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Abstract
Thought leaders in palliative care have long recognized the spiritual implications of illness, including Dame Cicely Saunders' groundbreaking concept of suffering as comprising physical, emotional, social, and spiritual sources of pain. However, despite such recognition, spirituality remains an oft-neglected component of the biopsychosocial spiritual model of caregiving in serious illness. We aim in this article to highlight, through an in-depth account of patients' experiences and attitudes, the concept of illness as a spiritual event.
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Affiliation(s)
- Tracy A Balboni
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA.
| | - Michael J Balboni
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Koss SE, Weissman R, Chow V, Smith PT, Slack B, Voytenko V, Balboni TA, Balboni MJ. Training Community Clergy in Serious Illness: Balancing Faith and Medicine. J Relig Health 2018; 57:1413-1427. [PMID: 29876716 PMCID: PMC6281818 DOI: 10.1007/s10943-018-0645-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Community-based clergy are highly engaged in helping seriously ill patients address spiritual concerns at the end of life (EOL). While they desire EOL training, no data exist in guiding how to conceptualize a clergy-training program. The objective of this study was used to identify best practices in an EOL training program for community clergy. As part of the National Clergy Project on End-of-Life Care, the project conducted key informant interviews and focus groups with active clergy in five US states (California, Illinois, Massachusetts, New York, and Texas). A diverse purposive sample of 35 active clergy representing pre-identified racial, educational, theological, and denominational categories hypothesized to be associated with more intensive utilization of medical care at the EOL. We assessed suggested curriculum structure and content for clergy EOL training through interviews and focus groups for the purpose of qualitative analysis. Thematic analysis identified key themes around curriculum structure, curriculum content, and issues of tension. Curriculum structure included ideas for targeting clergy as well as lay congregational leaders and found that clergy were open to combining resources from both religious and health-based institutions. Curriculum content included clergy desires for educational topics such as increasing their medical literacy and reviewing pastoral counseling approaches. Finally, clergy identified challenging barriers to EOL training needing to be openly discussed, including difficulties in collaborating with medical teams, surrounding issues of trust, the role of miracles, and caution of prognostication. Future EOL training is desired and needed for community-based clergy. In partnering together, religious-medical training programs should consider curricula sensitive toward structure, desired content, and perceived clergy tensions.
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Affiliation(s)
- Sarah E Koss
- Harvard Divinity School, Cambridge, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ross Weissman
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Graduate School of Education, Cambridge, MA, USA
| | - Vinca Chow
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Patrick T Smith
- Harvard Medical School Center for Bioethics, Boston, MA, USA
- Gordon-Conwell Theological Seminary, S. Hamilton, MA, USA
| | | | | | - Tracy A Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Initiative on Health Religion and Spirituality within Harvard, Boston, MA, USA
| | - Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
- Initiative on Health Religion and Spirituality within Harvard, Boston, MA, USA.
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Balboni MJ, Sullivan A, Smith PT, Zaidi D, Mitchell C, Tulsky JA, Sulmasy DP, VanderWeele TJ, Balboni TA. The Views of Clergy Regarding Ethical Controversies in Care at the End of Life. J Pain Symptom Manage 2018; 55:65-74.e9. [PMID: 28818632 PMCID: PMC5735011 DOI: 10.1016/j.jpainsymman.2017.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/19/2017] [Accepted: 05/09/2017] [Indexed: 11/22/2022]
Abstract
CONTEXT Although religion often informs ethical judgments, little is known about the views of American clergy regarding controversial end-of-life ethical issues including allowing to die and physician aid in dying or physician-assisted suicide (PAD/PAS). OBJECTIVE To describe the views of U.S. clergy concerning allowing to die and PAD/PAS. METHODS A survey was mailed to 1665 nationally representative clergy between 8/2014 to 3/2015 (60% response rate). Outcome variables included beliefs about whether the terminally ill should ever be "allowed to die" and moral/legal opinions concerning PAD/PAS. RESULTS Most U.S. clergy are Christian (98%). Clergy agreed that there are circumstances in which the terminally ill should be "allowed to die" (80%). A minority agreed that PAD/PAS was morally (28%) or legally (22%) acceptable. Mainline/Liberal Christian clergy were more likely to approve of the morality (56%) and legality (47%) of PAD/PAS, in contrast to all other clergy groups (6%-17%). Greater end-of-life medical knowledge was associated with moral disapproval of PAD/PAS (adjusted odds ratio [AOR], 1.51; 95% CI, 1.04-2.19, P = 0.03). Those reporting distrust in health care were less likely to oppose legalization of PAD/PAS (AOR 0.93; 95% CI, 0.87-0.99, P < 0.02). Religious beliefs associated with disapproval of PAD/PAS included "life's value is not tied to the patient's quality of life" (AOR 2.12; 95% CI, 0.1.49-3.03, P < 0.001) and "only God numbers our days" (AOR 2.60; 95% CI, 1.77-3.82, P < 0.001). CONCLUSION Most U.S. clergy approve of "allowing to die" but reject the morality or legalization of PAD/PAS. Respectful discussion in public discourse should consider rather than ignore underlying religious reasons informing end-of-life controversies.
