Managing spiritual distress in patients with advanced cancer pain

Longitudinal changes in spiritual well-being and associations with emotional distress, pain, and optimism-pessimism: a prospective observational study of terminal cancer patients admitted to a palliative care unit

PURPOSE

Although spiritual well-being (SWB) is gaining increasing attention within the international palliative care (PC) guidelines, a lack of insight exists into the correlates and course of SWB among cancer patients. We therefore conducted a prospective observational study to capture trend of SWB and to identify their predictors in Chinese inpatients with terminal cancer receiving short-term PC.

METHODS

A prospective observational study was conducted of terminal cancer inpatients in the hospice ward, Shengjing Hospital of China Medical University. A total of 108 patients completed self-report questionnaires on Functional Assessment of Chronic Illness Therapy-Spiritual Well-being, Hospital Anxiety and Depression Scale, Numerical Rating Scales, and Life Orientation Scale-Revised anonymously at baseline; SWB, depression, anxiety, and pain were subsequently assessed at 1-week interval. Multilevel regression was used to analyze the temporal course and predictors of SWB.

RESULTS

Patients' existential well-being (B =  - 0.99, p = 0.008; 95%CI =  - 1.72 to - 0.26) and meaning dimension (B =  - 0.87, p < 0.001; 95% CI =  - 1.29 to - 0.43) significantly decreased after admission to the PC unit, but peace and faith did not change over time. Increases in depression and pain were related to lower existential well-being, particularly in the meaning dimension. Optimism-pessimism moderated the linear trend of existential well-being and meaning domain, such that those with higher optimism and lower pessimism paired with a decrease in outcomes.

CONCLUSIONS

Terminal cancer patients experienced worsening existential well-being, particularly in the meaning facet while hospitalized, indicating that PC should include content that targets the existential concerns of spirituality in China. These findings also supported the need for an integrated PC to address personality traits and emotional and physical distress in this population.

A pilot study of acupuncture at pain acupoints for cervical cancer pain

This retrospective study aimed to investigate the feasible effectiveness of acupuncture at pain acupoints for the treatment of patients with cervical cancer pain (CCP). A total of 64 cases were analyzed. All these cases were assigned to an acupuncture group or a control group according to the different therapies they received. The cases in the acupuncture group received acupuncture treatment at pain acupoints, while the subjects in the control group underwent acupuncture at regular acupoints. The primary endpoint was CCP, assessed by numeric rating scale (NRS). The secondary endpoints were evaluated by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), and Karnofsky Performance Status (KPS). In addition, adverse events were also recorded during the treatment period. After treatment, patients in the acupuncture group exerted greater outcomes in CCP reduction when compared with patients in the control group (P < .01). In addition, no adverse events were recorded in either group. The results of this study showed that acupuncture at pain acupoints might be efficacious in patients with CCP after 14-day treatment.

Therapeutic life review in palliative care: a systematic review of quantitative evaluations

CONTEXT

There is increasing interest in providing nonpharmacological treatments, including therapeutic life review interventions, to enhance palliative care patients' existential/spiritual domains.

OBJECTIVES

To review quantitative evaluations of therapeutic life review interventions to assist palliative care patients with prognoses of 6 months or fewer in addressing existential and spiritual domains.

METHODS

Comprehensive searches of PubMed, Medline, Web of Science, CINAHL, Scopus, and PsycINFO were undertaken using a validated palliative care search filter in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. Each publication that met the inclusion criteria was read and classified according to the American Heart Association's Disease Management Taxonomy, Consolidated Standards of Reporting Trials, QualSyst, and the Task Force on Psychological Interventions. Intervention procedures and outcomes were described.

RESULTS

The searches yielded 1768 articles, of which 14 met the inclusion criteria. The articles reported six interventions evaluated once and four interventions evaluated twice, resulting in 10 distinct interventions. The interventions were evaluated in randomized controlled trials (n = 9), single-arm studies (n = 3), and a cohort study (n = 1). Interventions were conducted in one to eight 15-160 minute sessions by psychologists, social workers, and nurses. Attrition rates were 12%-50% because of patient death and deterioration. Participants lived 28-110 days after completion. Significant results were reported in 11 of 14 studies.

