Spirituality, religiosity, and spiritual pain in advanced cancer patients

Trial of Therapy on Trial: Inconsistent Thresholds for Discussing Withdrawal of Life-Sustaining Therapies in the Neonatal Intensive Care Unit

OBJECTIVE

 This study aimed to establish the degree of variability in thresholds for discussing withdrawal of life-sustaining therapies (WLST) in periviable infants among neonatal intensive care unit (NICU) personnel.

STUDY DESIGN

 A vignette-style survey was administered to NICU personnel at two urban NICUs assessing likelihood of discussing WLST or support for discussing WLST (on a scale from 1, not at all likely/supportive to 10, extremely likely/supportive) in 10 clinical scenarios.

RESULTS

 Response rates ranged by clinical role from 26 to 89%. Participant responses ranged from 1 to 10 in 5 out of 10 vignettes for NICU attendings, and 9 out of 10 vignettes for bedside nurses. Lower gestational age (22-23 vs. 24-25 weeks) was associated with increased likelihood to discuss WLST in some but not all scenarios.

CONCLUSION

 NICU personnel have widely variable criteria for discussing WLST which threatens the informed consent process surrounding resuscitation decisions in a "trial of therapy" framework.

KEY POINTS

· NICU personnel have variable criteria for WLST.. · Parents have little say in whether WLST is offered.. · Disclosure of variable criteria is not routine..

The impact of spiritual care delivered by nurses on patients' comfort: A propensity score matched cohort utilizing electronic health record data

BACKGROUND

Spiritual care has been associated with better health outcomes. Despite increasing evidence of the benefits of spiritual care for older patients coping with illness and aggressive treatment, the role of spirituality is not well understood and implemented. Nurses, as frontline holistic healthcare providers, are in a position to address patients' spiritual needs and support them in finding meaning in life. This study aimed to identify spiritual care by analyzing nursing data and to compare the psychological and physical comfort between older chronically ill patients who received spiritual care versus those who did not receive spiritual care.

MATERIAL AND METHODS

A propensity score matched cohort utilizing nursing care plan data was used to construct balanced groups based on patient characteristics at admission. 45 older patients (≥65 years) with chronic illnesses received spiritual care with measured psychological or physical comfort and 90 matched controls. To ensure the robustness of our results, two sensitivity analyses were performed. Group comparisons were performed to assess the average treatment effect of spiritual care on psychological and physical comfort outcomes.

RESULTS

The mean psychological comfort was 4.3 (SD = 0.5) for spiritual care receivers and 3.9 (SD = 0.9) for non-receivers. Regression analysis showed that spiritual care was associated with better psychological comfort (estimate = 0.479, std. error = 0.225, p = 0.041). While its effect on physical comfort was not statistically significant (estimate = -0.265, std. error = 0.234, p = 0.261). This study provides suggestive evidence of the positive impact of nurses' spiritual care in improving psychological comfort for older patients with chronic illnesses.

CONCLUSION

Using interoperable nursing data, our findings suggest that spiritual care improves psychological comfort in older patients facing illness. This finding suggests that nurses may integrate spiritual care into their usual care to support patients experiencing distress.

Spirituality in Oncology: Relations between Spirituality, Its Facets, and Psychological and Demographic Factors in Cancer Patients in Germany

INTRODUCTION

Cancer diagnoses are constantly increasing in clinical practice. Therefore, more and more patients are interested in how they can actively participate in the process of treatment. Spirituality represents a hidden issue of the population, which counts as a branch of complementary and alternative treatment. Therefore, the aim of our study was to investigate whether there are associations between spirituality and demographic and psychosocial factors, as well as religious beliefs, in cancer patients.

METHODS

We conducted a survey with 451 participants in 10 oncology centers between March and July 2021. A composition of the following 9 different questionnaires was used to collect data on spirituality, demographics, resilience, self-efficiency, life satisfaction, and sense of coherence: Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp12), General Life Satisfaction Short Scale (L-1), Resilienzskala Kurzform (RS-13), Sense of Coherence Scale - Leipziger Kurzform (SOC-L9), Allgemeine Selbstwirksamkeit Kurzskala (AKSU), Adolescent Food Habits Checklist, Likert-Scale of daily activities, questionnaire of the Working group Prävention und Integrative Onkologie (PRiO), and personal opinion on the cause of the disease. Calculated data and analyzed group differences using ANOVA Bonferroni were used to test associations between spirituality and the variables studied. For more detailed examination of spirituality, we took a closer look at the different components of spirituality - peace, meaning, and faith - and their relation to each other (three-factor spirituality analyses).

RESULTS

Higher spirituality scores in total as well as meaning, peace, and faith were each associated with higher levels of resilience and life satisfaction. Higher religious belief was found to be associated with higher spiritual attitudes. High personal self-efficiency was found in people with higher spiritual beliefs in general as well as higher meaning and peace. Meaning and peace emerge as essential components of spiritual well-being and show a stronger association with expressions of general spirituality than faith.

CONCLUSION

Spirituality takes a crucial role among the resources of life-threatening diseases. As such, further research is needed to expand and integrate patient options into a modernized concept of care. Our data indicate that higher spiritual well-being is associated with a more tolerant approach to illness. Thus, addressing spiritual needs in therapy is associated with better psychological adjustment to the individual situation and reduces negative distress. To promote spiritual needs in the future, cognitive as well as affective components of spirituality should be emphasized.

Coping Strategies and Associated Symptom Burden Among Patients With Advanced Cancer

BACKGROUND

Few studies examine how patients with advanced cancer cope with stress. The objective of our study was to evaluate coping strategies adopted by patients with cancer and their relationship with symptom burden.

METHODS

A secondary data analysis of a prospective cross-sectional survey of patients with cancer and tobacco use was conducted, which examined demographics, symptom burden (Edmonton Symptom Assessment System), and coping strategies (the Brief COPE Questionnaire). Demographic characteristics were summarized by standard summary statistics; we also examined associations between patient characteristics and coping strategies using t-test, rank-sum test, chi-squared test, or Fisher's exact test depending on the distribution of data.

RESULTS

Among 399 patients, the majority were female (60%), Caucasian (70%), the mean age was 56.5 (±12.0) years, and the most common malignancies were gastrointestinal (21%) and breast (19%). Patients with cancer adopted multiple adaptive coping strategies, most frequently acceptance (86.7%) and emotional support (79.9%), with humor (18.5%) being the least. Common maladaptive strategies included venting (14.5%) and self-distraction (36.6%), while substance use (1.0%) was infrequently reported. Of the adaptive strategies, female gender was significantly associated with higher engagement with emotional and instrumental support, positive reframing, religious coping, and acceptance (P < .05 for all). College educated patients reported significantly higher implementation of humor, planning, and acceptance. Maladaptive coping strategies such as denial were associated with increased pain and depression, while patients adopting emotional-focused strategies rated decreased emotional distress.

CONCLUSIONS

The majority of patients with advanced cancer reported adopting multiple, adaptive coping strategies, and a minority utilized maladaptive or avoidant strategies, rarely substance use, and may need additional psychological support.

The role of patients' stories in medicine: a systematic scoping review

BACKGROUND

Patients' stories provide Palliative Care physicians with a glimpse into the former's lives and their psycho-emotional, sociocultural, and contextual considerations. Yet, few physicians are trained to interpret and apply patients' stories in their practice. Inherent variability in how stories are transmitted and interpreted raises questions over their potential effects on care. Amidst a dearth of accounts in Palliative Care, we map current use of patient stories to guide the training, assessment, and oversight of this 'care influencing' practice in medicine.

METHODS

This systematic scoping review was guided by the Systematic Evidence-Based Approach (SEBA) to ensure a reproducible and structured approach. The themes and categories identified through the Split Approach's concurrent and independent thematic and directed content analyses provided a comprehensive sketch of the included articles. The Jigsaw Perspective combined the themes and categories identified. The last stage of SEBA compared these results with two recent reviews of storytelling to ensure consistency of the domains created that guided the discussion.

RESULTS

Ten thousand two hundred seven articles were reviewed, 963 full text articles were evaluated, and 199 articles were included. The four domains identified were study characteristics, benefits, approaches, and positive effects and concerns.

CONCLUSION

Stories support patient-centered, personalized, and holistic clinical care. However, variability in the stories, their interpretations and use in care decisions underscore the need for further study on the structuring, teaching, assessing, and delivery of this 'care influencing' practice.

Finding the Hidden Professional Culture of Mental Health Nursing-Spiritual Care for Individuals with a Co-morbid Life-Limiting Illness

People with severe mental illness are dying up to thirty years earlier than the general population. The limited literature on their experience of dying indicates that they often suffer from inequities in their access to healthcare services, and further, what care they do receive is frequently poor. Living with both a mental illness and facing death can engender spiritual concerns and dying at a younger age is a risk factor for spiritual despair. Hence, addressing spiritual concerns can be an important dimension of mental health nursing care. The aim of this ethnographic study of 11 senior and experienced mental health nurses was to determine if the culture of the mental health service impacted their spiritual care for those patients who were facing death. The data highlighted that the nurses felt comfortable in providing spiritual care when the person was suffering from psychosis. Yet, the results also revealed that nurses felt disempowered by the dominance of the biomedical culture, in which they felt unable to articulate their care. However, it was identified that their spiritual care was inherent within the professional values, knowledge, and skills of mental health nursing and framed through their therapeutic relationships. Therefore, strategies need to be used by the organization to assist nurses to reclaim their power and assist the mental health service to further develop and engage in spiritual care practices.