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Affiliation(s)
- Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA.
| | - Adam Sullivan
- Department of Biostatistics, Brown University, Providence, Rhode Island, USA
| | - Patrick T Smith
- Harvard Medical School Center for Bioethics, Boston, Massachusetts, USA
| | - Danish Zaidi
- Harvard Medical School Center for Bioethics, Boston, Massachusetts, USA
| | | | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Tyler J VanderWeele
- Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Departments of Epidemiology and Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; and Brigham and Women's Hospital, Boston, Massachusetts, USA
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Balboni MJ, Sullivan A, Enzinger AC, Smith PT, Mitchell C, Peteet JR, Tulsky JA, VanderWeele T, Balboni TA. U.S. Clergy Religious Values and Relationships to End-of-Life Discussions and Care. J Pain Symptom Manage 2017; 53:999-1009. [PMID: 28185893 PMCID: PMC5474165 DOI: 10.1016/j.jpainsymman.2016.12.346] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 12/27/2016] [Accepted: 12/29/2016] [Indexed: 11/24/2022]
Abstract
CONTEXT Although clergy interact with approximately half of U.S. patients facing end-of-life medical decisions, little is known about clergy-congregant interactions or clergy influence on end-of-life decisions. OBJECTIVE The objective was to conduct a nationally representative survey of clergy beliefs and practices. METHODS A mailed survey to a nationally representative sample of clergy completed in March 2015 with 1005 of 1665 responding (60% response rate). The primary predictor variable was clergy religious values about end-of-life medical decisions, which measured belief in miracles, the sanctity of life, trust in divine control, and redemptive suffering. Outcome variables included clergy-congregant end-of-life medical conversations and congregant receipt of hospice and intensive care unit (ICU) care in the final week of life. RESULTS Most U.S. clergy are Christian (98%) and affirm religious values despite a congregant's terminal diagnosis. Endorsement included God performing a miracle (86%), pursuing treatment because of the sanctity of life (54%), postponement of medical decisions because God is in control (28%), and enduring painful treatment because of redemptive suffering (27%). Life-prolonging religious values in end-of-life medical decisions were associated with fewer clergy-congregant conversations about considering hospice (adjusted odds ratio [AOR], 0.58; 95% CI 0.42-0.80), P < 0.0001), stopping treatment (AOR 0.58, 95% CI 0.41-0.84, P = 0.003), and forgoing future treatment (AOR 0.50, 95% CI 0.36-0.71, P < 0.001) but not associated with congregant receipt of hospice or ICU care. Clergy with lower medical knowledge were less likely to have certain end-of-life conversations. The absence of a clergy-congregant hospice discussion was associated with less hospice (AOR 0.45; 95% CI 0.29-0.66, P < 0.001) and more ICU care (AOR 1.67; 95% CI 1.14-2.50, P < 0.01) in the final week of life. CONCLUSION American clergy hold religious values concerning end-of-life medical decisions, which appear to decrease end-of-life discussions. Clergy end-of-life education may enable better quality end-of-life care for religious patients.
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Affiliation(s)
- Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA.