CONCLUSION

There are few studies evaluating therapeutic life review interventions, although results are promising. Further studies are required that use stricter selection criteria to demonstrate efficacy before these interventions are adopted into clinical practice. Further study may include the effect of these interventions on the interventionist and the bereaved family and caregivers in long-term follow-up.

Conceptual analysis of suffering in cancer: a systematic review

OBJECTIVE

Patient suffering is a neglected area of care, partly because of poor definitions. The aim of this study was to distill what is currently known about suffering in the health literature in order to generate a conceptual basis for further research.

METHODS

A systematic review focusing on suffering across all cancers was undertaken. The search included peer-reviewed English articles published between 1992 and 2012 in MEDLINE, Embase, PsycINFO and the Cochrane Library databases focusing on conceptualisation of suffering in adult cancer patients. Seminal theoretical articles conceptualising suffering more generally were also eligible. To ensure identification of a sufficiently broad range of conceptualisations of suffering in cancer, the search strategy was drafted iteratively. Study findings were subjected to conceptual analysis using the evolutionary method.

RESULTS

One hundred twenty-eight studies were identified, which discussed definitions or conceptualisations of suffering. In terms of its attributes, suffering is defined as 'an all-encompassing, dynamic, individual phenomenon characterized by the experience of alienation, helplessness, hopelessness and meaninglessness in the sufferer which is difficult for them to articulate. It is multi-dimensional and usually incorporates an undesirable, negative quality.' Surrogate terms, antecedents and consequences of suffering are described.

CONCLUSIONS

The systematic review revealed that suffering includes holistic suffering, which is multidimensional, oscillating, individual and difficult for individuals to express. Opportunities should be provided for patients to express their suffering. The potential for suffering to be transcended needs to be recognized and facilitated by healthcare staff.

Spiritual distress-proposing a new definition and defining characteristics

OBJECTIVE

To identify the definition and defining characteristics (DCs) of spiritual distress (00066).

METHOD

Integrative literature review.

RESULTS

Thirty-seven articles and 35 DCs were identified. Spiritual distress as a response to health problems in the context of nursing care is different from an impaired ability to experience and integrate meaning in life.

CONCLUSIONS

The diagnosis misses some DCs that emerged from the literature review and lacks comprehensiveness. The domain and the class are reductionist toward its meaning. The taxonomy lacks a spiritual domain to include this and other diagnoses currently dispersed in other domains.

IMPLICATIONS FOR PRACTICE

Further content and clinical validation is needed, as well as an assessment, to determine the diagnosis' class and domain.

Sacred healing stories told at the end of life

INTRODUCTION

Cancer is a challenging disease to diagnose and treat, and oftentimes even with the best medical intervention, it spreads and is deemed incurable, requiring a shift from cure to end-of-life care. This study used a spirituality measure and the PATS© storytelling intervention developed by the principal investigator to better understand the experience of being diagnosed with cancer and being told no further curative treatments are warranted.

PURPOSE

The purpose of this exploratory study was to implement a storytelling approach to explore the experience of living with terminal cancer. Second, the study documented the presence of spirituality and healing in the narratives.

METHOD

The qualitative data were analyzed by narrative analysis developed by Riessman.

FINDINGS

Seven synoptic stories were written and later sorted into healing categories. The narrative analysis yielded three themes. There were instances of religion and spirituality found in the transcribed stories. The participants' scores on the Spiritual Health Inventory indicated the presence of spirituality.

CONCLUSION

Storytelling allowed the seven study participants to share personal experiences and achieve a sense of connectedness and intimacy. The use of the PATS© intervention is a way to facilitate physical, emotional, and spiritual healing and provide holistic end-of-life care.

Preliminary results of an individually tailored psychosocial intervention for patients with advanced hepatobiliary carcinoma

BACKGROUND

A plethora of research now exists documenting the benefits of psychosocial interventions for cancer patients; however, no studies have been conducted with people diagnosed with hepatobiliary carcinoma.