Assessing suffering of patients on cancer treatment and of those no longer treated using ESAS-Total Care (TC)

AIM

The aim of the study was to assess the suffering of patients on oncologic treatment and of those no longer on treatment. Preliminarily, we aimed to confirm the psychometric properties of Edmonton Symptom Assessment System-Total Care (ESAS-TC) in different stages of the disease. The ESAS-TC screens physical and psychological symptoms, but also spiritual pain, discomfort deriving from financial problems associated with illness, and suffering related to social isolation.

METHODS

A sample of consecutive advanced cancer patients on oncologic therapies treated at the Internistic and Geriatric Supportive Care Unit (IGSCU) of Istituto Nazionale dei Tumori, Milano, and of terminal patients no longer on treatment and cared for by the Fondazione ANT palliative home care team were asked to fill the ESAS-TC. In order to strengthen the previous validation study of the ESAS-TC, 3-ULS (to assess social isolation), JSWBS (to assess spiritual well-being), COST-IT (to assess financial distress), and KPS (to assess functional status) were administered too.

RESULTS

The questionnaires were self-reported by 108 patients on treatment (52% >60 years old, female 53%, and 61% with KPS 90-100) and by 94 home care patients (71% >60 years old, female 51%, and 68% with KPS 10-50). The sound psychometric characteristics of ESAS-TC were confirmed. Patients on treatment showed lower total ESAS-TC score (19.3 vs 52.7, p<.001) after controlling for age and functional status, and lower financial distress (p.<001). Financial distress, spiritual suffering, and social isolation, after controlling for age, showed a significantly higher score in home care patients.

CONCLUSIONS

Only through an adequate routine assessment with validated tools is it possible to detect total suffering, the "Total pain" of patients, and treat it through a multidisciplinary approach. The study confirms the reliability and validity of the Italian version of ESAS-TC and the importance of supportive and early palliative care fully integrated with oncological treatment.

The effect of physical and psychological symptoms on spiritual well-being and emotional distress in inpatient cancer patients

PURPOSE

This study was conducted to examine the effects of physical and psychological symptoms seen in inpatient cancer patients on spiritual well-being and emotional distress.

METHOD

This descriptive and cross-sectional study was conducted with 98 cancer patients treated in oncology, haematology, and stem cell services at a university hospital between April and June 2022. Socio-demographic characteristic form, Karnofsky performance scale, Nightingale Symptom Assessment Scale, Hospital Anxiety and Depression Scale, distress thermometer and spiritual well-being scale were used to collect data. Statistical analyses were made by taking the descriptive features of the data.

RESULTS

It was determined that 55.1% of the patients were diagnosed with cancer for more than one year, 53.1% receiving treatment for more than one year, 61.2% were diagnosed with haematological cancer, and 62.2% were treated only with chemotherapy. Cancer type (p<0.01), treatment (p<0.05) and Karnofsky scores (p<0.01) had an effect on the spiritual well-being and distress scores. It was determined that 39.8% of the patients were in the yellow zone of the distress thermometer, could not manage their stress well and needed psychological support. As the psychological symptoms of the patients increased, their spiritual well-being declined (r=-0.447, p<0.01), and as their physical (r=0.222, p<0.05) and psychological (r=0.311, p<0.01) symptoms increased, their distress scores increased.

CONCLUSION

It is anticipated that identifying the problems that patients have and making interventions to solve those problems by oncology nurses would significantly contribute to the patient's spiritual well-being and emotional distress.

Spiritual coping strategies: Relationship with physical, anxiety, and depression symptoms of patients with cancer

Introduction

Spirituality is considered an important source against chronic diseases and can promote self-esteem, mental comfort, and hope in patients. Concerning its importance, the present study aims to investigate spiritual coping strategies and its relationship with physical, anxiety, and depression symptoms of patients with cancer who are referred to the oncologic ward.

Method

This was a descriptive-correlative study that 159 patients with cancer participated in the study. Information was collected using a four-part questionnaire including sociodemographic characteristics, Spiritual Coping Strategies Scale, physical symptoms as well as anxiety and depression symptoms. Data were analyzed using the Mann-Whitney U test, Kruskal-Wallis, and Spearman correlation coefficient.

Results

Results of the study showed that the mean (±SD) of the application of methods of spiritual coping strategies was 35.69 ± 10.92 and for its subscales the mean (±SD) of the application of religious coping and nonreligious coping strategies were 16.92 ± 5.6 and 18.77 ± 6.24, respectively. Furthermore, physical symptoms perceived by patients were tiredness, drowsiness, and lack of appetite. There was no significant correlation between physical, anxiety, and depression symptoms and spiritual coping strategies (r = -0.12, P = 0.12; r = 0.07, P = 0.41; and r = -0.05, P = 0.5 respectively).

Discussion

Regarding no significant relationship between physical, anxiety and depression symptoms and spiritual (religious and nonreligious) coping strategies in this study, belief towards cancer and cultural aspects of patients may be more essential to their sense of wellness and help them to cope with negative aspects of illness or treatment. Therefore, more study needs to be done in this area.

The effect of death education course utilizing constructivist learning theory on first grade undergraduate nursing student attitudes and coping abilities towards death: A mixed study design

Inadequate clinical preparation for palliative care is often reflected in inadequate education about death. Nursing students as nurses of the future, it is necessary to make them aware of death and overcome fear of it so that they can cope with their future careers and provide qualified and warmly care service.

OBJECTIVES

To determine the effect of death education course using constructivist learning theory on first grade undergraduate nursing student attitudes and coping abilities towards death.

DESIGN

This study was designed using a mixed-methods design.

SETTING

Two campuses of a university school of nursing in China.

PARTICIPANTS

First grade Bachelor of Nursing Science students (n = 191).

METHODS

Data collection includes questionnaires and reflective writing as after class task. Quantitative data were analyzed using descriptive statistics, the Wilcoxon Signed Rank test, and the Mann-Whitney U test. As for reflective writing, content analysis was hired to analysis.

RESULTS

The intervention group's attitude towards death tended to be neutral acceptance. The intervention group's ability to deal with death (Z = -5.354, p < 0.001) and expression of thoughts about death (Z = -3.89 b, p < 0.001) greater than that of the control group. Four themes (Awareness of death before class, Knowledge, The meaning of palliative care, New cognition) were identified from reflecting writing.

CONCLUSION

Compared with the conventional teaching, death education course utilizing constructivist learning theory was found to be a more effective method for developing students' death coping skills and reducing fear of death.

Survival as a clinical outcome and its spiritual significance in a cohort of patients with advanced central pelvic neoplastic disease undergoing total pelvic evisceration: a poorly debated issue

Background

Patients with either treatment-resistant or relapsing advanced central pelvic neoplastic disease present with a condition responsible for debilitating symptoms and consequently poor quality of life (QoL). For these patients, therapeutic strategies are very limited and total pelvic evisceration is the only option for relieving the symptoms and increasing survival. Of note, taking charge of these patients cannot be limited to increasing their lifespan but must also be aimed at improving the clinical, psychological, and spiritual conditions. This study aimed to prospectively evaluate the improvement in survival and QoL, focusing on spiritual wellbeing (SWB), in patients with poor life expectancy who underwent total pelvic evisceration for advanced gynecological cancers at our center.

Patients and methods

The QoL and SWB were assessed using the European Organisation for Research and Treatment of Cancer QoL questionnaire (EORTC QLQ-C30), EORTC QLQ-SWB32, and SWB scale, which were repeatedly administered: 30 days before surgery, 7 days after the procedure, 1 and 3 months after surgery, and then every 3 months until death or the last follow-up assessment. Operative outcomes (blood loss, operative time, hospitalization, and incidence of complications) were evaluated as secondary endpoints. The patients and their families were included in a dedicated psycho-oncological and spiritual support protocol, which was managed by specifically trained and specialized personnel who accompanied them during all phases of the study.

Results

A total of 20 consecutive patients from 2017 to 2022 were included in this study. Of these patients, 7 underwent total pelvic evisceration by laparotomy and 13 underwent laparoscopy. The median survival was 24 months (range: 1-61 months). After a median follow-up of 24 months, 16 (80%) and 10 patients (50%) were alive at 1 year and 2 years after surgery, respectively. The EORTC-QLQ-C30 scores significantly improved yet at 7 days and at 1, 3, 6, and 12 months, as compared with the preoperative values. In particular, an early improvement in pain, overall QoL, and physical and emotional functions was observed. With respect to the SWB, the global SWB item score of the EORTC QLQ-SWB32 questionnaire significantly increased after 1 month and 3 months, as compared with preoperative values (p = 0.0153 and p = 0.0018, respectively), and remained stable thereafter. The mean SWB scale score was 53.3, with a sense of low overall SWB in 10 patients, a sense of moderate SWB in eight patients, and a sense of high SWB in two patients. The SWB scale score significantly increased after 7 days, 1 month, and 3 months, as compared with the preoperative value (p = 0202, p = 0.0171, and p = 0.0255, respectively), and remained stable thereafter.