| | - Adam Sullivan
- Department of Biostatistics, Brown University, Providence, Rhode Island
| | - Andrea C Enzinger
- Departments of Medical Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Patrick T Smith
- Harvard Medical School Center for Bioethics, Boston, Massachusetts, USA; Gordon-Conwell Theological Seminary, S. Hamilton, Massachusetts, USA
| | - Christine Mitchell
- Department of Social and Behavioral Health, Harvard School of Public Health, Boston, Massachusetts, USA
| | - John R Peteet
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tyler VanderWeele
- Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Department of Epidemiology and Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Brigham and Women's Hospital, Boston, Massachusetts, USA
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Sanders JJ, Chow V, Enzinger AC, Lam TC, Smith PT, Quiñones R, Baccari A, Philbrick S, White-Hammond G, Peteet J, Balboni TA, Balboni MJ. Seeking and Accepting: U.S. Clergy Theological and Moral Perspectives Informing Decision Making at the End of Life. J Palliat Med 2017; 20:1059-1067. [PMID: 28387570 DOI: 10.1089/jpm.2016.0545] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND People with serious illness frequently rely on religion/spirituality to cope with their diagnosis, with potentially positive and negative consequences. Clergy are uniquely positioned to help patients consider medical decisions at or near the end of life within a religious/spiritual framework. OBJECTIVE We aimed to examine clergy knowledge of end-of-life (EOL) care and beliefs about the role of faith in EOL decision making for patients with serious illness. DESIGN Key informant interviews, focus groups, and survey. SETTING/SUBJECTS A purposive sample of 35 active clergy in five U.S. states as part of the National Clergy End-of-Life Project. MEASUREMENT We assessed participant knowledge of and desire for further education about EOL care. We transcribed interviews and focus groups for the purpose of qualitative analysis. RESULTS Clergy had poor knowledge of EOL care; 75% desired more EOL training. Qualitative analysis revealed a theological framework for decision making in serious illness that balances seeking life and accepting death. Clergy viewed comfort-focused treatments as consistent with their faith traditions' views of a good death. They employed a moral framework to determine the appropriateness of EOL decisions, which weighs the impact of multiple factors and upholds the importance of God-given free will. They viewed EOL care choices to be the primary prerogative of patients and families. Clergy described ambivalence about and a passive approach to counseling congregants about decision making despite having defined beliefs regarding EOL care. CONCLUSIONS Poor knowledge of EOL care may lead clergy to passively enable congregants with serious illness to pursue potentially nonbeneficial treatments that are associated with increased suffering.
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Affiliation(s)
- Justin J Sanders
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,11 Brigham and Women's Hospital , Boston, Massachusetts
| | - Vinca Chow
- 2 Department of Anesthesia, Duke University , Durham, North Carolina
| | - Andrea C Enzinger
- 3 Departments of Medical Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Tai-Chung Lam
- 4 Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, University of Hong Kong , Hong Kong, China
| | - Patrick T Smith
- 5 Harvard Medical School Center for Bioethics , Boston, Massachusetts.,6 Gordon-Conwell Theological Seminary , South Hamilton, Massachusetts
| | - Rebecca Quiñones
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | | | - Sarah Philbrick
- 8 Kirksville College of Osteopathic Medicine, A.T. Still University , Kirksville, Missouri
| | | | - John Peteet
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Tracy A Balboni
- 10 Department of Radiation Oncology, Dana-Farber Cancer Institute , Boston, Massachusetts.,11 Brigham and Women's Hospital , Boston, Massachusetts.,12 Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts
| | - Michael J Balboni
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,12 Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts
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Mitchell CM, Epstein-Peterson ZD, Bandini J, Amobi A, Cahill J, Enzinger A, Noveroske S, Peteet J, Balboni T, Balboni MJ. Developing a Medical School Curriculum for Psychological, Moral, and Spiritual Wellness: Student and Faculty Perspectives. J Pain Symptom Manage 2016; 52:727-736. [PMID: 27693904 PMCID: PMC5319601 DOI: 10.1016/j.jpainsymman.2016.05.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/31/2016] [Accepted: 05/20/2016] [Indexed: 11/30/2022]
Abstract
CONTEXT Although many studies have addressed the integration of a religion and/or spirituality curriculum into medical school training, few describe the process of curriculum development based on qualitative data from students and faculty. OBJECTIVES The aim of this study is to explore the perspectives of medical students and chaplaincy trainees regarding the development of a curriculum to facilitate reflection on moral and spiritual dimensions of caring for the critically ill and to train students in self-care practices that promote professionalism. METHODS Research staff conducted semiscripted and one-on-one interviews and focus groups. Respondents also completed a short and self-reported demographic questionnaire. Participants included 44 students and faculty members from Harvard Medical School and Harvard Divinity School, specifically senior medical students and divinity school students who have undergone chaplaincy training. RESULTS Two major qualitative themes emerged: curriculum format and curriculum content. Inter-rater reliability was high (kappa = 0.75). With regard to curriculum format, most participants supported the curriculum being longitudinal, elective, and experiential. With regard to curriculum content, five subthemes emerged: personal religious and/or spiritual (R/S) growth, professional integration of R/S values, addressing patient needs, structural and/or institutional dynamics within the health care system, and controversial social issues. CONCLUSION Qualitative findings of this study suggest that development of a future medical school curriculum on R/S and wellness should be elective, longitudinal, and experiential and should focus on the impact and integration of R/S values and self-care practices within self, care for patients, and the medical team. Future research is necessary to study the efficacy of these curricula once implemented.
