Questions posed to hospital chaplains by palliative care patients

Spiritual conversation model for patients and loved ones in palliative care: a validation study

OBJECTIVES

In palliative care, validated tools for professionals that facilitate day-to-day spiritual conversations with patients and loved ones are scarce. The objective of this study was to validate the Diamond spiritual conversation model across different palliative care settings as well as professional and educational levels.

METHODS

An online survey was filled in by 387 professionals providing palliative care for patients in hospice, home care, hospital and nursing home settings. The five polarities of the Diamond model: holding on-letting go, doing-undergoing, remembering-forgetting, me-the other and believing-knowing were operationalised and evaluated on reported occurrence.

RESULTS

In conversations with patients, palliative care professionals reported letting go of loved ones (81.8%), dealing with pain and suffering (88.1%), dealing with issues from the past (67.2%), dealing with own versus loved one's wishes (69.4%) and giving meaning to death (66.7%) as themes occurring regularly to very often. In conversations with loved ones, this was 70.8%, 78.5%, 55.4%, 68,8% and 62%, respectively. Respondents working in hospices reported these themes significantly more than those working in home care settings, nursing homes or hospitals. Nurse assistant respondents reported the themes significantly less than nurses or chaplains.

CONCLUSION

From the perspective of professionals providing palliative care in different palliative care settings, the Diamond model offers a validated framework for addressing relevant spiritual themes for patients and loved ones.

Older Adults' Experience of Meaning at the End of Life in Two Danish Hospices: A Qualitative Interview Study

The aim of this study was to explore how older adults (aged > 65) confronted with imminent death express their thoughts and feelings about death and dying and verbalize meaning. Furthermore, the aim was to investigate how health professionals could better address the needs of this patient group to experience meaning at the end of life. The study applied a qualitative method, involving semi-structured interviews with 10 participants at two hospices. The method of analysis was interpretative phenomenological analysis. We found three chronological time-based themes: (1) Approaching Death, (2) The time before dying, and (3) The afterlife. The participants displayed scarce existential vernacular for pursuing meaning with approaching death. They primarily applied understanding and vocabulary from a medical paradigm. The participants' descriptions of how they experienced and pursued meaning in the time before dying were also predominantly characterized by medical vernacular, but these descriptions did include a few existential words and understandings. When expressing thoughts and meaning about the afterlife, participants initiated a two-way dialogue with the interviewer and primarily used existential vernacular. This indicates that the participants' scarce existential vernacular to talk about meaning might be because people are not used to talking with healthcare professionals about meaning or their thoughts and feelings about death. They are mostly "trained" in medical vernacular. We found that participants' use of, respectively, medical or existential vernacular affected how they experienced meaning and hope at the end of life. We encourage healthcare professionals to enter into existential dialogues with people to support and strengthen their experiences of meaning and hope at the end of life.

Elements of chaplaincy in Danish intensive care units: key-informant interviews with hospital chaplains

Critically ill patients often require spiritual counseling. In Denmark, most hospital chaplains are provided by the State Church. More knowledge is needed regarding health care chaplaincy in this semi-agnostic non-secular welfare society. Our study aimed to explore how hospital chaplains describe their role and elements of chaplaincy in relation to patient, family and healthcare professionals in Danish intensive care units. Using a multicenter qualitative design, we performed semi-structured key-informant interviews with ten hospital chaplains. Content analysis exposed elements of chaplaincy based on spirituality, rituality, neutrality, confidentiality, advocacy, and equality. Most elements are similar in other countries; the main differences are related to educational requirements, institutional integration, research activity, and documentation practice. Chaplains fill an ambiguous role, negotiating values of church and hospital. Modern chaplaincy is propelled toward professionalism, quantification, certification and evaluation. We discuss the contemporary role of hospital chaplains and the consequences of categorizing them as part of the ICU team.

Association of Religious and Spiritual Factors With Patient-Reported Outcomes of Anxiety, Depressive Symptoms, Fatigue, and Pain Interference Among Adolescents and Young Adults With Cancer

IMPORTANCE

The associations of spiritual and religious factors with patient-reported outcomes among adolescents with cancer are unknown.