Conclusion

Total pelvic evisceration is a valid approach for improving both survival and QoL in selected patients with advanced pelvic neoplasms and poor life expectancy. Our results particularly underline the importance of accompanying the patients and their families during the journey with dedicated psychological and spiritual support protocols.

A Concept Analysis of Spiritual Pain at the End-of-Life in the Iranian-Islamic Context: A Qualitative Hybrid Model

This study aimed to explore the spiritual pain concept in the Iranian-Islamic context using a hybrid research model during 2020-2021. During the first phase, international and Iranian-Islamic literature was systematically searched and reviewed. During the second phase, the researchers referred to oncology wards, palliative care centers, and intensive care units and conducted unstructured interviews with 19 dying patients. In the third phase, attributes, and final analysis of spiritual pain was extracted from the first phase, and following the second phase, the definition of spiritual pain was finalized. The results showed that spiritual pain is a type of unique transcendental pain in the context of a continuum, rooted in human nature. At the one end of the continuum, there is the pain of deprivation from worldly pleasures (oneself, the family, and others). At the other end, there is the pain of breaking away from and striving to return to one's origin (God). Exploring spiritual pain in the Iranian-Islamic context can help develop tools and clinical guidelines and plan for the presence of specialists at the bedside to relieve this pain.

Spiritual Pain: A Symptom in Search of a Clinical Definition

We conducted a literature search to identify and compare definitions of the experiential dimension of spiritual pain. Key databases were searched, up to the year 2021 inclusive, for papers with a definition of "spiritual" or "existential" pain/distress in a clinical setting. Of 144 hits, seven papers provided theoretical definitions/descriptions; none incorporated clinical observations or underlying pathophysiological constructs. Based on these findings, we propose a new definition for "spiritual pain" as a "self-identified experience of personal discomfort, or actual or potential harm, triggered by a threat to a person's relationship with God or a higher power." Our updated definition can inform future studies in pain assessment and management.

Considerations for Pain Assessments in Cancer Patients: A Narrative Review of the Latin American Perspective

Cancer incidence in Latin America is lower than in Europe or the United States but morbidity and mortality rates are disproportionately high. A barrier to adequate pain control is inadequate pain assessment, which is a relatively easy and inexpensive metric. The objective of this narrative review is to describe pain assessment for cancer patients in Latin America. Cultural factors may influence pain perception, including contextualizing pain as noble or natural suffering and aspects of what is now called "spiritual pain." Unlike other painful conditions, cancer pain may be strongly associated with existential fear, psychosocial distress, anxiety, and spiritual concerns. Pain assessment allows not just quantification of pain intensity but may elucidate pain mechanisms involved or psychosocial aspects that may color the pain. Many current pain assessment instruments capture only pain intensity, which is but one aspect of the pain experience; some have expanded to include functional assessments, mental health status evaluations, and quality of life metrics. A quality-of-life assessment may be appropriate for cancer patients since chronic pain can severely impact function, which can in turn create a vicious cycle by exacerbating pain. The incidence of cancer in Latin America is expected to increase in the ensuing years. Better pain assessment and clinician education are needed to help manage pain in this large and growing patient population.

Benefits of Spiritual and Religious Support in the Pain Management of Cancer Patients: A Literature Scoping Review

Pain is one of the main symptoms of cancer and the most difficult to control due to its complexity as it can involve physical, psychological, social, and spiritual aspects. We proposed to summarize the scientific knowledge already published related to the influence of spirituality on pain therapy in cancer patients. Articles were searched in PubMed, SciELO, SciFinder, PsycInfo, and ScienceDirect databases using the following descriptors: "Spirituality," "Religion," "Religion," "Chronic Pain," "Pain Management" and "Cancer." A total of 68 articles were included and discussed. Most articles dealt with the influence of spirituality in palliative care, focussed on patient quality, and highlighted the importance of integrative oncology. Although few studies associated spirituality with chronic pain, most articles reported that spirituality could confer greater pain control.

A 6-Week Program to Strengthen Resiliency Among Women With Metastatic Cancer: A Randomized Clinical Trial

PURPOSE

The objective of this study was to evaluate the effect of an intervention (Growing Resilience And CouragE; GRACE) on spiritual well-being, quality of life, and general well-being in women with metastatic cancers reporting existential or spiritual distress.

PATIENTS AND METHODS

Prospective, randomized, wait-list control clinical trial. Women with metastatic cancer experiencing existential or spiritual concerns were randomized to GRACE or waitlist control. Survey data were collected at baseline, end of program, and 1-month follow-up. Participants included English-speaking women, 18 or older, with metastatic cancer, existential or spiritual concerns, and reasonable medical stability. Eighty-one women were assessed for eligibility; 10 were excluded (not meeting exclusion criteria, refusal to participate, and death). The primary outcome was spiritual well-being measured pre- and post-program. Secondary measures assessed quality of life, anxiety, depression, hopelessness, and loneliness.

RESULTS

Seventy-one women (aged 47-72) were enrolled (GRACE n = 37, waitlist control n = 34). GRACE participants demonstrated significant improvements in spiritual well-being compared to control at end of program (parameter estimate (PE), 16.67, 95% CI, 13.17, 20.16) and 1-month follow-up (PE, 10.31, 95% CI, 6.73, 13.89). Additionally, significant improvements were demonstrated in quality of life at the end of program (PE, 8.51, 95% CI, 4.26, 12.76) and 1-month follow-up (PE, 6.17, 95% CI, 1.75, 10.58). GRACE participants also demonstrated improved depression and hopelessness at follow-up, as well as improved anxiety.

CONCLUSIONS

Findings suggest the value of evidence-based psychoeducational and experiential interventions for improving the well-being and quality of life of women with advanced cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02707510.

"A Pain Deep in Your Soul (Being) that is Not Physical:" Assessing Spiritual Pain in Integrative Oncology Consultations

CONTEXT

Spiritual pain contributes to the suffering of cancer patients. However, it is unclear whether patients seen outside of palliative care report spiritual pain and its relationship with symptom burden.

OBJECTIVES

Characteristics of patients reporting spiritual pain were examined, as well as the association of spiritual pain with symptom burden and how spiritual pain affected the factor structure of the Edmonton Symptom Assessment System (ESAS).

METHODS

A retrospective chart review was conducted of integrative oncology patients who completed the PROMIS10 and a modified ESAS (ESAS-FS) including financial distress and spiritual pain (pain deep in your soul/being that is not physical). Multiple logistic regression was used to assess associations between demographics and spiritual pain. T-tests compared ESAS-FS symptoms and global health for patients endorsing spiritual pain (0 vs. ≥1). Principal component analyses (oblique rotation) were also used to determine ESAS-FS symptom clusters.

RESULTS

The sample (N = 1662) was mostly women (65%) and 39% endorsed spiritual pain at least ≥one. Men and older individuals were less likely to endorse spiritual pain (ps < 0.05). Presence of spiritual pain was associated with worse symptoms on the ESAS-FS and global health (ps < 0.001). The ESAS-FS had two symptom clusters, with the psychological factor including depression, anxiety, wellbeing, sleep, financial distress, and spiritual pain (Cronbach's alpha 0.78).

CONCLUSION

Assessing spiritual pain and understanding the effects of its presence or absence in the context of other physical and psychosocial symptoms may provide additional opportunities for preventing exacerbation of symptoms, improving quality of life, and enhancing overall experience of care.

Needs evaluation questionnaire for liver disease: a novel assessment of unmet needs in patients with chronic liver disease

Patients with chronic liver disease face debilitating complications in their daily living and constantly report several types of unmet needs, but there is a paucity of validated questionnaires to assess these needs. In this study, we present the development of the Needs Evaluation Questionnaire for Liver Diseases (NEQ-LD) for the assessment of unmet needs in patients with chronic liver disease. Two hundred eighty-six outpatients with chronic liver diseases from a single tertiary referral center completed the NEQ-LD and related validity measures. Item response theory analyses were performed and demonstrated the strong psychometric properties of the questionnaire. Differential item functioning analyses showed that the scale functions equally across groups differing for age, sex, and presence of cirrhosis, suggesting the large applicability of the NEQ-LD for the assessment of unmet needs and between-group comparisons. Criterion validity measures provided evidence that unmet needs were positively associated with measures of depression and anxiety and negatively associated with measures of subjective well-being and physical and mental health. Unmet needs were expressed by a high percentage of patients, especially in the areas of information and dialogue with clinicians. One third of the sample reported material needs. Most of the items describing unmet needs were reported more frequently by patients with cirrhosis. Conclusion: We developed a reliable, valid, and largely employable instrument that can promote patient-centered care and facilitate support services in Hepatology.

Spirituality and spiritual distress in neurologic illness

Neurologic illnesses present multiple challenges to patients and their families from the time of initial diagnosis and throughout their illness trajectory, including challenges related to accepting the diagnosis and its various impacts and anxiety about future living with their illness. Often patients and their families rely on their spirituality to cope with and to maintain meaning and dignity in the midst of disease. As a result, spiritual care provision is a critical component of holistic medical care to patients with neurologic illness. Spiritual care provision follows a generalist-specialist model, which requires all healthcare professionals involved in the care of patients facing serious illness to play a role in recognizing and addressing spiritual needs. This model is characterized by generalist spiritual care providers (e.g., nurses, physicians, social workers) who perform spiritual screenings through history taking. Chaplains function as specialist spiritual care providers and can address spiritual care more deeply. In addition, several developed psychotherapeutic approaches may be useful for patients with neurologic disease, and chaplains are especially trained to offer supportive spiritual care to patients with neurologic illnesses and their families and to work together with physicians and other members of the healthcare team as part of a holistic approach to care.