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Affiliation(s)
- Christine M Mitchell
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Julia Bandini
- Department of Sociology, Brandeis University, Waltham, Massachusetts, USA
| | - Ada Amobi
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Cahill
- Theology Department, Boston College, Chestnut Hill, Massachusetts, USA
| | - Andrea Enzinger
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sarah Noveroske
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - John Peteet
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tracy Balboni
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael J Balboni
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
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Bandini J, Mitchell C, Epstein-Peterson ZD, Amobi A, Cahill J, Peteet J, Balboni T, Balboni MJ. Student and Faculty Reflections of the Hidden Curriculum. Am J Hosp Palliat Care 2016; 34:57-63. [DOI: 10.1177/1049909115616359] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The hidden curriculum, or the socialization process of medical training, plays a crucial role in the development of physicians, as they navigate the clinical learning environment. The purpose of this qualitative study was to examine medical faculty and students’ perceptions of psychological, moral, and spiritual challenges during medical training in caring for critically ill patients. Focus groups were conducted with 25 Harvard Medical School (HMS) students, and interviews were conducted with 8 HMS faculty members. Five major themes emerged as important in shaping students’ medical training experiences. First, students and faculty discussed the overall significance of the hidden curriculum in terms of the hierarchy of medicine, behavioral modeling, and the value placed on research versus clinical work. Second, respondents articulated values modeled in medicine. Third, students and faculty reflected on changes in student development during their training, particularly in terms of changes in empathy and compassion. Fourth, respondents discussed challenges faced in medical school including professional clinical education and the psychosocial aspects of medical training. Finally, students and faculty articulated a number of coping mechanisms to mitigate these challenges including reflection, prayer, repression, support systems, creative outlets, exercise, and separation from one’s work. The results from this study suggest the significance of the hidden curriculum on medical students throughout their training, as they learn to navigate challenging and emotional experiences. Furthermore, these results emphasize an increased focus toward the effect of the hidden curriculum on students’ development in medical school, particularly noting the ways in which self-reflection may benefit students.
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Affiliation(s)
- Julia Bandini
- Department of Sociology, Brandeis University, Waltham, MA, USA
| | - Christine Mitchell
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, USA
| | | | - Ada Amobi
- Harvard Medical School Boston, Boston, MA, USA
| | | | - John Peteet
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School Boston, Boston, MA, USA
| | - Tracy Balboni
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School Boston, Boston, MA, USA
| | - Michael J. Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School Boston, Boston, MA, USA
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LeBaron VT, Smith PT, Quiñones R, Nibecker C, Sanders JJ, Timms R, Shields AE, Balboni TA, Balboni MJ. How Community Clergy Provide Spiritual Care: Toward a Conceptual Framework for Clergy End-of-Life Education. J Pain Symptom Manage 2016; 51:673-681. [PMID: 26706624 PMCID: PMC5987222 DOI: 10.1016/j.jpainsymman.2015.11.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/18/2015] [Accepted: 11/21/2015] [Indexed: 11/22/2022]
Abstract
CONTEXT Community-based clergy are highly engaged in helping terminally ill patients address spiritual concerns at the end of life (EOL). Despite playing a central role in EOL care, clergy report feeling ill-equipped to spiritually support patients in this context. Significant gaps exist in understanding how clergy beliefs and practices influence EOL care. OBJECTIVES The objective of this study was to propose a conceptual framework to guide EOL educational programming for community-based clergy. METHODS This was a qualitative, descriptive study. Clergy from varying spiritual backgrounds, geographical locations in the U.S., and race/ethnicities were recruited and asked about optimal spiritual care provided to patients at the EOL. Interviews were audio taped, transcribed, and analyzed following principles of grounded theory. A final set of themes and subthemes were identified through an iterative process of constant comparison. Participants also completed a survey regarding experiences ministering to the terminally ill. RESULTS A total of 35 clergy participated in 14 individual interviews and two focus groups. Primary themes included Patient Struggles at EOL and Clergy Professional Identity in Ministering to the Terminally Ill. Patient Struggles at EOL focused on existential questions, practical concerns, and difficult emotions. Clergy Professional Identity in Ministering to the Terminally Ill was characterized by descriptions of Who Clergy Are ("Being"), What Clergy Do ("Doing"), and What Clergy Believe ("Believing"). "Being" was reflected primarily by manifestations of presence; "Doing" by subthemes of religious activities, spiritual support, meeting practical needs, and mistakes to avoid; "Believing" by subthemes of having a relationship with God, nurturing virtues, and eternal life. Survey results were congruent with interview and focus group findings. CONCLUSION A conceptual framework informed by clergy perspectives of optimal spiritual care can guide EOL educational programming for clergy.