METHODS

A total of 28 patients agreed to participate in the study in which 14 patients were randomized to the intervention arm of the study and 14 patients to an attention-standard of care arm. Evaluation of the benefits of the intervention was performed using the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep), the Center for Epidemiological Studies-Depression, the State Trait Anxiety Index (STAI) to assess anxiety, peripheral blood leukocytes to measure immune system modulation, and survival.

RESULTS

Results indicate that patients who were randomly assigned to the intervention arm of the study reported clinically, but not statistically, significant improvements on symptoms of depression and anxiety, disease-related symptoms and treatment side effects, health-related quality of life (HRQL), and modest improvements in peripheral blood leukocytes and survival when compared with the standard of care group.

CONCLUSIONS

The findings of this study suggest that the individually tailored intervention was feasible and preliminary data suggested that the intervention may improve patients' HRQL, mood, and had modest improvements in immune system functioning and survival. Further research is needed with a larger sample size to test the statistical significance and generalizability of the individually tailored intervention.

Depression and quality of life in cancer patients with and without pain: the role of pain beliefs

Background

Pain is said to be one of the most feared and distressing symptoms of cancer and one that disrupts all aspects of life. The purposes of this study were: 1) to compare depression and quality of life among Iranian cancer patients with and without pain; and 2) to determine the relationships between pain beliefs and depression and quality of life.

Method

A consecutive sample of gastrointestinal cancer patients attending to Tehran Cancer Institute were entered into the study. Three standard instruments were used to measure quality of life (the EORTC QLQ-C30), depression (the HADS) and pain beliefs (the PBPI).

Results

A total of 142 hospitalized gastrointestinal cancer patients, 98 with pain and 44 without pain were studied. The main findings of this study were that cancer patients with pain reported significantly lower levels of role functioning, emotional functioning and global quality of life. They also showed higher levels of depression than cancer patients who did not experience pain. Among patients with pain, higher scores on pain permanence and pain consistency were positively and significantly associated with higher depression. Also, higher scores on pain consistency were negatively and significantly associated with global quality of life.

Conclusion

This study has demonstrated the effect of cancer pain on patients' quality of life and emotional status and has supported the multidimensional notion of the cancer pain experience in cancer patients. Although these data are correlational, they provide additional support for a biopsychosocial model of chronic pain.

Sedation for the care of patients with advanced cancer

Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness (i.e. unconsciousness) in order to relieve the burden of otherwise intractable suffering. Sedation is used in palliative care in several settings: transient controlled sedation, sedation in the management of refractory symptoms at the end of life, emergency sedation, respite sedation, and sedation for refractory psychological or existential suffering. Sedation is controversial in that it diminishes the capacity of the patient to interact, function, and, in some cases, live. There is no distinct ethical problem in the use of sedation to relieve otherwise intolerable suffering in patients who are dying. Since all medical treatments involve risks and benefits, each potential option must be evaluated for its promise with regards to achieving the goals of care. When risks of treatment are involved, to be justified these risks must be proportionate to the gravity of the clinical indication. Some aspects of management, such as the need for hydration in patients undergoing sedation and the use of sedation in the management of psychological and spiritual suffering, remain controversial.

Spiritual distress in adult cancer patients: toward conceptual clarity

Spiritual distress is conceptualized as impairments in 7 constructs of a person's sense of spirituality: (1) connectedness, (2) faith and religious belief system, (3) value system, (4) meaning and purpose in life, (5) self-transcendence, (6) inner peace and harmony, and (7) inner strength and energy. This article clarifies spiritual distress through concept analysis and provides nurses with cues for its recognition in adult patients with cancer.

