated the patient perspective (n = 29), while 2 studies evaluated the provider perspective and 1 study examined both. In assessing patient R&S relative to treatment decision making, we thematically characterized articles according to decision-making contexts, including general (n = 11), end-of-life/advance care planning (n = 13), and other: specific (n = 8). Specific contexts included, but were not limited to, clinical trial participation (n = 2) and use of complementary and alternative medicine (n = 4). Within end-of-life/advance care planning, there was a discrepancy regarding how R&S influenced treatment decision making. The influence of R&S on general treatment decision making was both active and passive, with some patients wanting more direct integration of their R&S beliefs in treatment decision making. In contrast, other patients were less aware of indirect R&S influences. Patient perception of the impact of R&S on treatment decision making varied relative to race/ethnicity, being more pronounced among Black patients.

CONCLUSION

Most articles focused on R&S relative to treatment decision making at the end of life, even though R&S appeared important across the care continuum. To improve patient-centered cancer care, providers need to be more aware of the impact of R&S on treatment decision making.

Teaching spirituality to medical students: a systematic review

PURPOSE

Though it has become increasingly clear that religion and spirituality are important aspects of whole patient care, little is known about how this topic is taught to medical students. This systematic review examined the structure of courses teaching spirituality to medical students and assessed their impact on reported student outcomes.

METHODS

In October 2020, the authors conducted a systematic review of the literature from 1926 to 2020 to identify published articles describing medical school spirituality curricula. Included studies were English-language articles that described spirituality courses predominantly designed for medical students, specified a curricular structure, and evaluated outcomes of the course. The authors used the Medical Education Research Study Quality Instrument (MERSQI) to assess the quality of the included studies and summarized course structures, curricular content, and study outcomes.

RESULTS

Nineteen publications of the 1889 reviewed met the inclusion criteria. These studies were of moderate quality (mean MERSQI = 9.9). The majority of curricula were taught in United States medical schools. Courses were evenly split between mandatory versus elective classes, with mandatory courses having a shorter duration and higher total student participation. Most studies with clear student outcome evaluation had a pre- and post-test design. Common themes throughout the curricula included teaching how to take a spiritual history, delineating differences between spirituality and religion, and experience shadowing chaplains interacting with patients.

CONCLUSIONS

This broad systematic review of the literature revealed a small but growing number of studies describing specific course structure and curricula for teaching spirituality at the medical student level. For the most concise approach, one short, mandatory didactic session followed by application with standardized or hospital patients can be an effective method of introducing students to the importance of spirituality. Important topics to address include the differences between religion and spirituality, recognizing spiritual distress, how to take a spiritual history, and the relevance of spirituality to student well-being. Measured student outcomes should encompass behavioral changes during patient care in addition to changes in knowledge and attitudes. Suggested methods of evaluation include reflective writing and adding a standardized patient case in which the patient is in spiritual distress in an Objective Structured Clinical Examination (OSCE).

Training to Conduct Research on Religion, Spirituality and Health: A Commentary

Scientific research on religion, spirituality and health is fundamental, or our health care systems will become spuriously tokenistic rather than being truly holistic. Likewise, training in scientific research with respect to the interconnection between religion/spirituality and health, is also essential so as to ensure the future inclusion and development of religion and spirituality across the disciplines of medicine, nursing, psychology, social work, pastoral/spiritual care, and other allied health disciplines. This paper describes research training programs now available to obtain the skills and knowledge to develop, fund, manage, and publish research in this area, and disseminate it to clinicians and the general public. First, a model research program is described, and then, three examples of training programs at Duke, Emory, and Yale University are presented. Such training programs seek to develop the next generation of researchers who will dedicate their lives and careers to conducting research on religion and health, teaching it to students, and integrating the findings into clinical practice both in the USA and around the world. Scholarships are now available for health professionals to obtain such training, particularly for academic scholars early in their careers (e.g., graduate students, junior faculty) and for more senior researchers wishing to conduct studies in this area. Nearly 80% of the world's population have religious or spiritual beliefs that influence their health and well-being in one way or another. Learning to carry out and publish systematic research will help fill the many gaps in knowledge concerning how religion affects health and health affects religion.