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Affiliation(s)
- Virginia T LeBaron
- University of Virginia School of Nursing, Charlottesville, Virginia, USA.
| | - Patrick T Smith
- Harvard Medical School Center for Bioethics, Boston, Massachusetts, USA; Gordon-Conwell Theological Seminary, Boston, Massachusetts, USA
| | | | | | | | | | - Alexandra E Shields
- Harvard/MGH Center on Genomics, Vulnerable Populations and Health Disparities, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality, Harvard University, Cambridge, Massachusetts, USA
| | - Michael J Balboni
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality, Harvard University, Cambridge, Massachusetts, USA
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Affiliation(s)
- Tracy A Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - George Fitchett
- Department of Religion, Health, and Human Values, Rush University Medical Center, Chicago, Illinois
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Balboni MJ, Bandini J, Mitchell C, Epstein-Peterson ZD, Amobi A, Cahill J, Enzinger AC, Peteet J, Balboni T. Religion, Spirituality, and the Hidden Curriculum: Medical Student and Faculty Reflections. J Pain Symptom Manage 2015; 50:507-15. [PMID: 26025271 PMCID: PMC5267318 DOI: 10.1016/j.jpainsymman.2015.04.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/13/2015] [Accepted: 04/24/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT Religion and spirituality play an important role in physicians' medical practice, but little research has examined their influence within the socialization of medical trainees and the hidden curriculum. OBJECTIVES The objective is to explore the role of religion and spirituality as they intersect with aspects of medicine's hidden curriculum. METHODS Semiscripted, one-on-one interviews and focus groups (n = 33 respondents) were conducted to assess Harvard Medical School student and faculty experiences of religion/spirituality and the professionalization process during medical training. Using grounded theory, theme extraction was performed with interdisciplinary input (medicine, sociology, and theology), yielding a high inter-rater reliability score (kappa = 0.75). RESULTS Three domains emerged where religion and spirituality appear as a factor in medical training. First, religion/spirituality may present unique challenges and benefits in relation to the hidden curriculum. Religious/spiritual respondents more often reported to struggle with issues of personal identity, increased self-doubt, and perceived medical knowledge inadequacy. However, religious/spiritual participants less often described relationship conflicts within the medical team, work-life imbalance, and emotional stress arising from patient suffering. Second, religion/spirituality may influence coping strategies during encounters with patient suffering. Religious/spiritual trainees described using prayer, faith, and compassion as means for coping whereas nonreligious/nonspiritual trainees discussed compartmentalization and emotional repression. Third, levels of religion/spirituality appear to fluctuate in relation to medical training, with many trainees experiencing an increase in religiousness/spirituality during training. CONCLUSION Religion/spirituality has a largely unstudied but possibly influential role in medical student socialization. Future study is needed to characterize its function within the hidden curriculum.
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Affiliation(s)
- Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
| | - Julia Bandini
- Department of Sociology, Brandeis University, Waltham, Massachusetts, USA
| | - Christine Mitchell
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts, USA
| | | | - Ada Amobi
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Cahill
- Theology Department, Boston College, Chestnut Hill, Massachusetts, USA
| | - Andrea C Enzinger
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - John Peteet
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Tracy Balboni
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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LeBaron VT, Cooke A, Resmini J, Garinther A, Chow V, Quiñones R, Noveroske S, Baccari A, Smith PT, Peteet J, Balboni TA, Balboni MJ. Clergy Views on a Good Versus a Poor Death: Ministry to the Terminally Ill. J Palliat Med 2015; 18:1000-7. [PMID: 26317801 DOI: 10.1089/jpm.2015.0176] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Clergy are often important sources of guidance for patients and family members making medical decisions at the end-of-life (EOL). Previous research revealed spiritual support by religious communities led to more aggressive care at the EOL, particularly among minority patients. Understanding this phenomenon is important to help address disparities in EOL care. OBJECTIVE The study objective was to explore and describe clergy perspectives regarding "good" versus "poor" death within the participant's spiritual tradition. METHODS This was a qualitative, descriptive study. Community clergy from various spiritual backgrounds, geographical locations within the United States, and races/ethnicities were recruited. Participants included 35 clergy who participated in one-on-one interviews (N = 14) and two focus groups (N = 21). Semistructured interviews explored clergy viewpoints on factors related to a "good death." Principles of grounded theory were used to identify a final set of themes and subthemes. RESULTS A good death was characterized by wholeness and certainty and emphasized being in relationship with God. Conversely, a "poor death" was characterized by separation, doubt, and isolation. Clergy identified four primary determinants of good versus poor death: dignity, preparedness, physical suffering, and community. Participants expressed appreciation for contextual factors that affect the death experience; some described a "middle death," or one that integrates both positive and negative elements. Location of death was not viewed as a significant contributing factor. CONCLUSIONS Understanding clergy perspectives regarding quality of death can provide important insights to help improve EOL care, particularly for patients highly engaged with faith communities. These findings can inform initiatives to foster productive relationships between clergy, clinicians, and congregants and reduce health disparities.