OBJECTIVE

To model the association of spiritual and religious constructs with patient-reported outcomes of anxiety, depressive symptoms, fatigue, and pain interference.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used baseline data, collected from 2016 to 2019, from an ongoing 5-year randomized clinical trial being conducted at 4 tertiary-referral pediatric medical centers in the US. A total of 366 adolescents were eligible for the clinical trial, and 126 were randomized; participants had to be aged 14 to 21 years at enrollment and be diagnosed with any form of cancer. Exclusion criteria included developmental delay, scoring greater than 26 on the Beck Depression Inventory II, non-English speaking, or unaware of cancer diagnosis.

EXPOSURES

Spiritual experiences, values, and beliefs; religious practices; and overall self-ranking of spirituality's importance.

MAIN OUTCOMES AND MEASURES

Variables were taken from the Brief Multidimensional Measurement of Religiousness/Spirituality (ie, feeling God's presence, daily prayer, religious service attendance, being very religious, and being very spiritual) and the spiritual well-being subscales of the Functional Assessment of Chronic Illness Therapy (meaning/peace and faith). Predefined outcome variables were anxiety, depressive symptoms, fatigue, and pain interference from Patient-Reported Outcomes Measurement Information System pediatric measures.

RESULTS

A total of 126 individuals participated (72 [57.1%] female participants; 100 [79.4%] white participants; mean [SD] age, 16.9 [1.9] years). Structural equation modeling showed that meaning and peace were inversely associated with anxiety (β = -7.94; 95% CI, -12.88 to -4.12), depressive symptoms (β = -10.49; 95% CI, -15.92 to -6.50), and fatigue (β = -8.90; 95% CI, -15.34 to -3.61). Feeling God's presence daily was indirectly associated with anxiety (β = -3.37; 95% CI, -6.82 to -0.95), depressive symptoms (β = -4.50; 95% CI, -8.51 to -1.40), and fatigue (β = -3.73; 95% CI, -8.03 to -0.90) through meaning and peace. Considering oneself very religious was indirectly associated with anxiety (β = -2.81; 95% CI, -6.06 to -0.45), depressive symptoms (β = -3.787; 95% CI, -7.68 to -0.61), and fatigue (β = -3.11, 95% CI, -7.31 to -0.40) through meaning and peace. Considering oneself very spiritual was indirectly associated with anxiety (β = 2.11; 95% CI, 0.05 to 4.95) and depression (β = 2.8, 95% CI, 0.07 to 6.29) through meaning and peace. No associations were found between spiritual scales and pain interference.

CONCLUSIONS AND RELEVANCE

In this study, multiple facets of spirituality and religiousness were associated with anxiety, depression, and fatigue, all of which were indirectly associated with the participant's sense of meaning and peace, which is a modifiable process. Although these results do not establish a causal direction, they do suggest palliative interventions addressing meaning-making, possibly including a spiritual or religious dimension, as a novel focus for intervention development.

The role of geriatric palliative care in hospitalized older adults

Take-Away Points:1. Geriatric palliative care requires integrating the disciplines of hospital medicine and palliative care in pursuit of delivering comprehensive, whole-person care to aging patients with serious illnesses.2. Older adults have unique palliative care needs compared to the general population, different prevalence and intensity of symptoms, more frequent neuropsychiatric challenges, increased social needs, distinct spiritual, religious, and cultural considerations, and complex medicolegal and ethical issues.3. Hospital-based palliative care interdisciplinary teams can take many forms and provide high-quality, goal-concordant care to older adults and their families.

Dealing with ethical and existential issues at end of life through co-creation

BACKGROUND

In research on co-creation in nursing, a caring manner can be used to create opportunities for the patient to reach vital goals and thereby increase the patient's quality of life in palliative home care. This can be described as an ethical cornerstone and the goal of palliative care. Nurses must be extra sensitive to patients' and their relatives' needs with regard to ethical and existential issues and situations in home care encounters, especially at the end of life.

AIM

The aim of this study was to explore nurses' experiences of dealing with ethical and existential issues through co-creation at the end of life in palliative home care.