Valuing the Spiritual

Identifying reforms that minimize US healthcare costs is imperative. This commentary explores one intervention with potential cost-saving implications that has received comparably minimal consideration: spiritual care provision. It highlights the staff and patient costing benefits of spiritual care in addressing spiritual distress and urges practical policy and research initiatives to maximize its impact.

Economic Evaluation of Palliative Care Interventions: A Review of the Evolution of Methods From 2011 to 2019

BACKGROUND

End-of-life care is a driver of increasing healthcare costs; however, palliative care interventions may significantly reduce these costs. Economic evaluations that measure the incremental cost per quality adjusted life years (QALY) are warranted to inform cost-effectiveness of the intervention relative to a comparator and permit evaluation of investment against other therapeutic interventions. Evidence from the literature up to 2011 indicates a scarcity of cost-utility studies in palliative care research.

AIM

This literature review evaluates economic studies published between 2011 and 2019 to determine whether the methods of economic evaluations have evolved since 2011.

DESIGN AND DATA SOURCES

A literature search was completed using CENTRAL, OVID MEDLINE, EMBASE and other sources for publications between 2011 and 2019. Study characteristics, methodology and key findings of publications that met the inclusion criteria were reviewed. Quality of studies were assessed using indicators developed by authors of the previous literature review.

RESULTS

46 papers were included for qualitative synthesis. Among them only 6 studies conducted formal cost-effectiveness evaluations-of these 5 measured QALYs and 1 employed probabilistic analyses. In addition, with the exception of 1 costing analysis, all other economic evaluations undertook a healthcare payer perspective. Quality of evidence were comparable to the previous literature review published in 2011.

CONCLUSION

Despite the small increase in the number of cost-utility studies, the methods of palliative care economic evaluations have not evolved significantly since 2011. More probabilistic cost-utility analyses of palliative care interventions from a societal perspective are necessary to truly evaluate the value for money.

Preferences of quality delivery of palliative care among cancer patients in low- and middle-income countries: A review

BACKGROUND

All forms of cancer pose a tremendous and increasing problem globally. The prevalence of cancer across the globe is anticipated to double over the next two decades. About 50% of most cancer cases are expected to occur in low- and middle-income countries (LMICs), where there is a greater disproportionate level in mortality. Access to effective and timely care for cancer patients remains a challenge, especially in LMICs due to late disease diagnosis and detection, coupled with the limited availability of appropriate therapeutic options and delay in proper interventions.

METHODOLOGY

This study explored several mixed-method researches and randomized trials that addressed the preferences of quality delivery of palliative care among cancer patients in LMICs. A designated set of keywords such as Palliative Care; Preferences; Cancer patients; Psycho-social Support; End-of-life Care; Low and Middle-Income Countries were inserted on electronic databases to retrieve articles. The databases include PubMed, Scinapse, Medline, The Google Scholar, Academic search premier, SAGE, and EBSCO host.

RESULTS

Findings from this review discussed the socioeconomic and behavioral factors, which address the quality delivery of palliative care among cancer patients. These factors if measured with acceptance level in cancer patients could help to address areas that need improvement from the stage of disease diagnosis to the end-of-life.

SIGNIFICANCE OF THE RESULTS

Valuable collaborations among international and local health institutions are needed to build and implement a systematic framework for palliative care in LMICs. Policies and programs that are country and culturally specific, encompassing both theoretical and practical models of care in the milieu of existing quandaries should be developed.

Coordinating assessment of spiritual needs: a cross-walk of narrative and psychometric assessment tools used in palliative care

Addressing spiritual needs of patients in healthcare settings improves patient experiences and clinical outcomes; however, non-chaplain providers typically assess spiritual needs differently (quantitative psychometric) than healthcare chaplains (long form narrative) and thus there is little shared language or cross-disciplinary evaluation frameworks across disciplines. This discrepancy impedes the provision of both team-based and patient-centered care. This paper used scoping review methodology to illustrate the overlap between narrative and psychometric assessment tools, comparing four narrative tools against eight psychometric tools. The SpNQ-120 and Brief RCOPE demonstrated consistent domain coverage across the four chaplain narrative tools. This work provides preliminary resources to aid clinicians and researchers in choosing an appropriate tool. Additionally, for those who do not work closely with chaplains, it provides a sense of what domains chaplains prioritize, from their professional and lived experience, in assessing the spiritual life of the patient. This improves interdisciplinary communication, and therefore, patient care.