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Affiliation(s)
| | - Amanda Cooke
- 3 Beth Israel Deaconness Medical Center , Boston, Massachusetts
| | | | | | - Vinca Chow
- 6 Brigham & Women's Hospital , Boston, Massachusetts
| | - Rebecca Quiñones
- 2 Dana-Farber Cancer Institute, Harvard Cancer Center , Boston, Massachusetts
| | - Sarah Noveroske
- 2 Dana-Farber Cancer Institute, Harvard Cancer Center , Boston, Massachusetts
| | | | - Patrick T Smith
- 8 Gordon-Conwell Theological Seminary , Boston, Massachusetts
| | - John Peteet
- 2 Dana-Farber Cancer Institute, Harvard Cancer Center , Boston, Massachusetts
| | - Tracy A Balboni
- 2 Dana-Farber Cancer Institute, Harvard Cancer Center , Boston, Massachusetts
| | - Michael J Balboni
- 2 Dana-Farber Cancer Institute, Harvard Cancer Center , Boston, Massachusetts
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12
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Zollfrank AA, Trevino KM, Cadge W, Balboni MJ, Thiel MM, Fitchett G, Gallivan K, VanderWeele T, Balboni TA. Teaching health care providers to provide spiritual care: a pilot study. J Palliat Med 2015; 18:408-14. [PMID: 25871494 DOI: 10.1089/jpm.2014.0306] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Health care providers' lack of education on spiritual care is a significant barrier to the integration of spiritual care into health care services. OBJECTIVE The study objective was to describe the training program, Clinical Pastoral Education for Healthcare Providers (CPE-HP) and evaluate its impact on providers' spiritual care skills. METHODS Fifty CPE-HP participants completed self-report surveys at baseline and posttraining measuring frequency of and confidence in providing religious/spiritual (R/S) care. Four domains were assessed: (1) ability and (2) frequency of R/S care provision; (3) comfort using religious language; and (4) confidence in providing R/S care. RESULTS At baseline, participants rated their ability to provide R/S care and comfort with religious language as "fair." In the previous two weeks, they reported approximately two R/S patient conversations, initiated R/S conversations less than twice, and prayed with patients less than once. Posttraining participants' reported ability to provide spiritual care increased by 33% (p<0.001). Their comfort using religious language improved by 29% (p<0.001), and frequency of R/S care increased 75% (p<0.001). Participants reported having 61% more (p<0.001) R/S conversations and more frequent prayer with patients (95% increase; p<0.001). Confidence in providing spiritual care improved by 36% overall, by 20% (p<0.001) with religiously concordant patients, and by 43% (p<0.001) with religiously discordant patients. CONCLUSIONS This study suggests that CPE-HP is an effective approach for training health care providers in spiritual care. Dissemination of this training may improve integration of spiritual care into health care, thereby strengthening comprehensive patient-centered care.
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Abstract
The integration of medicine and religion is challenging for historical, ethical, practical and conceptual reasons. In order to make more explicit the bases and goals of relating spirituality and medicine, we distinguish here three complementary perspectives: a whole-person care model that emphasizes teamwork among generalists and spiritual professionals; an existential functioning view that identifies a role for the clinician in promoting full health, including spiritual well-being; and an open pluralism view, which highlights the importance of differing spiritual and cultural traditions in shaping the relationship.