RESEARCH DESIGN, PARTICIPANTS, AND RESEARCH CONTEXT

The material consisted of texts from interviews with 12 nurses in a home care context. A hermeneutical approach was used, and the method was inspired by a thematic analysis.

ETHICAL CONSIDERATIONS

Informed consent was sought from the participants regarding study participation and the storage and handling of data for research purposes. Ethical permission to conduct the study was given from organizations that participated in this study.

FINDINGS

A main theme and four subthemes emerged. The main theme was "Deep co-creative relationships are needed to manage ethical and existential issues at the end of life." A model was created to display the findings and relations between ethical issues and situations and the need for a deep trustful caring relationship to solve problems in palliative home care.

DISCUSSION

Together, the themes can be considered as a tool for learning and dealing with ethical and existential issues at the end of life in home care. The themes can also be seen as a part of nurses' ethical competence within this context.

CONCLUSION

The quality of life at the end of life can be improved through co-creation, despite difficult ethical and existential issues. Future research should focus on co-creation from the patients' perspective.

Effects of psychosocial interventions on meaning and purpose in adults with cancer: A systematic review and meta-analysis

Meaning and purpose in life are associated with the mental and physical health of patients with cancer and survivors and also constitute highly valued outcomes in themselves. Because meaning and purpose are often threatened by a cancer diagnosis and treatment, interventions have been developed to promote meaning and purpose. The present meta-analysis of randomized controlled trials (RCTs) evaluated effects of psychosocial interventions on meaning/purpose in adults with cancer and tested potential moderators of intervention effects. Six literature databases were systematically searched to identify RCTs of psychosocial interventions in which meaning or purpose was an outcome. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, rater pairs extracted and evaluated data for quality. Findings were synthesized across studies with standard meta-analytic methods, including meta-regression with robust variance estimation and risk-of-bias sensitivity analysis. Twenty-nine RCTs were identified, and they encompassed 82 treatment effects among 2305 patients/survivors. Psychosocial interventions were associated with significant improvements in meaning/purpose (g = 0.37; 95% CI, 0.22-0.52; P < .0001). Interventions designed to enhance meaning/purpose (g = 0.42; 95% CI, 0.24-0.60) demonstrated significantly higher effect sizes than those targeting other primary outcomes (g = 0.18; 95% CI, 0.09-0.27; P = .009). Few other intervention, clinical, or demographic characteristics tested were significant moderators. In conclusion, the results suggest that psychosocial interventions are associated with small to medium effects in enhancing meaning/purpose among patients with cancer, and the benefits are comparable to those of interventions designed to reduce depression, pain, and fatigue in patients with cancer. Methodological concerns include small samples and ambiguity regarding allocation concealment. Future research should focus on explicitly meaning-centered interventions and identify optimal treatment or survivorship phases for implementation.

Life Story Themes: A Qualitative Analysis of Recordings From Patients Approaching the End of Life

OBJECTIVE

To identify common themes and topics that patients nearing the end of life want to discuss when sharing their life stories.

METHODS

Twenty audio-recorded transcripts of open-ended interviews of patients cared for by a palliative care team when approaching the end of life were analyzed using a qualitative analysis.

RESULTS

Qualitative analysis revealed that the primary contextual factors that patients drew upon to generate his or her life story are life events (including upbringing, job, education, travel, trauma, hardships, special events, military history, and hobbies), family and support system, and values and beliefs. Participants used their current medical condition, which included mortality, morbidity, and prognosis, to frame their life story.

CONCLUSION

Patients facing serious illness incorporate four major themes when reflecting upon their lives to create their personal life story: life events, family and support system, values and beliefs, and current medical condition.

End-of-life spiritual care at a VA medical center: Chaplains' perspectives

Objective:

Spiritual care is an essential component of quality palliative care. Recognizing the importance, the Department of Veterans Affairs (VA) mandates the inclusion of chaplains in a palliative care consult team (PCCT). The purpose of this study is to explain the process and content of spiritual care provided in a VA Medical Center from chaplains' perspectives.