Challenges and opportunities for spiritual care practice in hospices in a middle-income country

BACKGROUND

Spiritual care is a key component of palliative care, but it has been overlooked and understudied in low- and middle-income country contexts, especially in Africa. In this study we sought to establish what the current spiritual care practices are in hospice palliative care settings in South  Africa with a focused view on what spiritual care training is currently offered and what training needs still remain unmet.

METHODS

We explored spiritual care practices, and training needs, through a national quantitative online study of palliative care organisations in South Africa registered with the Hospice Palliative Care Association of South Africa. A survey was sent to representatives of all member organisations listed on the national database of Hospice Palliative Care Association of South Africa. Viable data from 41% (n = 40) member organisations were analysed through the use of simple statistics.

RESULTS

An expressed need (75%; n = 30) was recorded for the development of a national spiritual care curriculum. Although 48% (n = 20) of the member organisations were willing to participate in the development of a spiritual care curriculum, 37% (n = 14) could not participate, citing financial (n = 27), time (n = 31) and expertise constraints (n = 22). A set of hard and soft skills were suggested to suit the diverse South African context.

CONCLUSIONS

Spiritual care was seen by participants as a key component of palliative care. International  curricula  in spiritual care, while useful, do not offer easy adaptation to the diversities of South Africa. A bespoke spiritual care curriculum was called for, for diverse South Africa.

What defines the comprehensive assessment of needs in palliative care? An integrative systematic review

BACKGROUND

The comprehensive assessment of needs in palliative care identifies where patients most want attention to guide clinical decisions that tailor care provision from their first encounters.

AIM

To define how and what needs are identified by the comprehensive assessment of needs in the original peer-reviewed articles in the field of palliative care.

DESIGN

An integrative systematic review as outlined by Whittemore and Knafl. Quality appraisal performed using the Mixed Methods Appraisal Tool.

DATA SOURCES

PubMed, CINAHL, PsycINFO, Web of Science databases searched through May 2019 and updated in July 2020.

RESULTS

Forty-nine articles met inclusion criteria for original articles in English or Spanish reporting comprehensive assessment of needs of adult patients receiving palliative care. The majority (41/49) of studies were moderate to high quality. Two themes were identified: (1) How a comprehensive assessment of needs should be carried out in palliative care, which reflected a preference to develop structured tools for assessment; (2) What needs of patients should be assessed in the comprehensive assessment of needs in palliative care, which conveyed a trend to assess beyond core domains - physical, psychological, social, spiritual - with information and practical most prevalent, but with substantial variation in specifying and classifying needs into domains.

CONCLUSIONS

The assessment of needs in palliative care is comprehensive but lacks consensus on the needs and domains that should be assessed by the palliative care team. Future studies should better define what needs can be standardized into the assessment to improve process of care and patient satisfaction.

Proposing religiously informed, relationally skillful chaplaincy theory

Research on the multiple uses of religion/spirituality (R/S) in healthcare and on the practices of healthcare chaplaincy support creation of a middle-range, prescriptive theory for chaplaincy for patients who use R/S in their healthcare experiences. Religiously Informed, Relationally Skillful Chaplaincy Theory (RIRSCT) seeks to integrate research into practice in order to improve spiritual care and allow for testing RIRSCT. The components of RIRSCT are: patients whose religion is a significant part of their worldview often use R/S in healthcare to make meaning, to cope, and to make medical decisions; chaplains should be the members of the healthcare team to assess and address R/S; healthcare teams could provide more personalized treatment by integrating patients' R/S into the treatment plan, which could improve patient experience. This article describes the components of RIRSCT and provides examples of chaplaincy guided by RIRSCT. Selected research articles supporting theory components are reviewed.

What is spiritual care? Professional perspectives on the concept of spiritual care identified through group concept mapping

OBJECTIVES

The overall study aim was to synthesise understandings and experiences regarding the concept of spiritual care (SC). More specifically, to identify, organise and prioritise experiences with the way SC is conceived and practised by professionals in research and the clinic.