Exploring nurses' experiences of supporting a cancer patient in their search for meaning

This article presents the findings from an interpretive phenomenology study looking at nurses' experiences of supporting cancer patients in their search for meaning. Eleven nurses were interviewed from a Medical Oncology Unit and a Bone Marrow Transplant Unit in a central London teaching hospital. Having analysed the interviews, six major themes were identified: the value of experience, understanding the search for meaning, the value of time, the relationships involved, caring and the skills used by nurses, and the difficulties nurses' experienced and the support they needed to continue this role. Like many aspects of nursing care that are intangible in nature, this aspect of care was seen as important and valuable to the nurses in the clinical environments of cancer care. The findings do not represent a definitive approach to this aspect of care, but offer an insight into nurses' experiences. In order to continue this aspect of cancer care, the findings suggest that nurses need support.

Effect of cancer pain on performance status, mood states, and level of hope among Taiwanese cancer patients

The purposes of this study were: 1) to compare performance status, mood states, and level of hope between patients with cancer pain and patients without cancer pain; and 2) to determine the relationships of pain intensity and pain interference with daily life to performance status, mood states, and level of hope. A total of 233 Taiwanese cancer patients with pain and 251 without pain participated. The self report instruments consisted of the Chinese version of the Profile of Mood States (POMS) short form, the Chinese version of the Herth Hope Index, the Brief Pain Inventory-Chinese version (BPI-C), the Chinese version of the Karnorfsy Performance Scale (KPS), and a demographic questionnaire. The major findings of this study were that cancer patients with pain reported significantly lower levels of performance status and higher levels of total mood disturbance than did cancer patients who did not experience pain after controlling for sex, disease stage, and recruitment site. In addition, patients with cancer pain experienced significantly more anger, fatigue, depression, confusion, and lethargy than did patients without pain after controlling for sex, disease stage, and recruitment site. Among patients with pain, pain intensity was significantly correlated with performance status and mood state, but not with level of hope. Pain interference with daily life was significantly correlated both with performance status, mood state, and level of hope. Pain intensity and pain interference were significantly correlated with each mood state as well as with total mood disturbance. This study has demonstrated the effect of cancer pain on patients' physical, psychological, and spiritual life and has supported the multidimensional notion of the cancer pain experience in Taiwanese patients.

Religious and spiritual variables in three major oncology nursing journals: 1990-1999

PURPOSE/OBJECTIVES

To review qualitative and quantitative research studies measuring religious and spiritual variables published in American oncology nursing journals from 1990-1999 and the types of measures used.

DATA SOURCES

All research studies published from 1990-1999 in Oncology Nursing Forum, Cancer Nursing, and the Journal of Pediatric Oncology Nursing.

DATA SYNTHESIS

A higher percentage of qualitative (27%) than quantitative (14%) oncology nursing studies reported findings on religious and spiritual variables. Religion or spirituality was the major focus of 14% of qualitative studies, and these concepts emerged in qualitative studies even when they were not a study's research focus. Religion or spirituality was the primary independent or dependent variable in 10% of quantitative studies and was a prominent measure in quantitative studies on patients' needs, coping, and quality of life.

CONCLUSIONS

Nursing researchers in oncology are more likely to study issues relating to religion and spirituality than researchers in other fields of nursing, and substantially more research on these topics has been reported in oncology nursing than in the research literature on psychology or various fields of medicine.

IMPLICATIONS FOR NURSING

Implications include the value of (a) combining qualitative and quantitative methods in a single study, (b) incorporating demographic measures, such as religious denomination, as independent variables in analyses, (c) using separate and multiple measures of religion and spirituality in research, and (d) differentiating between religious and spiritual needs in research and practice.

An integrated psychosocial-spiritual model for cancer pain management

PURPOSE

Cancer pain is known to be a multidimensional and complex experience that can cause severe suffering and can lessen quality of life. The psychosocial and spiritual aspects of cancer pain play an important role in this phenomenon. This article describes a multidisciplinary model for cancer pain management that focuses on the psychosocial and spiritual aspects of cancer pain and the needs of patients.

DESCRIPTION OF PROGRAM

This multidisciplinary model has been organized to provide the most effective pain management to a variety of patients within a comprehensive cancer center. Our model includes multiple oncology mental health professionals, including psychologists, social workers, spiritual care providers, and psychiatrists. Each discipline provides a unique assessment and an evaluation of the needs of patients with cancer pain and their support system that is integrated into a comprehensive treatment plan. Regular collaboration occurs between disciplines to ensure that the patients receive optimal pain management.