Method:

Five Christian chaplains who provide care to patients at end of life were interviewed. Each interview was recorded and transcribed. Analysis based on the grounded theory was used to identify themes from each interview question.

Results:

The PCCT in this study appeared to have a strong referral and communication system in which every palliative care patient was seen by a chaplain and the care plan was discussed with an interdisciplinary team. Chaplains reported providing a range of services, which addressed religious, spiritual, emotional, family, and illness concerns. Chaplains were aware of the unique spiritual needs of veterans, including working through guilt for killing in war and requiring forgiveness. Chaplains' ideas for improvement of spiritual care services included increasing time to provide care, providing bereavement care and support to families, and adding chaplains with different religious backgrounds. Chaplains reported how their own spirituality influenced the care they provided.

Significance of results:

Spiritual care in the VA can include a range of services and should consider the unique needs of the veteran population. Future studies can build upon our findings from chaplains to learn about the perspectives of patients, family, and other healthcare providers of spiritual care. This information would allow identification of strengths of current spiritual care practices and areas for care improvement, and ultimately could improve the well-being of patients at the end of life.

The use of massage therapy for reducing pain, anxiety, and depression in oncological palliative care patients: a narrative review of the literature

A considerable number of cancer patients use complementary medicine therapies in order to alleviate different symptoms such as pain, anxiety, and depression, occurring in connection with cancer. This paper explores the question to what extent massage therapies are able to reduce the amount of pain, anxiety, and depression. For this purpose, a systematic literature analysis was carried out in the electronic databases and specialist journals. There is already evidence that massage therapies can influence the symptoms of pain, anxiety, and depression in a positive way.

Health care behaviours and beliefs in Hasidic Jewish populations: a systematic review of the literature

Cultural issues impact on health care, including individuals' health care behaviours and beliefs. Hasidic Jews, with their strict religious observance, emphasis on kabbalah, cultural insularity and spiritual leader, their Rebbe, comprise a distinct cultural group. The reviewed studies reveal that Hasidic Jews may seek spiritual healing and incorporate religion in their explanatory models of illness; illness attracts stigma; psychiatric patients' symptomatology may have religious content; social and cultural factors may challenge health care delivery. The extant research has implications for clinical practice. However, many studies exhibited methodological shortcomings with authors providing incomplete analyses of the extent to which findings are authentically Hasidic. High-quality research is required to better inform the provision of culturally competent care to Hasidic patients.

Dying cancer patients' experiences of powerlessness and helplessness

GOALS OF WORK

Experiences of powerlessness and helplessness are closely linked to incurable diseases but seldom studied in patients with disseminated cancer. The aim is to explore the perception, experiences and significance of powerlessness and helplessness, to study triggering factors and to make quantifications.

MATERIALS AND METHODS

One hundred three patients, enrolled in four different palliative home-care settings, completed a questionnaire with both Likert-type questions and open-ended questions. The response rate was 58%, and background data was reported as frequencies, whereas the main material was analysed using a qualitative content analysis.

MAIN RESULTS

Impending death, symptoms, loss of control and autonomy, ignorance, isolation and uncertainty constituted the basis for powerlessness and helplessness, but each factor was reinforced by the occurrence of suddenness, high intensity and/or lengthiness. In total, 65% reported definite experiences of powerlessness and helplessness. These feelings also held a deeper meaning, involving aspects such as existential loneliness and hopelessness. They were ultimately caused by an incapacity to control feelings and cope with the situation related to the impending death. The results are discussed in relation to Cassel's theory of suffering and existential psychology.

The Impact of the Hospice Environment on Patient Spiritual Expression

PURPOSE/OBJECTIVES

To understand how hospital inpatients express their spirituality and to investigate the impact of hospice environment on this expression.

RESEARCH APPROACH

Qualitative.

SETTING

Two metropolitan hospice centers in southern Australia.

PARTICIPANTS

12 inpatients (7 males, 5 females) who were residents for at least four days.

METHODOLOGIC APPROACH

Influenced by Heidegger's Phenomenological Hermeneutics, semistructured interviews were conducted. Interview transcripts and field notes were analyzed to reduce data into codes and themes. Data were coded by extracting verbatim phrases used to describe spiritual expression and the impact of hospice environment on it.