DESIGN

Group concept mapping (GCM).

SETTING

The study was conducted within a university setting in Denmark.

PARTICIPANTS

Researchers, students and clinicians working with SC on a daily basis in the clinic and/or through research participated in brainstorming (n=15), sorting (n=15), rating and validation (n=13).

RESULTS

Applying GCM, ideas were identified, organised and prioritised online. A total of 192 unique ideas of SC were identified and organised into six clusters. The results were discussed and interpreted at a validation meeting. Based on input from the validation meeting a conceptual model was developed. The model highlights three overall themes: (1) 'SC as an integral but overlooked aspect of healthcare' containing the two clusters SC as a part of healthcare and perceived significance; (2) 'delivering SC' containing the three clusters quality in attitude and action, relationship and help and support, and finally (3) 'the role of spirituality' containing a single cluster.

CONCLUSION

Because spirituality is predominantly seen as a fundamental aspect of each individual human being, particularly important during suffering, SC should be an integral aspect of healthcare, although it is challenging to handle. SC involves paying attention to patients' values and beliefs, requires adequate skills and is realised in a relationship between healthcare professional and patient founded on trust and confidence.

"Give them the door but don't push them through it": Family Attitudes Toward Physician-Led Spiritual Care in Pediatric Palliative Medicine

Little is known about pediatric caregivers' perceptions of religious or spiritual (R/S) care provided by physicians. We conducted a qualitative, semistructured interview study to understand perceptions of pediatric caregivers toward physician-led R/S care. Participants were 20 primary caregivers whose children were hospitalized and receiving palliative care services. Interviews were audio recorded, transcribed verbatim, and analyzed using constant comparative methods. Three recurrent themes emerged regarding physician-led R/S care: (1) Most caregivers view providing R/S care as a positive sign of physician empathy, while a minority (3/20) prefer to keep R/S and medical care separate, (2) many caregivers prefer R/S care from a physician with whom they have a close relationship and/or share a faith background, and (3) physicians should open the door, but allow families to lead conversations about R/S care. Caregivers have mixed perceptions on physicians engaging in R/S care; most prefer that families set the direction of R/S care for themselves and their loved ones. Physicians should be trained to evaluate families' spiritual backgrounds and needs in ways that respectfully open the door to these conversations.

Chaplaincy in the outpatient setting-getting from here to there

One of the most evident trends in US health care and health care generally in the developed world is that more and more care is shifting to outpatient settings. This change opens up substantial opportunities, and in many cases, expectations for chaplains to extend the breadth of the care they provide in any health system. However, it also brings many challenges. This paper describes the journey of four very different inpatient chaplaincy services into the outpatient setting. These four examples focus on settings that would historically be thought of as outpatient-those that see patients within the brick and mortar of the health system.

Quality of life of cancer patients at palliative care units in developing countries: systematic review of the published literature

Purpose

This systematic review aims to summarize factors that influence the quality of life (QOL) of advanced cancer patients in palliative care (PC) in developing countries. Understanding this context in developing countries milieu is necessary; however, this outcome is rarely reported.

Methods

Following the PRISMA guidelines, the electronic databases MEDLINE, Embase, CINAHL, and Web of Science were systematically searched using the search terms: QOL, cancer, PC, and names of all developing countries. Studies with less than ten subjects, qualitative or pilot studies, reviews, conference abstracts, and that reported validation of QOL questionnaires were excluded.

Results

Fifty-five studies from 15 developing countries in the African (n = 5), Latin America and the Caribbean (n = 10), and Asian (n = 40) region were included in the narrative synthesis. 65.4% were cross-sectional, 27.3% were cohort studies, 7.3% were RCTs or quasi-experimental studies. Around 30 QOL factors were studied with 20 different types of QOL instruments. Advanced cancer patients who were older, married/ever married, participated in additional care within PC, used complementary and alternative medicine (CAM), and practiced spirituality/religiosity showed higher QOL score. Low educational level and high depression were associated with a lower QOL.

Conclusion

Various factors affect QOL among cancer patients in PC. Patients valued the use of CAMs; however, the quality and safety aspects should be properly addressed. Important factors that influenced the QOL score were social and spiritual support. While there is a general need to develop PC strategies further, recognizing patients’ needs should be prioritized in national cancer programs.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02633-z) contains supplementary material, which is available to authorized users.