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Affiliation(s)
- Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02115, USA
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14
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Balboni MJ, Sullivan A, Enzinger AC, Epstein-Peterson ZD, Tseng YD, Mitchell C, Niska J, Zollfrank A, VanderWeele TJ, Balboni TA. Nurse and physician barriers to spiritual care provision at the end of life. J Pain Symptom Manage 2014; 48:400-10. [PMID: 24480531 PMCID: PMC4569089 DOI: 10.1016/j.jpainsymman.2013.09.020] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 09/24/2013] [Accepted: 10/04/2013] [Indexed: 10/25/2022]
Abstract
CONTEXT Spiritual care (SC) from medical practitioners is infrequent at the end of life (EOL) despite national standards. OBJECTIVES The study aimed to describe nurses' and physicians' desire to provide SC to terminally ill patients and assess 11 potential SC barriers. METHODS This was a survey-based, multisite study conducted from October 2008 through January 2009. All eligible oncology nurses and physicians at four Boston academic centers were approached for study participation; 339 nurses and physicians participated (response rate=63%). RESULTS Most nurses and physicians desire to provide SC within the setting of terminal illness (74% vs. 60%, respectively; P=0.002); however, 40% of nurses/physicians provide SC less often than they desire. The most highly endorsed barriers were "lack of private space" for nurses and "lack of time" for physicians, but neither was associated with actual SC provision. Barriers that predicted less frequent SC for all medical professionals included inadequate training (nurses: odds ratio [OR]=0.28, 95% confidence interval [CI]=0.12-0.73, P=0.01; physicians: OR=0.49, 95% CI=0.25-0.95, P=0.04), "not my professional role" (nurses: OR=0.21, 95% CI=0.07-0.61, P=0.004; physicians: OR=0.35, 95% CI=0.17-0.72, P=0.004), and "power inequity with patient" (nurses: OR=0.33, 95% CI=0.12-0.87, P=0.03; physicians: OR=0.41, 95% CI=0.21-0.78, P=0.007). A minority of nurses and physicians (21% and 49%, P=0.003, respectively) did not desire SC training. Those less likely to desire SC training reported lower self-ratings of spirituality (nurses: OR=5.00, 95% CI=1.82-12.50, P=0.002; physicians: OR=3.33, 95% CI=1.82-5.88, P<0.001) and male gender (physicians: OR=3.03, 95% CI=1.67-5.56, P<0.001). CONCLUSION SC training is suggested to be critical to the provision of SC in accordance with national care quality standards.
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Affiliation(s)
- Michael J Balboni
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Center for Psychosocial Epidemiology and Outcomes Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; McGraw/Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Adam Sullivan
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Andrea C Enzinger
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Center for Psychosocial Epidemiology and Outcomes Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; McGraw/Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Yolanda D Tseng
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christine Mitchell
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joshua Niska
- Harvard Medical School, Boston, Massachusetts, USA
| | - Angelika Zollfrank
- Department of Chaplaincy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tyler J VanderWeele
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA; Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Center for Psychosocial Epidemiology and Outcomes Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; McGraw/Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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15
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Epstein-Peterson ZD, Sullivan AJ, Enzinger AC, Trevino KM, Zollfrank AA, Balboni MJ, VanderWeele TJ, Balboni TA. Examining Forms of Spiritual Care Provided in the Advanced Cancer Setting. Am J Hosp Palliat Care 2014; 32:750-7. [PMID: 25005589 DOI: 10.1177/1049909114540318] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Spiritual care (SC) is important to the care of seriously ill patients. Few studies have examined types of SC provided and their perceived impact. This study surveyed patients with advanced cancer (N = 75, response rate [RR] = 73%) and oncology nurses and physicians (N = 339, RR = 63%). Frequency and perceived impact of 8 SC types were assessed. Spiritual care is infrequently provided, with encouraging or affirming beliefs the most common type (20%). Spiritual history taking and chaplaincy referrals comprised 10% and 16%, respectively. Most patients viewed each SC type positively, and SC training predicted provision of many SC types. In conclusion, SC is infrequent, and core elements of SC-spiritual history taking and chaplaincy referrals-represent a minority of SC. Spiritual care training predicts provision of SC, indicting its importance to advancing SC in the clinical setting.