The Impact of Spiritual Well-Being on the Quality of Life of Cancer Patients: A Cross-Sectional Study

BACKGROUND

Quality of life is a multidimensional concept that involves physical, social, emotional, and functional well-being. Spirituality represents a potentially influential factor in the quality of life. This study aimed to evaluate the quality of life and spirituality among cancer patients.

METHODS

A cross-sectional study was carried out on 354 cancer patients in Palestine. A self-administered questionnaire was used for data collection. The questionnaire was made up of 4 sections: sociodemographic factors, clinical data, FACT-G, and FACIT-sp.

RESULTS

A total of 354 cancer patients with a mean age of 46.4 ± 15.3 years were enrolled in the study. The spiritual well-being of patients reported in this study was measured by using the median FACIT-Sp total score, and it was 35 (IQR: 29-42). The quality of life of patients was measured using the median of the FACT-G total score, and it was 63 (IQR: 52-85). The FACT-G score was significantly variable based on several factors including age, marital status, cancer type, presence of metastasis, presence of treatment side effects, and the period since diagnosis (P-value < .05). The FACIT-Sp total score had a significantly strong positive relationship with FACT-G total score (r = .705, P < .001). Moreover, moderate to strong significant correlations were found between spirituality and quality of life subscales.

CONCLUSIONS

Quality of life among cancer patients is affected by their basic and clinical characteristics and is highly correlated with their spirituality level. Thus, addressing palliative support through spiritual care besides primary clinical treatment is of great importance to improve the quality of life among cancer patients.

Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies

BACKGROUND

Frameworks are the conceptual underpinnings of the study. Both conceptual and theoretical frameworks are often used in palliative and end-of-life care studies to help with study design, guide, and conduct investigations. While an increasing number of investigators have included frameworks in their study, to date, there has not been a comprehensive review of frameworks that were utilized in palliative and end-of-life care research studies.

AIM

To summarize conceptual and theoretical frameworks used in palliative and end-of-life care research studies. And to synthesize which of eight domains from the National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care (fourth edition) each framework belongs to.

DESIGN

Systematic review.

DATA SOURCES

Four electronic databases (EMBASE, the Cumulative Index to Nursing and Allied Health, PsychINFO, and PubMed) were searched from July 2010 to September 2021.

RESULTS

A total 2231 citations were retrieved, of which 44 articles met eligibility. Across primary studies, 33,801 study participants were captured. Twenty-six investigators (59.1%) proposed previously unpublished frameworks. In 10 studies, investigators modified existing frameworks, mainly to overcome inherent limitations. In eight studies, investigators utilized existing frameworks referenced in previously published studies. There were eight orientations identified among 44 frameworks we reviewed (e.g. system, patient, patient-doctor).

CONCLUSIONS

We examined palliative and end-of-life research studies to identify and characterize conceptual or theoretical frameworks proposed or utilized. Of 44 frameworks we reviewed, 21 studies (47.7%) were aligned with a Clinical Practice Guideline's single domain, while the rest two or more of eight guidelines in quality palliative care domains.

Concordant palliative care delivery in advanced head and neck cancer

OBJECTIVES

To describe the palliative care consultation practices in an academic head and neck surgery practice.

METHODS

This is a retrospective review of a palliative care database and the health record for all palliative care consultations of patients suffering from advanced stage head and neck cancer within a 21-month period.

RESULTS

Ten head and neck cancer patients received palliative care consults while on the otolaryngology service. One consultation occurred preoperatively; nine occurred postoperatively, on a median of hospital day 9. At the time of referral, seven patients were in the ICU and three were on a surgical floor. Code status de-escalation occurred in six patients and psycho-socio-spiritual suffering was supported in all consultations. Nine patients died within six months, with a median post-consultation survival of 35 days. Of these, two died in an ICU, five were discharged to hospice, one to a SNF, and one to a LTACH.

CONCLUSION

Palliative care consultation in this advanced head and neck cancer cohort was commonly late, however, significant suffering was mitigated following most consults. Palliative care specialists are experts at eliciting patient values, determining acceptable tradeoffs and suffering limitations by employing a shared decision-making process that ends with a patient-centered value-congruent treatment recommendation. Oftentimes, this embraces curative-intent or palliative surgery, along with contingency plans for unacceptable value-incongruent postoperative outcomes. Enhanced awareness of the benefits of embracing concordant palliative care in advanced head and neck cancer patients may help overcome the significant barriers to involving palliative care experts earlier.

Parental Views of Social Worker and Chaplain Involvement in Care and Decision Making for Critically Ill Children with Cancer

Background: Social workers (SWs) and chaplains are trained to support families facing challenges associated with critical illness and potential end-of-life issues. Little is known about how parents view SW/chaplain involvement in care for critically ill children with cancer. Methods: We studied parent perceptions of SW/chaplain involvement in care for pediatric intensive care unit (PICU) patients with cancer or who had a hematopoietic cell transplant. English- and Spanish-speaking parents completed surveys within 7 days of PICU admission and at discharge. Some parents participated in an optional interview. Results: Twenty-four parents of 18 patients completed both surveys, and six parents were interviewed. Of the survey respondents, 66.7% and 75% interacted with SWs or chaplains, respectively. Most parents described SW/chaplain interactions as helpful (81.3% and 72.2%, respectively), but few reported their help with decision making (18.8% and 12.4%, respectively). Parents described SW/chaplain roles related to emotional, spiritual, instrumental, and holistic support. Few parents expressed awareness about SW/chaplain interactions with other healthcare team members. Conclusions: Future work is needed to determine SWs’/chaplains’ contributions to and impact on parental decision making, improve parent awareness about SW/chaplain roles and engagement with the healthcare team, and understand why some PICU parents do not interact with SWs/chaplains.

Prospective feasibility study of a mindfulness-based program for breast cancer patients in the southeastern US

BACKGROUND

Mindfulness interventions can improve psychological distress and quality of life (QoL) in cancer survivors. Few mindfulness programs for cancer recovery exist in Southeastern U.S. The primary objective of this study was to assess the feasibility of a modified mindfulness-based stress reduction (MBSR) program for breast cancer patients in Birmingham, Alabama. The secondary objective was to explore potential program effects on mindfulness skills and QoL.

METHODS

This study was a prospective, quasi-experimental feasibility study conducted over 10 months at a university hospital. Feasibility was achieved if 80% of eligible patients screened enrolled in the study and 70% of enrolled patients attended all 8 program sessions. Effectiveness was estimated by changes in mindfulness and QoL indicators measured with validated scales administered at 3 time points and assessed with a non-parametric Friedman test. Sessions included meditation, yoga, and an attention practice called body scan. There were 3 groups of 2-5 patients.

RESULTS

The sample totaled 12 patients. Forty-four percent (12/27) of eligible patients enrolled in the study, and two out of 12 enrolled patients completed 8 program sessions, resulting in 16.7% (2/12) retention. However, more than half (66.7%) of participants completed at least 7 sessions. Between baseline and 8-week follow-up, patients demonstrated statistically significant improvements in distress, general wellbeing, and fatigue-related QoL.

CONCLUSIONS

Feasibility objectives were not achieved. However, a majority of participants (66.7%) completed 7 of 8 program sessions. Program effects were promising for distress, fatigue, and wellbeing. Results warrant further research on MBSR-like programs for breast cancer patients in Alabama.

Gender Differences in Coping, Depression, and Anxiety in Patients with Non-Metastatic Lung Cancer

Background

Depression and anxiety are prevalent issues amongst individuals suffering from thoracic cancer. Gender differences in coping with thoracic cancer have a serious impact upon the management of emotional distress. The purpose of our study has been to assess sex variations in handling anxiety and depression, including the use of coping mechanisms and their relationship with respect to anxiety and depression.

Methods

This cross-sectional study registered 18 women and 22 men with non-metastatic lung cancer and operated upon. Pre-operatively and at one month post-operatively, the patients were assessed by means of scales (COPE, GAD-7 and PHQ-9).

Results

Post-operatively, the intensity of depression and anxiety was substantially greater in males than in females (p = 0.049, p = 0.042). Male individuals tended to use coping mechanisms of humour (p = 0.009) and restraint (p = 0.029) significantly more frequently than women. Moreover, in women, depression correlated significantly with denial and behavioural deactivation (rho = 0.465, p = 0.029, respectively, rho = 0.562, p = 0.006); whilst anxiety, similarly, correlated with positive interpretation, behavioural deactivation, and use of social-emotional support (rho = 0.484, p = 0.022, respectively, rho = 0.590, p = 0.004 and rho = 0.502, p = 0.017). Furthermore, in males, depression correlated significantly with mental deactivation, use of social-instrumental and social-emotional support (rho = 0.702, p = 0.001, respectively, rho = 0.505, p=0.033, and rho = 0.773 with p < 0.001), whilst anxiety correlated significantly with mental deactivation, denial, and use of social-emotional support (rho = 0.597, p = 0.009, respectively, rho = 0.553 with p = 0.017 and rho = 0.755, p < 0.001).