'I'm praying for a miracle': characteristics of spiritual statements in paediatric intensive care unit care conferences

CONTEXT

Supporting spiritual needs is a well-established aspect of palliative care, but no data exist regarding how physicians engage with patients and families around spirituality during care conferences in paediatric intensive care units (PICU).

OBJECTIVES

To assess the frequency and characteristics of family and physician spiritual statements in PICU care conferences.

METHODS

We performed qualitative analysis of 71 transcripts from PICU conferences, audio-recorded at an urban, quaternary medical centre. Transcripts were derived from a single-centre, cross-sectional, qualitative study.

RESULTS

We identified spiritual language in 46% (33/71) of PICU care conferences. Spiritual statements were divided relatively evenly between family member (51%, 67/131) and physician statements (49%, 64/131). Physician responses to families' spiritual statements were coded as supportive (46%, 31/67), deferred (30%, 20/67), indifferent (24%, 16/67) or exploratory (0/67).

CONCLUSIONS

In this single-centre PICU, spiritual statements were present 46% of the time during high stakes decision-making conferences, but there was little evidence of spiritual care best practices, such as offering chaplain support and performing open-ended spiritual assessments. PICU clinicians should expect spiritual statements in care conferences and be prepared to respond.

Strengthening the spiritual domain in palliative care through a listening consultation service by spiritual caregivers in Dutch PaTz-groups: an evaluation study

Background

Palliative care should be holistic, but spiritual issues are often overlooked. General practitioners and nurses working together in PaTz-groups (palliative home care groups) consider spiritual issues in palliative care to be relevant, but experience barriers in addressing spiritual issues and finding spiritual caregivers. This study evaluates the feasibility and perceived added value of a listening consultation service by spiritual caregivers in primary palliative care.

Methods

From December 2018 until September 2019, we piloted a listening consultation service in which spiritual caregivers joined 3 PaTz-groups whose members referred patients or their relatives with spiritual care needs to them. Evaluation occurred through (i) monitoring of the implementation, (ii) in-depth interviews with patients (n = 5) and involved spiritual caregivers (n = 5), (iii) short group interviews in 3 PaTz-groups (17 GPs, 10 nurses and 3 palliative consultants), and (iv) questionnaires filled out by the GP after each referral, and by the spiritual caregiver after each consultation. Data was analysed thematically and descriptively.

Results

Consultations mostly took place on appointment at the patients home instead of originally intended walk-in consultation hours. Consultations were most often with relatives (72%), followed by patients and relatives together (17%) and patients (11%). Relatives also had more consecutive consultations (mean 4.1 compared to 2.2 for patients). Consultations were on existential and relational issues, loss, grief and identity were main themes. Start-up of the referrals took more time and effort than expected. In time, several GPs of each PaTz-group referred patients to the spiritual caregiver. In general, consultations and joint PaTz-meetings were experienced as of added value. All patients and relatives as well as several GPs and nurses experienced more attention for and awareness of the spiritual domain. Patients and relatives particularly valued professional support of spiritual caregivers, as well as recognition of grief as an normal aspect of life.

Conclusions

If sufficient effort is given to implementation, listening consultation services can be a good method for PaTz-groups to find and cooperate with spiritual caregivers, as well as for integrating spiritual care in primary palliative care. This may strengthen care in the spiritual domain, especially for relatives who are mourning.

[Comment] Ethical and practical considerations on cancer recommendations during COVID-19 pandemic

National and international authorities and societies have recently published important cancer treatment recommendations in order to propose extra measures that should be taken during the COVID-19 pandemic, such as prioritisation of intend-to-cure treatments and younger patients, omission of non-urgent cases, and reduction of personnel present. These measures raise important ethical considerations, since they prioritise protection of Health Systems and Professionals without seemingly taking cancer patient feelings of stress into consideration. This could lead to an erosion of the physician-patient relationship, which is considered the core element of medical ethics. Moreover, they raise practical concerns about the continuous education of Health Professionals, the status of reference centres and the evaluation of the hitherto cancer treatments.