CLINICAL IMPLICATIONS

This model provides a framework from which treatment interventions can be implemented. The emphasis on consistent collaboration between disciplines is a vital component in providing effective cancer pain management. This multidisciplinary psychosocial-spiritual model can be replicated, modified, or both, to become standard practice in other comprehensive cancer centers.

Spiritual needs as defined by Swedish nursing staff

A study was undertaken to describe how Swedish nursing staff at six different units characterize spiritual needs in a broad context, including both religious and existential issues. Another aim was to study whether there are any special groups of patients for whom these needs are considered to be of utmost importance. A questionnaire comprising two open-ended questions (the focus of the study) and six background questions was mailed to 191 nurses. Data were obtained from 141 nurses who worked on the oncology, palliative, neurological, neurosurgery and psychiatric units or in nursing homes. Data from the open-ended questions were analysed using content analysis and classified into three categories: (i) (general) spiritual issues, (ii) religious issues, and (iii) existential issues. Sub-categories of the latter were (a) meaning, (b) freedom, (c) isolation and (d) death, i.e. the four central issues in existentialism as previously defined by existential philosophers. A majority of the nurses only had limited theoretical knowledge about definitions. Nevertheless, their suggestions for improved spiritual and existential support contained essential elements that could be allocated to the three main categories. They had some difficulty distinguishing between spiritual and psychosocial care. According to the nurses, special groups of interest for spiritual and existential support were severely ill, dying persons and immigrants who actively practiced their religion. We conclude that there is a willingness to pay attention to spiritual and existential needs, but nurses still have difficulty defining what such care should include. The study revealed that nursing staff needed, and also made inquiries about, more education in order to deepen their knowledge.

'Someone who cares:' a qualitative investigation of cancer patients' experiences of psychotherapy

Although psychotherapy for cancer patients is known to be effective, there is little in the research to indicate what elements of their therapy patients find most helpful. To explore this question, we interviewed cancer patients diagnosed with metastatic disease who had been offered two different forms of individual psychotherapy as part of a larger funded study. These interviews were then transcribed and analysed using grounded theory. Our aim was to explore patients' psychotherapy experience from their perspective and to determine what common elements in the two approaches they felt were of greatest benefit. Results indicated that patients offered cognitive behavioural therapy had similar experiences to those who received a type of relaxation therapy that included time for non-specific, patient-centred 'chat'. Central to participants' experiences was the opportunity both therapies gave them to enter a relationship in which they could safely share their thoughts and feelings with someone who seemed genuinely interested in understanding their cancer experience and 'truly cared'. These findings suggest that the unique perspectives of cancer patients can add considerably to our understanding of individual psychotherapy in cancer care settings and how this might be improved.

Storytelling. A strategy for living and coping with cancer

The purpose of this focused program evaluation was to explore attitudes and beliefs about storytelling as a strategy for coping with cancer among participants who attended a cancer-related storytelling workshop. The response rate was 70% (n = 94) and included persons with a diagnosis of cancer, their loved ones, and members of the public. The program coordinators used a theoretical model described by Heiney (1995) that explains how storytelling may produce therapeutic effects in four domains: cognitive, affective, interpersonal, and personal. A questionnaire was designed to determine the extent that conference participants perceived therapeutic benefits in these domains as a result of attending the workshop. Statistical analysis consisted of descriptive summaries of individual questions and domain scores. Findings showed that 97% of the respondents agreed that storytelling was a helpful way to cope with cancer. Most of the respondents reported agreement with the therapeutic benefits of storytelling in all domains, with 85% agreeing that hearing others' stories of living with cancer gave them hope. Although the results of the evaluation were very positive, further study is needed to demonstrate the efficacy of storytelling as a strategy for coping with cancer.