Conclusion

There were gender divergences in the use of coping mechanisms and the level of post-surgical anxiety and depression. We found significant positive relationships between some coping mechanisms and depression/anxiety. The patient’s gender governs the coping style, which in turn has bearing upon the post-operative evolution.

Is spiritual well-being related to survival time of inpatients with advanced cancer? An East Asian cohort study

OBJECTIVES

It has been suggested that psychosocial factors are related to survival time of inpatients with cancer. However, there are not many studies examining the relationship between spiritual well-being (SWB) and survival time among countries. This study investigated the relationship between SWB and survival time among three East Asian countries.

METHODS

This international multicenter cohort study is a secondary analysis involving newly admitted inpatients with advanced cancer in palliative care units in Japan, South Korea, and Taiwan. SWB was measured using the Integrated Palliative Outcome Scale (IPOS) at admission. We performed multivariate analysis using the Cox proportional hazards model to identify independent prognostic factors.

RESULTS

A total of 2,638 patients treated at 37 palliative care units from January 2017 to September 2018 were analyzed. The median survival time was 18.0 days (95% confidence interval [CI] 16.5-19.5) in Japan, 23.0 days (95% CI 19.9-26.1) in Korea, and 15.0 days (95% CI 13.0-17.0) in Taiwan. SWB was a significant factor correlated with survival in Taiwan (hazard ratio [HR] 1.27; 95% CI 1.01-1.59; p = 0.04), while it was insignificant in Japan (HR 1.10; 95% CI 1.00-1.22; p = 0.06), and Korea (HR 1.02; 95% CI 0.77-1.35; p = 0.89).

SIGNIFICANCE OF RESULTS

SWB on admission was associated with survival in patients with advanced cancer in Taiwan but not Japan or Korea. The findings suggest the possibility of a positive relationship between spiritual care and survival time in patients with far advanced cancer.

Spiritual Care Needs of Patients in Oncology Units and Nursing Practices in Turkey: A Qualitative Study

This descriptive qualitative study was planned to determine the spiritual care needs of patients hospitalized in the oncology department and nursing care practices. Twenty-five patients and 15 nurses were interviewed. Concerning the spiritual care practices expected from nurses, the following themes were determined: Interest-Compassion, Smiling Face, Confidence, Being Informative, Morale, and Understanding. The themes for spiritual nursing practices were Chatting-Suggesting, Smiling Face, Giving Opportunities for Religious Practice, Love and Belonging, Giving Hope-Precedent Examples, and Giving Information. Patients expected nurses to ask about their spiritual needs. However, nurses did not ask about spiritual issues because they were afraid of affecting patients adversely.

Pain and Spiritual Distress at End of Life: A Correlational Study

Objective: The purpose of this study is to examine the relationship between unmanaged pain and spiritual distress in adults newly admitted to hospice. Background: Current evidence supports the presence of a positive relationship between increased physical pain and spiritual distress for those with advanced cancer and/or receiving palliative care services. Nonetheless, spiritual distress remains a relatively understudied area; anecdotally, assessment and management of physical symptoms often take precedence over interventions for spiritual distress in patients at end of life (EOL) on hospice. Further research is needed to examine the relationships between physical pain, spiritual distress, and factors such as age, gender, and religious affiliation/spiritual practice specific to EOL patients receiving home hospice care. The Total Pain Model underpins this study. Methods: In this cross-sectional correlational study, pre-existing data were extracted from a hospice agency's electronic health record (EHR) to examine age, gender, marital status, race/ethnicity, religious affiliation and/or spiritual practice, hospice diagnosis, pain severity, and spiritual distress in adult patients (age 18 and over) admitted to home hospice services (N = 3484). Descriptive, bivariate, and multivariate analyzes were conducted. Results: The age range for this sample was 25 to 107 years old (M = 82, SD = 12.08). Over half of the sample were female and white. One third of the patients were married or had a designated life partner. Over 85% identified as either Catholic or Protestant. Sixteen percent reported moderate to severe pain and 9.6% experienced spiritual distress. Marital status (χ² (3, N = 2483) = 20.21, P < .001, Cramer's V = .09), hospice diagnosis (χ² (5, N = 3481) = 22.66, P < .001, Cramer's V = .08), pain severity (χ² (1, N = 3464) = 19.75, P < .001, Cramer's V = .08), and age (t (393.17) = 2.84, P = .005, d = .17) were significantly related to spiritual distress. The binary logistic model was statistically significant, χ² (11) = 45.25, P < .001, and cases indicating the highest odds of experiencing spiritual distress had pulmonary disease (OR = 1.8, P = .02), were single (OR = 1.6, P = .02), and had moderate to severe pain (OR = 1.4, P = .04). Conclusions: Moderate to severe pain, marital status, and diagnosis should be considered for inclusion in a refined spiritual distress hospice admission screening process. Future research should examine the unique contributions of diagnosis in predicting spiritual distress, particularly pulmonary disease.

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.

Cross Cultural Adaptation and Cognitive Testing of a Psycho-Social-Spiritual Healing Measure, the NIH Healing Experiences in All Life Stressors-NIH-HEALS

Background

Cancer is associated with trauma and stress which impacts the physical, psychological, and spiritual/existential well-being of patients. Psychological/behavioral healing may help alleviate this distress and the associated health-related suffering. Psycho-Social-Spiritual healing outcome measures are thus needed to stimulate service development. The NIH Healing Experiences in All Life Stressors (NIH-HEALS), is a novel 35-item measure of psycho-social-spiritual healing, developed in USA and is yet to be validated and adapted for use in African countries.

Objectives

This study aimed to assess the face and content validity of the NIH-HEALS in the population of cancer patients in Uganda and to culturally adapt this measure.

Methods

Cross-sectional study using cognitive interviewing alongside standard piloting. We recruited adult (18 years and above) patients with advanced cancer from Hospice Africa Uganda. Interviews were conducted in two phases, using the think aloud technique and concurrent probing and were audio recorded. Phase 1 was used to identify initial concerns around clarity of the statements, and phase 2 further explored whether the issues of clarity had been addressed, alongside the standard cognitive interview parameters. The transcripts were imported into NVivo-12 analyzed using the content analysis technique and categorized using Tourengeau’s information processing model.

Results

We recruited thirty-five (35) patients: phase one (n = 5) two (n = 30). The median completion time was 20 minutes. Problems identified included comprehension of some statements, words, and phrases, suggestions to include local examples, highlighting of potentially sensitive statements that lean towards difficult conversations, and some cultural differences in the construction of the “Trust and Acceptance” construct, our sample showed less emphasis on family/friend relations. This feedback was used to adapt the NIH-HEALS for the local context.

Conclusion

The NIH-HEALS has sufficient face and content validity properties to be used among palliative cancer patients in Uganda. We propose some changes to inform the adaptation of this measure for the local context.

Verbalizing spiritual needs in palliative care: a qualitative interview study on verbal and non-verbal communication in two Danish hospices

Denmark is considered one of the World's most secular societies, and spiritual matters are rarely verbalized in public. Patients report that their spiritual needs are not cared for sufficiently. For studying spiritual care and communication, twelve patients admitted to two Danish hospices were interviewed. Verbal and non-verbal communication between patients and healthcare professionals were identified and analysed. Methodically, the Interpretative Phenomenological Analysis was used, and the findings were discussed through the lenses of existential psychology as well as philosophy and theory of caring sciences. Three themes were identified: 1. When death becomes present, 2. Direction of the initiative, and 3. Bodily presence and non-verbal communication. The encounter between patient and healthcare professional is greatly influenced by sensing, decoding, and interpretation. A perceived connection between the patient and the healthcare professional is of great importance as to how the patient experiences the relationship with the healthcare professional.The patient's perception and the patient's bodily experience of the healthcare professional are crucial to whether the patient opens up to the healthcare professional about thoughts and needs of a spiritual nature and initiates a conversation hereabout. In this way we found three dynamically connected movements toward spiritual care: 1. From secular to spiritual aspects of care 2. From bodily, sensory to verbal aspects of spiritual care and 3. From biomedical to spiritual communication and care. Thus, the non-verbal dimension becomes a prerequisite for the verbal dimension of spiritual communication to develop and unfold. The behaviour of the healthcare professionals, characterised by the way they move physically and the way they touch the patient, was found to be just as important as verbal conversation when it comes to spiritual care. The healthcare professional can create a connection to the patient through bodily and relational presence. Furthermore, the healthcare professionals should let their sensing and impressions guide them when meeting the patient in dialog about matters of a spiritual nature. Their perception of the patient and non-verbal communication are a prerequisite for being able to meet patient's spiritual needs with care and verbal communication.