Care of the Spirit: Effects of an Interdisciplinary Undergraduate End-of-Life Course on Knowledge, Competence, and Response Empathy

The purpose of this pilot was to identify the effects of a 4-credit interdisciplinary undergraduate course focused on communication strategies to enhance spiritual care at the end of life. The course provided students with opportunities to enhance their ability to communicate empathically with individuals facing the end of life. Evidence-based content focused on ways to live each day with hope and gratitude, strengthen relationships, create a legacy, and find meaning and purpose in life and death. Narayanasamy's (1999) Actioning Spirituality and Spiritual Care Education and Training in Nursing model guided project development. The study used a prospective, pretest/posttest design. Participants included undergraduate students (n = 34) from nursing, premedicine, athletic training, business, economics, and religious studies at a Midwest liberal arts college. Statistically significant differences were found in students' attitudes toward and knowledge of spirituality/spiritual care (P < .0001, Cohen's d = 0.59), spiritual care competence (P < .0001, Cohen's d = 0.79), and level of response empathy through role play (P < .0001, Cohen's d = 0.92). Many students referred to this course as "life changing" and "healing." As our students go out into the community, they may intimately touch the lives and hearts of future patients, family, and friends who face the end of life with their compassionate words.

The Catalogue of Spiritual Care Instruments: A Scoping Review

Spiritual care has been a growing focus in international healthcare research over the last decades. The approaches to spiritual care are many and derive from many different medical fields and different cultural contexts and often remain unknown across healthcare areas. This points to a potential knowledge gap between existing instruments and the knowledge and use of them cross-disciplinarily and cross-culturally, and thus best practice insights are not sufficiently shared. This article contributes to the growing field of spiritual care by providing an overview of the various approaches (henceforth instruments) to assess patients’ spiritual needs in view of improving spiritual care. This was done through a scoping review method. The results of the review were collected and catalogued and presented here as ‘The Catalogue of Spiritual Care Instruments’. The included instruments derive from a wide range of geographical contexts and healthcare areas and are aimed at patients and healthcare professionals alike, clearly showing that spiritual care is a focus in healthcare internationally. However, it also shows the difficulties of defining spiritual care, the importance of local contexts, and the difficulties of cross-cultural validity. The catalogue contains 182 entries and is available as an interactive platform for the further development of spiritual care internationally.

An existential support program for people with cancer: Development and qualitative evaluation

PURPOSE

To describe the development process of an existential support program and to explore participants' evaluation of supportive/unsupportive processes of change.

METHOD

A five-day existential support program called "Energy for life" was designed including three main elements: 1. existential group counseling, 2. art therapy and 3. interaction with nature and aesthetic surroundings. The program was implemented at two different study sites. Focus group interviews were conducted to evaluate the program.

RESULTS

40 subjects were recruited (20 for each one of the two study sites) and 36 completed the study (31 women, five men) in the age range from 31 to 76 years and living with cancer across all stages and types. The program resulted in supportive processes of "existential sharing". The existential group counseling included a sharing process which led to an increased awareness and acceptance of one's existential situation and a preparation for the next steps in one's life. Art therapy offered a respite from the illness or the opportunity to express and share difficult thoughts and feelings connected to the illness experience. The interaction with nature/surroundings induced feelings of calmness and peace, increasing self-worth and spiritual belonging. Unsupportive processes of change related to the organization of the existential counseling groups, feelings of discomfort with creative engagement and feelings of distress provoked by a hospital environment.

CONCLUSION

Through "Energy for life" existential concerns and distress were shared, contained and transformed. Knowledge has been gained about how an existential support program can be designed that explicitly focuses on alleviating patients' existential distress.

Identifying End-of-Life Preferences Among Chinese Patients With Cancer Using the Heart to Heart Card Game

Background:

Understanding the preferences for end-of-life (EOL) care is imperative in providing quality care to patients with life-threatening illness. However, it is difficult for patients, families, and health-care providers to initiate EOL conversations in China. An easy-to-use tool that could help health-care providers initiate EOL discussions is the Heart to Heart Card Game (HHCG), originally designed for Chinese Americans.

Objective:

To evaluate the EOL preferences among Chinese patients with cancer using the HHCG.

Methods:

We conducted a descriptive study to assess EOL preferences using HHCG among patients at the oncology chemoradiotherapy department of a Chinese tertiary hospital.