MAIN RESEARCH VARIABLES

The nature of spiritual expression and the impact of the hospice environment on the spiritual expression of hospice inpatients.

FINDINGS

Participants were comfortable discussing their spiritual expression within the context of four main themes: Relationships, That Which Uplifts, Spiritual Practice, and Having Hope. Finding meaning was a common link among these themes. The impact of the hospice environment was variable. Most believed that it facilitated their spiritual expression to some degree.

CONCLUSIONS

Spiritual expression is important but is facilitated by individualized spiritual care. Nurses play an important role in the provision of spiritual care within a hospice setting.

INTERPRETATION

Nurses are significant in assisting in patients' spiritual expression. Nurses' needs for training in listening skills, confidence in discussing spiritual issues, and time to provide individualized spiritual care should be assessed to ensure optimal patient expression.

Interventions to enhance the spiritual aspects of dying

In recent years, medical and allied health publications have begun to address various topics on spirituality. Scholars have posited numerous definitions of spirituality and wrestled with the notion of spiritual pain and suffering. Researchers have examined the relationship between spirituality and health and explored, among other topics, patients' perceptions of their spiritual needs, particularly at the end of life. This paper summarizes salient evidence pertaining to spirituality, dying patients, their health care providers, and family or informal caregivers. We examine the challenging issue of how to define spirituality, and provide a brief overview of the state of evidence addressing interventions that may enhance or bolster spiritual aspects of dying. There are many pressing questions that need to be addressed within the context of spiritual issues and end-of-life care. Efforts to understand more fully the constructs of spiritual well-being, transcendence, hope, meaning, and dignity, and to correlate them with variables and outcomes such as quality of life, pain control, coping with loss, and acceptance are warranted. Researchers should also frame these issues from both faith-based and secular perspectives, differing professional viewpoints, and in diverse cultural settings. In addition, longitudinal studies will enable patients' changing experiences and needs to be assessed over time. Research addressing spiritual dimensions of personhood offers an opportunity to expand the horizons of contemporary palliative care, thereby decreasing suffering and enhancing the quality of time remaining to those who are nearing death.

“Nobody Understands”: On a Cardinal Phenomenon of Palliative Care

In the clinical practice of palliative medicine, recommended communication models fail to approximate the truth of suffering associated with an impending death. I provide evidence from patients' stories and empiric research alike to support this observation. Rather than attributing this deficiency to inadequate training or communication skills, I examine the epistemological premises of the biomedical language governing the patient-physician communication. I demonstrate that the contemporary biomedicine faces a fundamental aporetic occlusion in attempting to examine death. This review asserts that the occlusion defines, rather than simply complicating, palliative care. Given the defining place of aporia in the care for the dying, I suggest that this finding shape the clinicians' responses to the needs of patients in clinical care and in designing palliative research. Lastly, I briefly signal that a genuinely apophatic voice construing the occlusion as a mystery rather than an aporia may be superior to the present communication and empathy models.

Existential pain--an entity, a provocation, or a challenge?

"Existential pain" is a widely used but ill-defined concept. Therefore the aim of this study was to let hospital chaplains (n=173), physicians in palliative care (n=115), and pain specialists (n=113) respond to the question: "How would you define the concept existential pain?" A combined qualitative and quantitative content analysis of the answers was conducted. In many cases, existential pain was described as suffering with no clear connection to physical pain. Chaplains stressed significantly more often the guilt issues, as well as various religious questions (P<0.001). Palliative physicians (actually seeing dying persons) stressed more often existential pain as being related to annihilation and impending separation (P<0.01), while pain specialists (seeing chronic patients) more often emphasized that "living is painful" (P<0.01). Thirty-two percent (32%) of the physicians stated that existential suffering can be expressed as physical pain and provided many case histories. Thus, "existential pain" is mostly used as a metaphor for suffering, but also is seen as a clinically important factor that may reinforce existing physical pain or even be the primary cause of pain, in good agreement with the current definition of pain disorder or somatization disorder.