Meaning-Centered Pain Coping Skills Training: A Pilot Feasibility Trial of a Psychosocial Pain Management Intervention for Patients with Advanced Cancer

Background: Pain from advanced cancer can greatly reduce patients' physical, emotional, and spiritual well-being. Objective: To examine the feasibility and acceptability of a behavioral pain management intervention, Meaning-Centered Pain Coping Skills Training (MCPC). Design: This trial used a single-arm feasibility design. Setting/Subjects: Thirty participants with stage IV solid tumor cancer, moderate-to-severe pain, and clinically elevated distress were enrolled from a tertiary cancer center in the United States. The manualized protocol was delivered across four 45- to 60-minute videoconference sessions. Measurements: Feasibility and acceptability were assessed through accrual, session/assessment completion, intervention satisfaction, and coping skills usage. Participants completed validated measures of primary outcomes (i.e., pain severity, pain interference, and spiritual well-being) and secondary outcomes at baseline, post-intervention, and four-week follow-up. Results: Eighty-eight percent (38/43) of patients who completed screening met inclusion criteria, and 79% (30/38) consented and completed baseline assessment. Sixty-seven percent (20/30) of participants were female (mean age = 57). Most participants were White/Caucasian (77%; 23/30) or Black/African American (17%; 5/30) with at least some college education (90%; 27/30). Completion rates for intervention sessions and both post-intervention assessments were 90% (27/30), 87% (26/30), and 77% (23/30), respectively. At the post-intervention assessment, participants reported a high degree of intervention satisfaction (mean = 3.53/4.00; SD = 0.46), and 81% (21/26) reported weekly use of coping skills that they learned. Participants also showed improvement from baseline on all primary outcomes and nearly all secondary outcomes at both post-intervention assessments. Conclusions: MCPC demonstrated strong feasibility and acceptability. Findings warrant further evaluation of MCPC in a randomized controlled trial. ClinicalTrials.gov Identifier: NCT03207360.

Top Ten Tips Palliative Care Clinicians Should Know About Spirituality in Serious Illness

Assessment of spiritual suffering and provision of spiritual care are a central component of palliative care (PC). Unfortunately, many PC clinicians, like most medical providers, have received limited or superficial training in spirituality and spiritual distress. This article, written by a group of spiritual care providers, and other PC and hospice clinicians, offers a more in-depth look at religion and spirituality to help to enhance readers' current skills while offering a practical roadmap for screening for spiritual distress and an overview of partnering with colleagues to ensure patients receive values-aligned spiritual care provision.

Spirituality in Primary Palliative Care and Beyond: A 20-Year Longitudinal Qualitative Study of Interacting Factors Impacting Physicians' Spiritual Care Provision Over Time

CONTEXT

Spiritual care (SC) is central to palliative care. However, a mismatch between patients' desire for SC and physicians' SC provision remains. The shortage of specialty-trained palliative physicians, necessitates that all physicians provide primary palliative care, including SC. Although several quantitative studies explore physicians' barriers to SC, few qualitative studies and no longitudinal studies exist.

OBJECTIVE

To gain in-depth understanding of factors influencing physicians' ability to provide SC over time.

METHODS

A 20-year longitudinal, individual interview study. In study year-1, we interviewed all residents in a USA primary care residency (full study-group) regarding SC beliefs, experiences and skills. The longitudinal study-group (PGY1 subgroup) was interviewed again in study-years 3, 11, and 20. Interviews were audio-recorded and transcribed. Four researchers analyzed transcripts using a grounded theory approach. IRB approval was obtained.

RESULTS

We analyzed 66 interviews from 34 physicians. Physicians had diverse personal spiritual beliefs. Seven themes emerged from both groups (response rate 89%): patients' needs; practice setting; beliefs regarding physician's role; personal spiritual beliefs; SC training; life experiences (professional, personal); self-care and reflection. Longitudinal interviews revealed thematic evolution and interactions over 20-years: patients' needs and physicians' belief in whole-person care remained primary motivators; cross-cultural SC communication training diminished impact of personal spiritual beliefs and worries; life experiences enhanced SC skills; work environment helped or hindered SC provision; and spiritual self-care/reflection fostered patient-centered, compassionate SC.

CONCLUSION

Facilitating SC provision by nonpalliative care specialists is complex and may require both individual and systems level interventions fostering motivation, SC skill development, and supportive work environments.

Gender Differences in Psychosocial, Religious, and Spiritual Aspects in Coping: A Cross-Sectional Study with Cancer Patients

Background: There is a growing awareness of religiosity and/or spirituality (R/S) as a possible resource in coping with cancer. Gender differences in religious coping have not yet been thoroughly examined. This study aimed to analyze differences in religious coping between men and women with cancer and compare the impact of R/S on anxiety and depression symptoms.

Methods: This cross-sectional study was conducted at the Divisions of Hematology and Oncology of the Medical University of Vienna. In total, 352 patients with a cancer diagnosis, who regarded themselves as religious and/or spiritual, were interviewed at Vienna's university hospital with standardized questionnaires. To answer our research questions, we used the Hospital Anxiety and Depression Scale (HADS), the Benefit Through Spirituality/Religiosity (Benefit) questionnaire, and collected demographic characteristics.

Results: Of 689 cancer patients, 51% (352) regard themselves as religious and/or spiritual. Women with cancer tend toward R/S more significantly (57%) than men (45%). In patients with an R/S belief, women scored higher in almost all items of the Benefit questionnaire and showed higher prevalence of anxiety (p < 0.001) and depression than men. Regarding the socioeconomic characteristics, more women were widowed, and had significantly lower income than men.

Conclusions: The results show a significant gender gap concerning the importance of R/S for cancer patients and the effect on psychological well-being.

Women in this study were more religious/spiritual than men and scored higher on anxiety and depression. We support the notion that the gender perspective is essential and can contribute to better patient care in identifying gender-specific concerns.

Development of a One-item Screening Question to Assess Spiritual Well-Being for Advanced Cancer Inpatients in Korea

CONTEXT

Spiritual well-being (SWB) is significant for patients with life-limiting illnesses. Thus, shortened versions of questions would be helpful in approaching SWB.

OBJECTIVES

Our goal was to develop a one-item screening question to assess the SWB of advanced cancer inpatients.

METHODS

This was a cross-sectional, multicenter study involving adult advanced cancer inpatients from seven palliative care units in South Korea. The candidate one-item questions were three questions scored using numeric rating scales from 0 to 10: feeling at peace (Are you at peace?), self-rated spirituality (Do you think of yourself as a spiritual person?), and self-rated religiosity (Do you think of yourself as a religious person?). The Functional Assessment of Chronic Illness Therapy-Spirituality 12 (FACIT-Sp-12) comprised of two subscales Meaning/Peace and Faith was used to assess SWB. Pearson's correlation test was conducted to determine the relationship between the three questions, the total FACIT-Sp-12 score, and its subscales.

RESULTS

A total of 202 patients were enrolled. A strong correlation was observed between self-rated spirituality (r = 0.732 and 0.790; P < 0.001 and < 0.001 respectively) and religiosity (r = 0.708 and 0.758; P < 0.001 and < 0.001 respectively) with the total FACIT-Sp-12 scores and faith subscale scores. Feeling at peace showed a moderate correlation with the total of FACIT-Sp-12 scores (r = 0.505, P < 0.01). All three questions had a moderate correlation with the meaning/peace subscale.

CONCLUSION

Self-rated spirituality and religiosity showed better convergence validity than feeling at peace. Therefore, we recommend self-rated spirituality or religiosity as a one-item question for screening SWB in inpatients with advanced cancer.

Four aspects of spiritual care: a phenomenological action research study on practicing and improving spiritual care at two Danish hospices

BACKGROUND

In Denmark and internationally, there has been an increased focus on strengthening palliative care by enhancing spiritual care. Dying patients, however, do not experience their spiritual needs being adequately met.

METHODS

Through an action research study design with four consecutive stages, namely, observation in practice, reflection-on-praxis, action-in-praxis, and evaluation of the action research process involving patients and hospice staff from two hospices in Denmark, two research questions were explored: (1) How do patients and staff perceive, feel, live, practice, and understand spiritual care at hospice? and (2) How can spiritual care be improved in hospice practice? The data material presented comprised 12 individual interviews with patients and nine focus group interviews with the staff.

RESULTS

We found four aspects of spiritual care through which patients and staff seemed to perceive, feel, live, practice, and understand spiritual care at hospice, and from where spiritual care may be improved in hospice practice. These aspects constituted four themes: (1) relational, (2) individualistic, (3) embodied, and (4) verbal aspects of spiritual care.

CONCLUSION

Staff realized immanent limitations of individual aspects of spiritual care but learned to trust that their relational abilities could improve spiritual care. Embodied aspects seemed to open for verbal aspects of spiritual care, but staff were reluctant to initiative verbal dialogue. They would bodily sense values about preserving patients' boundaries in ways that seemed to hinder verbal aspects of spiritual care. During action-in-praxis, however, staff realized that they might have to initiate spiritual conversation in order to care for patients' spiritual needs.

Italian version of the Edmonton Symptom Assessment System (ESAS)-Total Care (TC): development and psychometric validation in patients undergoing cancer treatment or follow-up

INTRODUCTION

The routine use of patient-reported outcomes (PROs) in clinical practice improves quality of care, it helps in reducing the access to emergency services and unscheduled visits, and it can improve cancer patients' time survival. The Edmonton Symptom Assessment System (ESAS) is a PRO largely used in different care settings to monitor physical and psychological symptoms. Nonetheless, along with these symptoms, literature also highlighted the presence and effect of spiritual pain, financial distress, and social isolation on quality of care, treatment effectiveness, and survival.