Results:

We recruited 58 patients in total of which 40 (69%) patients completed HHCG. The most frequently selected card was “I want my family to get along,” followed by “I don’t want to be a burden to my family,” and “I want to maintain my dignity.” Among the 3 cards selected, social needs were rated as the most important (36.7%), followed by spiritual needs (35.8%), physical needs (20.0%), and financial needs (7.5%). The evaluation of the HHCG revealed that more than 70% of the participants highly valued HHCG.

Conclusion:

The HHCG can be used as a communication tool to encourage EOL discussions between cancer patients and health-care providers in China. Moreover, Chinese patients with cancer attach significant importance to their family and maintaining dignity at the EOL.

Healthcare Chaplains' Perspectives on Nurse-Chaplain Collaboration: An Online Survey

The collaboration between nurses and chaplains is essential to provide spiritual support in healthcare institutions. Given challenges in collaboration exist between these disciplines, this study sought to further understand the nature of the chaplain-nurse relationship. Data obtained from an online survey of members of the Association of Professional Chaplains (N = 266) provide a quantified and nuanced picture of how chaplains perceive nurse collaboration and provision of spiritual care. This study not only provides evidence that can inform chaplain and nurse practice, but also an instrument for measuring perceptions about collaboration to provide spiritual care.

Religious observance and perceptions of end-of-life care

This study examines the impact of the level of religious observance on the attitudes toward end-of-life (EOL) decisions and euthanasia of Jews in Israel-where euthanasia is illegal-as compared to Jews living in the USA, in the states where euthanasia is legal. A self-reporting questionnaire on religiosity and personal beliefs and attitudes regarding EOL care and euthanasia was distributed, using a convenience sample of 271 participants from Israel and the USA. Findings show that significant differences were found in attitudes between Jews of different levels of religious observance with respect to patient autonomy, right to die with dignity, and dying in familiar and supportive surroundings. The USA and Israeli Jews have similar knowledge regarding EOL care and expressed similar attitudes and perceptions toward the issues of authority of medical staff and religious figures and patient's autonomy. Findings indicate that the level of religious observance has more potency in shaping their attitudes and perceptions of EOL decisions than the state law. We conclude by discussing the implications of our findings with regard to multicultural health systems and providing practical recommendations.

Proactive and systematic multidimensional needs assessment in patients with advanced cancer approaching palliative care: a study protocol

INTRODUCTION

The benefits of palliative care rely on how healthcare professionals assess patients' needs in the initial encounter/s; crucial to the design of a personalised therapeutic plan. However, there is currently no evidence-based guideline to perform this needs assessment. We aim to design and evaluate a proactive and systematic method for the needs assessment using quality guidelines for developing complex interventions. This will involve patients, their relatives and healthcare professionals in all phases of the study and its communication to offer clinical practice a reliable approach to address the palliative needs of patients.

METHODS AND ANALYSIS

To design and assess the feasibility of an evidence-based, proactive and systematic Multidimensional needs Assessment in Palliative care (MAP) as a semistructured clinical interview guide for initial palliative care encounter/s in patients with advanced cancer. This is a two-phase multisite project conducted over 36 months between May 2019 and May 2022. Phase I includes a systematic review, discussions with stakeholders and Delphi consensus. The evidence gathered from phase I will be the basis for the initial versions of the MAP, then submitted to Delphi consensus to develop a preliminary guide of the MAP for the training of clinicians in the feasibility phase. Phase II is a mixed-methods multicenter feasibility study that will assess the MAP's acceptability, participation, practicality, adaptation and implementation. A nested qualitative study will purposively sample a subset of participants to add preliminary clues about the benefits and barriers of the MAP. The evidence gathered from phase II will build a MAP user guide and educational programme for use in clinical practice.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the university research ethics committee where the study will be carried out (approval reference MED-2018-10). Dissemination will be informed by the results obtained and communication will occur throughout.

The Association of Surrogate Decision Makers' Religious and Spiritual Beliefs With End-of-Life Decisions

CONTEXT

Although religion and spirituality are important to surrogate decision makers, little is known about the role of religion in decision making regarding life-sustaining treatments.