Developing a community-based reminiscence group for the elderly

Advanced practice nurses expect to care for many older adults in a variety of community settings. Through the process of reminiscence, older adults can actively evaluate their life experiences and explore the meaning of memorable events. This paper discusses the experiences of two advanced practice nurses who collaborated to conduct a reminiscence therapy group with community-based senior citizens. The process of reminiscence and group theory will be examined as applied to the well elderly in a community setting.

Breast cancer in older women: treatment, psychosocial effects, interventions, and outcomes

It is estimated that 48% of women with breast cancer are age 65 and older; yet, scant research focuses on this cohort. Recent advances in breast cancer management have raised many questions regarding appropriate treatment of older patients with cancer. Despite recent emphasis on medical interventions for older women, there is little focus on the unique clinical presentation and psychological sequelae of breast cancer in this population. While elderly women who survive breast cancer seem to cope better than their younger counterparts, their distress must not be overlooked. Interventions such as use of social support, spirituality, and exercise demonstrate therapeutic benefits for older women with cancer and should be explored. Nurses play a key role in educating and supporting older women with breast cancer and can help dispel many age-related myths and misconceptions.

Chronic pain and distress in older people: a cluster analysis

Chronic pain represents a major health problem among older people. The aims of the present study were to: (i) identify various profiles of pain and distress experiences among older patients; and (ii) compare whether background variables, sense of coherence, functional ability and experiences of interventions aimed at reducing pain and distress varied among the patient profiles. Interviews were carried out with 42 older patients. A cluster analysis yielded three clusters, each representing a different profile of patients. Case illustrations are provided for each profile. There were no differences between the clusters, regarding intensity and duration of pain. One profile, with subjects of advanced age, showed a decreased functional ability and favourable scores in most of the categories of pain and distress. Another profile of patients showed favourable mean scores in all categories. The third cluster of patients showed unfavourable scores in most categories of pain and distress. There appears to be a need to treat the three groups of patients in different ways in the caring situation.

Transacting self-preservation: a grounded theory of the spiritual dimensions of people with terminal cancer

This study describes the spiritual meanings people with terminal cancer give to their everyday life-experiences. Transcriptions from semi-structured, in-depth interviews of 19 adults who had a diagnosis of cancer and who were living in Queensland and New South Wales, Australia, were analysed using the constant comparative approach of grounded theory. The study found that people with terminal cancer develop a spiritual perspective that strengthens their approaches to life and death. Their discovery of spiritual meaning is enacted through a process of transacting self-preservation. This process incorporates three phases, taking it all in, getting on with things and putting it all together. As people with terminal cancer move through these phases they transact self-preservation by discovering deeper levels of understanding self. This discovery of self incorporates a higher level of spiritual growth, spiritual perspective, spiritual awareness and spiritual experiences. The study indicates that nurses can help people with terminal cancer develop coping strategies that allow them to engage in the process of transacting self-preservation. This study also shows that there needs to be more emphasis on spirituality, spiritual issues and the role of spiritual caring in nursing curricula and practice.

Replenishing the spirit by meditative prayer and guided imagery

OBJECTIVES

To review relevant literature describing prayer and guided imagery, and to demonstrate via the use of a vignette, the use of both prayer and guided imagery as one approach to offer spiritual care to oncology patients.

DATA SOURCES

Review and research articles from multiple disciplines, and personal clinical experience.

CONCLUSION

Meditative prayer and guided imagery are two approaches that can be used to provide spiritual care to cancer patients and families. While research has focused on elements of spirituality, research related to clinical interventions is limited.

IMPLICATIONS FOR NURSING PRACTICE

Guided imagery, metaphors, meditative prayer, and prayers of silence are effective approaches the nurse can implement when caring for the patient with cancer.

Dungan model of dynamic integration

TOPIC

The Dungan Model of Dynamic Integration (DMDI), which views humans as having three synergistic dimensions of body, mind, and spirit.

PURPOSE

To present a new nursing model for practice and education.

SOURCE

This is the author's model and it is composed of concepts and constructs that are well-documented in nursing literature.

CONCLUSIONS

Dynamic Integration is a broad conceptual model that allows for testing a number of mid-range theories to add to the science and discipline of nursing.