AIM

The aims of the current study were (a) to complete the Italian version of the ESAS validation process by adding the missing symptom "insomnia" and (b) to develop and validate the ESAS-Total Care (ESAS-TC) that is intended to evaluate and screen not only physical and psychological symptoms but also spiritual pain, discomfort deriving from financial problems associated with illness, and suffering related to social isolation.

METHODS

A sample of Italian native outpatients, who referred to the dedicated Supportive Care Unit of the Fondazione IRCCS, Istituto Nazionale deiTumori (INT), Milano, were asked to fill the ESAS-TC to assess item properties, factorial structure, internal consistency, test-retest reliability (patients were asked to retake the scale after 2-6 weeks), and external validity. Concerning the latter, other self-administered scales were employed to assess perceived stress (Perceived Stress Scale), unmet needs (using theNeed Evaluation Questionnaire that describes informative, assistance/care, relational, needs for psycho-emotional support, material needs), and perceived social support (administering the Multidimensional Scale of Perceived Social Support that evaluates perceived support of family, friends, and significant others in the wider social field).

RESULTS

The scales were administered to 243 patients with solid (90%) and hematologic (10%) cancers, mean age 62.6, female 76.5%. Analysis suggested that a single factor better represents the structure of the ESAS scales, their internal consistency and test-retest reliability were good, and evidence of construct and criterion validity were provided. Additionally, incremental validity of the ESAS-TC was proved showing that the added items offer a unique contribution in predicting the patient's stress. Finally, known groups validity was confirmed testing the differences in the ESAS scores due to the Karnofsky Performance Status.

CONCLUSIONS

The current study allowed to complete the validation of the Italian version of the ESAS and to develop a psychometrically sound scale, the ESAS-Total Care, that potentially helps in moving cancer research toward personalized total cancer care.

Developing an Educational Course in Spiritual Care: An Action Research Study at Two Danish Hospices

Further improvement of spiritual care in palliative care is warranted. Particularly reducing barriers and enhancing spiritual care competencies among the healthcare professionals is needed. The aim was to develop a training course in spiritual care in close collaboration with patients and staff from two Danish hospices. We applied an action research design to ensure that the training course was rooted in everyday practice of patients and staff. The methodology applied was based on philosophical hermeneutics and existential phenomenology. The action research process enabled the division into three topics on how a training course can reduce barriers towards spiritual care among the healthcare professionals. These three topics functioned as a theoretical framework for educating staff at a hospice in spiritual care. The three topics were: (1) the vulnerable encounter; (2) self-reflection concerning spiritual needs, thoughts, beliefs, and values; and (3) shared professional language for spiritual care. We operationalized the three topics into a flexible course design that could be adaptable to the practical possibilities and limitations of the individual hospice. The curriculum includes theoretical teaching, reflection exercises, and an improvisation theater workshop with professional actors. Educating staff led to the improvement of spiritual care at the hospices involved in the study.

The Role of Religiosity in Symptom Expression of Advanced Cancer Patients

AIM

The aim of this study was to assess the religious pattern and its impact on symptom expression in patients with advanced cancer.

METHODS

A consecutive sample of advanced cancer patients screened at admission to palliative care. Standard epidemiological data were recorded. Patients were asked about their religious beliefs, the degree of social relationship to existing religions, the role of religion in their life, and the frequency of their prayer. The Edmonton Symptom Assessment Scale (ESAS) and Hospital Anxiety Depression scale (HADS) were assessed.

RESULTS

Two-hundred-eighty-three patients were screened. Age and gender were found to be independently correlated with religious belief (p = 0.042 and p = 0.016, respectively). Gender (females, p = 0.026), age (p = 0.003), lower Karnofsky performance status (KPS) (p = 0.022), and higher values of HADS-A (p = 0.003) were independently correlated with the degree of social relationship to existing religions. Gender (females, p = 0.002), lower KPS (p = 0.005), and higher values of HADS-A (p = 0.04) were independently correlated with a more relevant role of religiosity. Gender (females, p < 0.0005), lower KPS (p = 0.001), and drowsiness (p = 0.05) were independently correlated with frequency of prayer.

CONCLUSION

The more the patients have demanding religious issues, the greater the state of anxiety, particularly in older and female patients with a lower KPS. The religious pattern did not have relevant role in the expression of other symptoms included in the ESAS.

Factors related to spiritual well-being in the last days of life in three East Asian countries: An international multicenter prospective cohort study

BACKGROUND

Some factors associated with spiritual well-being in dying patients have previously been reported. However, there has been no cross-cultural study comparing factors related to spiritual well-being. The current investigation may shed light on this under-investigated area through a comparison of diverse factors.

AIM

We aimed to (1) examine factors associated with spiritual well-being in the last days and (2) compare those factors across three East Asian countries.

DESIGN

This is an international multicenter prospective cohort study.

SETTING/PARTICIPANTS

Newly admitted inpatients with far advanced cancer in palliative care units in Japan, Korea and Taiwan were enrolled. Each patient was classified into one of two groups based on spiritual well-being score in the last days of life. Univariate and multivariate analyses were performed to identify the factors related to better spiritual well-being score in each country.

RESULTS

A total of 1761 patients treated at 37 palliative care units from January 2017 to September 2018 were analyzed. Seven variables were significant in Japan, three in Korea, and five in Taiwan. "Good death scale [acceptance]," "fatigue" and "expressed wish for hastened death" were unique in Japan. "Visit from a pastoral care worker within 48 h of death" was unique in Korea. "Patient's preferences for place of death," "dyspnea" and "continuous deep sedation" were unique in Taiwan.

CONCLUSIONS

This study found novel factors related to spiritual well-being in the last days of life, several of which differed according to country. Recognition of factors associated with spiritual well-being can improve the quality of palliative care.

Spiritual Care Assessment and Intervention (SCAI) for Adult Outpatients With Advanced Cancer and Caregivers: A Pilot Trial to Assess Feasibility, Acceptability, and Preliminary Effects

BACKGROUND

Although religion and spirituality are important to adults with cancer and their family caregivers, few studies have tested spiritual care interventions in the outpatient setting.

AIM

To determine the feasibility, acceptability, and preliminary effects of chaplain-delivered, semi-structured spiritual care to adult outpatients with advanced cancer and their caregivers.

DESIGN

In this pre/post pilot intervention study, board-certified chaplains utilized the Spiritual Care Assessment and Intervention (SCAI) framework during 4 individual sessions. Surveys at baseline and at 1, 6, and 12 weeks post-intervention assessed spiritual well-being, quality of life, depression, anxiety, and religious coping.

SETTING/PARTICIPANTS

We enrolled U.S. adult outpatients with or without an eligible family caregiver. Eligible patients were at least 18 years old and at least 2 weeks post-diagnosis of incurable and advanced-stage lung or gastrointestinal (GI) cancer.

RESULTS

Of 82 eligible patients, 24 enrolled (29.3%); of 22 eligible caregivers, 18 enrolled (81.8%). Four planned chaplain visits were completed by 87.5% of patients and 77.8% of caregivers. All enrolled participants completed baseline surveys, and more than 75% completed follow-up surveys at 2 of 3 time points. More than 80% of patients and caregivers reported they would recommend the sessions to a friend or family member. Patients' spiritual well-being improved significantly at all timepoints compared to baseline: 1-week post (p < .006), 6-weeks post (p < .001), and 12-weeks post (p < .004).

CONCLUSIONS

Spiritual care through SCAI is feasible, acceptable, and shows promise in improving spiritual well-being and other important outcomes in advanced-stage cancer patients and family caregivers. Further investigation is warranted.

Prevalence, Predictors and Correlates of Religious and Spiritual Struggles in Palliative Cancer Patients

CONTEXT

Religion and spirituality (r/s) are important resources in coping with cancer. However, there are aspects of r/s, such as religious and spiritual struggles, found to be associated with poorer outcomes. A new measure has been adapted from the Religious and Spiritual Struggles Scale (RSS) to assess r/s struggles: the RSS-14. This concise measure allows for the assessment of multiple types of r/s struggles for people from different religious backgrounds or none.

OBJECTIVES

The aim of the present study was to examine the prevalence, predictors and correlates of r/s struggles as measured by the RSS-14 and its subdomains in a cancer population receiving palliative care.

METHODS

Data were collected from six outpatient palliative care services across the US. Inclusion criteria for patients were age 55 or older with a cancer diagnosis. In addition to demographic and r/s characteristics, study measures included the Edmonton Symptom Assessment Scale (ESAS), the Patient Dignity Inventory (PDI) and the Quality of Life at the End of Life (QUAL-E).

RESULTS

The study included 331 participants. Some r/s struggle was reported by 66%, moderate to high struggle for at least one item was reported by 20% of the patients. In bivariate analyses, r/s struggle was associated with greater symptom burden, greater dignity-related problems and poorer quality of life; in multivariable analyses, dignity-related problems remained a predictor of total r/s struggle.

CONCLUSION

R/S struggles may compromise well-being for cancer patients receiving palliative care. Clinicians should consider periodic screening for r/s struggles and referrals for spiritual care if indicated.

Explaining the Process of Spiritual healing of Critically-ill Patients: A Grounded Theory Study

Background

Spiritual healing is one of the most intriguing category of alternative and complementary medicine. The aim of this study was to explain the process of spiritual healing in patients with refractory diseases in Iran.