OBJECTIVES

To determine the relationships between dimensions of religion and spirituality and medical treatment decisions made by surrogates.

METHODS

This prospective observational study enrolled patient/surrogate dyads from three hospitals in one metropolitan area. Eligible patients were 65 years or older and admitted to the medicine or medical intensive care services. Baseline surveys between hospital days 2 and 10 assessed seven dimensions of religion and spirituality. Chart reviews of the electronic medical record and regional health information exchange six months after enrollment identified the use of life-sustaining treatments and hospice for patients who died.

RESULTS

There were 291 patient/surrogate dyads. When adjusting for other religious dimensions, demographic, and illness factors, only surrogates' belief in miracles was significantly associated with a lower surrogate preference for do-not-resuscitate status (adjusted odds ratio [aOR] 0.39; 95% CI 0.19, 0.78). Among patients who died, higher surrogate intrinsic religiosity was associated with lower patient receipt of life-sustaining treatments within the last 30 days (aOR 0.66; 95% CI 0.45, 0.97). Belief in miracles (aOR 0.30; 95% CI 0.10, 0.96) and higher intrinsic religiosity (aOR 0.70; 95% CI 0.53, 0.93) were associated with lower hospice utilization.

CONCLUSION

Few religious variables are associated with end-of-life preferences or treatment. Belief in miracles and intrinsic religiosity may affect treatment and should be identified and explored with surrogates by trained chaplains or other clinicians with appropriate training.

Spiritual care in the intensive care unit: An integrative literature research

PURPOSE

The aim of this study is to review the literature for three major domains in relation to spiritual care in the ICU, namely Quality of Life (QoL), Quality of Care (QoC), and Education (E).

METHOD

An integrative literature research.

RESULTS

The 113 selected articles reveal that spirituality is an essential component of QoL and that complementary and effective spiritual care (SC) relieves distress of patients and their relatives. Furthermore, the contribution of SC to quality of care is: 1) diagnosing and addressing spiritual and emotional needs among patients and their relatives; 2) offering spiritual comfort to the patient in distress; 3) increased spiritual well-being of both patients and their relatives; 4) increased family satisfaction in general and by shared decision-making. Finally, the literature reveals the necessity to improve SC knowledge and skills of ICU healthcare professionals (IC HCPs) through relevant training courses.

CONCLUSION

SC contributes to QoL and QoC. The literature indicates that IC HCPs acknowledge the need to improve their SC knowledge and skills to enhance complementary, effective SC. Further research on SC as an integrated part of daily ICU care is necessary to improve QoL and QoC of patients and their relatives.

Patients' and Caregivers' Contested Perspectives on Spiritual Care for Those Affected by Advanced Illnesses: A Qualitative Descriptive Study

CONTEXT

Spiritual care refers to practices and rituals addressing spiritual/religious concerns. It supports coping with loss and finding hope, meaning, and peace. Although integral to palliative care, its implementation is challenging.

OBJECTIVE

To understand an Australian cohort of patients' and caregivers' perspectives about experiencing and optimizing spiritual care in the context of advanced illness.

METHODS

Patients and caregivers of patients with ≤12 month prognosis were recruited from a broader spiritual study via criterion sampling and agreed to opt-in interviews. Participants from an Australian, metropolitan health service received a spiritual care definition and were interviewed. Transcripts were analyzed using qualitative description.

RESULTS

30 patients (17 male; mean age 70 years) and 10 caregivers (six male; mean age 58.9 years) participated. 27 identified as Christian, and 10 had no religion. Participants described multifaceted and contested beliefs about spirituality. Many queried the tangibility of spirituality, but all valued respectful staff who affirmed personhood, that is, each individual's worth, especially when care exceeded expectations. They also resonated with positive organizational and environmental tones that improved holistic well-being. Participants stressed the importance of the hospital's welcoming context and skilled care, which comforted and reassured.

CONCLUSION

Although many patients and caregivers did not resonate with the term "spiritual care," all described how the hospital's hospitality could affirm their values and strengthen coping. The phrase "spiritual care and hospitality" may optimally articulate and guide care in similar, pluralist inpatient palliative care contexts, recognizing that such care encompasses an interplay of generalist and specialist pastoral care staff and organizational and environmental qualities.