Methods

This grounded theory study was conducted in Iran from 2018 to 2019. The participants were 14 patients with refractory diseases and 4 healers whom were first selected through purposeful and then theoretical sampling. Semi-structured interviews were used to collect data on patients and healers. All the interviews were transcribed verbatim. Data were coded and grouped under specific categories and analyzed using the Strauss and Corbin's approach (2008).

Results

Four main categories emerged from data analysis including: I) frustration to initial acceptance II) disbelief to trust III) evaluation to action and IV) doubt to certainty.

Conclusion

The results of our study provide context-specific factors affecting the complex and multifactorial nature of spiritual healing process in patients with refractory diseases. Health care professional can use these findings in designing and implementing appropriate interventions to integrate spiritual healing into their holistic practices of care.

Exploring the Meaning of Spirituality and Spiritual Care with Help From Viktor Frankl

Problem: A difficult concept to understand, spirituality is not often addressed in healthcare. Purpose: This paper will explore the concept of spirituality and spiritual care using the theory of meaning by Viktor Frankl. Implications: Authors will provide ways for nurses to think about spiritual needs and spiritual care for patients and identify barriers to spiritual care implementation. Suggestions are made for spiritual inquiry, resources are provided for spiritual care education and training, and recommendations are made for nursing education curricula and health care policy change. Conclusions: With a greater understanding of spirituality, nurses practicing holistic care can increase their spiritual care competence and implement spiritual care into practice.

Spiritual distress: symptoms, quality of life and hospital utilisation in home-based palliative care

OBJECTIVES

The purpose of this study was to use a spiritual screening question to quantify the prevalence of spiritual distress (SD) in a large cohort of seriously ill patients at admission to home-based palliative care (HBPC) and to examine the associations between SD with symptom burden, quality of life and hospital-based utilisation up to 6 months after admission to HBPC.

METHODS

Data for this cohort study (n=658) were drawn from a pragmatic comparative-effectiveness trial testing two models of HBPC. At admission to HBPC, SD was measured using a global question (0-10-point scale: none=0; mild=1-4; moderate-to-severe=5+); symptoms and quality of life were measured with the Edmonton Symptom Assessment Scale (ESAS) and PROMIS-10. Hospital utilisation was captured using electronic records and claims. Median regression and proportional hazard competing risk models assessed the association between SD with symptoms and quality of life, and hospital utilisation, respectively.

RESULTS

Nearly half of the patients/proxies reported some level of SD. Increasing SD was significantly associated with higher symptom burden (increase of 7-14 points on ESAS) and worse mental well-being (decrease of 2.7 to 4.6 points on PROMIS-10-mental) in adjusted models. Compared with patients/proxies who reported no SD, those with at least some level of SD were not at increased risk for hospital-based utilisation over a median follow-up period of 2 months.

CONCLUSION

While SD is cross-sectionally associated with worse symptoms and mental well-being, it did not predict downstream hospital-based utilisation. Our results highlight the importance of assessing for and managing SD in patients with serious illness.

Essential Package of Palliative Care for Women With Cervical Cancer: Responding to the Suffering of a Highly Vulnerable Population

Women with cervical cancer, especially those with advanced disease, appear to experience suffering that is more prevalent, complex, and severe than that caused by other cancers and serious illnesses, and approximately 85% live in low- and middle-income countries where palliative care is rarely accessible. To respond to the highly prevalent and extreme suffering in this vulnerable population, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an essential package of palliative care for cervical cancer (EPPCCC). The EPPCCC consists of a set of interventions, medicines, simple equipment, social supports, and human resources, and is designed to be safe and effective for preventing and relieving all types of suffering associated with cervical cancer. It includes only inexpensive and readily available medicines and equipment, and its use requires only basic training. Thus, the EPPCCC can and should be made accessible everywhere, including for the rural poor. We provide guidance for integrating the EPPCCC into gynecologic and oncologic care at all levels of health care systems, and into primary care, in countries of all income levels.

Association between Spirituality, Religiosity, Spiritual Pain, Symptom Distress, and Quality of Life among Latin American Patients with Advanced Cancer: A Multicenter Study

Objectives: The purpose of this multicenter study was to characterize the association between spirituality, religiosity, spiritual pain, symptom distress, coping, and quality of life (QOL) among Latin American advanced cancer patients. Methods: Three hundred twenty-five advanced cancer patients from palliative care clinics in Chile, Guatemala, and the United States completed validated assessments: Faith, Importance and Influence, Community, and Address (FICA) (spirituality/religiosity), Edmonton Symptom Assessment Scale-Financial/Spiritual (ESAS-FS), including spiritual pain, Penn State Worry Questionnaire-Abbreviated (PSWQ-A), Center for Epidemiologic Studies Depression Scale (CES-D), Brief-coping strategies (COPE) and Brief religious coping (RCOPE) and RCOPE, respectively, and Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being, Expanded version (FACIT-Sp-Ex). Results: Median age: 58 years (range: 19-85); 60% female; and 62% Catholic and 30% Christian, but not Catholic. Three hundred fifteen patients (97%) considered themselves spiritual and 89% religious, with median intensities of 7 (interquartile range [IQR]: 5-10) and 7 (5-9), respectively (0-10 scale, 10 = "very much"). Median importance of spirituality/religiosity was 10 (IQR: 8-10). The frequency and associations between spirituality/religiosity and various items were as follows: helps to cope with illness (98%; r = 0.66303; p < 0.0001), positive effect on physical symptoms (81%; r = 0.42067; p < 0.0001), and emotional symptoms (84%; r = 0.16577; p < 0.0001). One hundred ninety-five patients (60%) reported that their spiritual/religious needs had not been supported by the medical team. Spiritual pain was reported in 162/311 patients (52%), with median intensity of 6 (IQR: 5-8). Spiritual pain was associated with pain (p = 0.0225), depression (p < 0.0001), anxiety (p < 0.0001), worry (p < 0.001), behavioral disengagement (p = 0.0148), FACIT-Sp-Ex score (p = 0.0002), and negative RCOPE (p < 0.0001). Significance of Results: Spirituality and religiosity are frequent, intense, and rarely addressed among Latin American patients. Spirituality/religiosity was associated with positive COPE and higher QOL. Spiritual pain was also frequent and associated with physical and psychosocial distress. These patients need increased spiritual/religious support.

How does spirituality manifest in family caregivers of terminally ill cancer patients? A qualitative secondary analysis

OBJECTIVE

Considering the risk of spiritual distress among terminally ill patients, experts long agree that spiritual care has to be an integral component of palliative care. Despite this consensus, the role of spirituality among family caregivers remains largely unexplored. We aimed to describe how spirituality manifests in the lived experience of family caregivers (FCs) in a palliative care context.

METHOD

As part of a secondary analysis, data derived from two qualitative primary studies on FCs' burdens and needs in the context of caring for a patient with a diagnosis of incurable cancer. Previously transcribed interviews were examined by means of a thematic analysis, transcending the focus of the primary studies to examine how spirituality arises and/or persists in the life of FCs from the time of diagnosis of incurable cancer up until bereavement.

RESULTS

Twenty-nine narratives were explored and all included spirituality as a relevant theme. Analysis revealed four aspects associated with the presence of spirituality among FCs' experiences: "Connectedness," "Religious Faith," "Transcendence," "Hope," and a fifth overarching aspect which we named "Ongoing integration of spiritual experience." Spirituality appeared as a multilayered phenomenon and was shaped individually among FCs' narratives.

SIGNIFICANCE OF RESULTS

In view of the results, exploring and discussing spirituality and underlying experiences in the situation as an FC seems likely to widen the perspective on FCs' problems and needs. Further research on spiritual needs among FCs of patients with incurable life-limiting cancer is deemed necessary.

Interactions of Spiritual Well-Being, Symptoms, and Quality of Life in Patients Undergoing Treatment for Non-Small Cell Lung Cancer: A Cross-Sectional Study

OBJECTIVES

To investigate the relationship of spiritual well-being and quality of life (QOL) in patients undergoing treatment for non-small cell lung cancer (NSCLC) and to identify the role of four different symptoms (ie, appetite loss, dyspnea, pain, and fatigue) in mediating this relationship DATA SOURCES: A total of 132 consecutive patients undergoing chemotherapy, radiotherapy, or concurrent chemoradiotherapy for NSCLC from National University Hospital were examined. Symptoms were assessed using the symptom subscale of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-C30 (QLQ-C30). Spiritual well-being was assessed using the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being scale. Global QOL was assessed using the item on global health status from the European Organization for Research and Treatment of Cancer. Data of all self-reported surveys were analyzed using serial multiple mediation analysis.

CONCLUSION

Spiritual well-being directly affected QOL in patients undergoing treatment for NSCLC. In addition, a serial multiple mediation model showed causal relationships of spiritual well-being on appetite loss, appetite loss on dyspnea, dyspnea on pain, pain on fatigue, and fatigue on QOL.

IMPLICATIONS FOR NURSING PRACTICE

Providing integrated care that considers spiritual well-being may improve the QOL of patients undergoing treatment for NSCLC. Our findings emphasized the need to conduct routine assessments of spiritual well-being and symptoms when characterizing patient QOL.