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Affiliation(s)
| | - Adam J Sullivan
- Departments of Biostatistics and Epidemiology, School of Public Health, Harvard University, Boston, MA, USA
| | - Andrea C Enzinger
- Harvard Medical School, Harvard University, Boston, MA, USA Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kelly M Trevino
- Department of Psychology, Rowan University, Glassboro, NJ, USA
| | | | - Michael J Balboni
- Harvard Medical School, Harvard University, Boston, MA, USA Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tyler J VanderWeele
- Departments of Biostatistics and Epidemiology, School of Public Health, Harvard University, Boston, MA, USA
| | - Tracy A Balboni
- Harvard Medical School, Harvard University, Boston, MA, USA Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
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16
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Affiliation(s)
- Tai Chung Lam
- Dana-Farber Cancer Institute/Brigham and Women's Cancer Center, Boston, MA
| | - Tracy A. Balboni
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Michael J. Balboni
- Center for Psychosocial Epidemiology and Outcomes Research, Dana-Farber Cancer Institute, Boston, MA
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17
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Abstract
Despite the difficulty in clearly defining and measuring spirituality, a growing literature describes its importance in oncology and survivorship. Religious/spiritual beliefs influence patients' decision-making with respect to both complementary therapies and aggressive care at the end of life. Measures of spirituality and spiritual well-being correlate with quality of life in cancer patients, cancer survivors, and caregivers. Spiritual needs, reflective of existential concerns in several domains, are a source of significant distress, and care for these needs has been correlated with better psychological and spiritual adjustment as well as with less aggressive care at the end of life. Studies show that while clinicians such as nurses and physicians regard some spiritual care as an appropriate aspect of their role, patients report that they provide it infrequently. Many clinicians report that their religious/spiritual beliefs influence their practice, and practices such as mindfulness have been shown to enhance clinician self-care and equanimity. Challenges remain in the areas of conceptualizing and measuring spirituality, developing and implementing training for spiritual care, and coordinating and partnering with chaplains and religious communities.
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Affiliation(s)
- John R Peteet
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
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18
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Balboni TA, Maciejewski PK, Balboni MJ, Enzinger AC, Paulk ME, Munoz F, Rivera L, Mutchler J, Finlay E, Marr L, McCorkle R, Temel JS, Weeks JC, Vanderweele TJ, Prigerson HG. Racial/ethnic differences in end-of-life (EoL) treatment preferences: The role of religious beliefs about care. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.6529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6529 Background: Racial/ethnic minorities and patients who turn to religion to cope receive more aggressive EOL care. Beliefs underlying these associations are unknown. Methods: Coping with Cancer is an ongoing, multi-site, NCI-funded study examining factors influencing racial/ethnic EoL disparities. From 11/2010-10/2012, 133 advanced cancer patients underwent baseline interviews, including 7 items assessing religious beliefs about EoL care (RBEC). Univariate analyses assessed racial/ethnic differences in RBEC and EoL treatment preferences. Multivariable analyses (MVA) modeled mean RBEC score as a function of race/ethnicity, controlling for confounders, and assessed the relationship of race/ethnicity and RBEC to treatment preferences. Results: Religious beliefs about EoL care are common and more often held by racial/ethnic minorities (Table); racial/ethnic differences persisted in MVA (p<.0001). Black patients were more likely than Whites to prefer aggressive EOL care (OR=5.03, p=.02), whereas Latino’s EOL preferences did not differ from Whites (p=.87). In MVA including race and RBEC score, Black race was not related to EOL care preferences (OR 1.61, p=0.55), whereas greater RBEC score was associated with greater preference for aggressive care (OR 2.48, p=0.003). Conclusions: Religious beliefs about EoL care are common and significantly more so among racial/ethnic minorities. Preliminary data suggest these beliefs mediate the relationship between race/ethnicity and EoL treatment preferences. [Table: see text]
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Affiliation(s)
- Tracy A. Balboni
- Center for Psychosocial Epidemiology and Outcomes Research, Boston, MA
| | | | | | | | | | | | | | | | | | - Lisa Marr
- University of New Mexico, Albuquerque, NM
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19
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Balboni MJ, Sullivan A, Amobi A, Phelps AC, Gorman DP, Zollfrank A, Peteet JR, Prigerson HG, Vanderweele TJ, Balboni TA. Why is spiritual care infrequent at the end of life? Spiritual care perceptions among patients, nurses, and physicians and the role of training. J Clin Oncol 2012; 31:461-7. [PMID: 23248245 DOI: 10.1200/jco.2012.44.6443] [Citation(s) in RCA: 273] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine factors contributing to the infrequent provision of spiritual care (SC) by nurses and physicians caring for patients at the end of life (EOL). PATIENTS AND METHODS This is a survey-based, multisite study conducted from March 2006 through January 2009. All eligible patients with advanced cancer receiving palliative radiation therapy and oncology physician and nurses at four Boston academic centers were approached for study participation; 75 patients (response rate = 73%) and 339 nurses and physicians (response rate = 63%) participated. The survey assessed practical and operational dimensions of SC, including eight SC examples. Outcomes assessed five factors hypothesized to contribute to SC infrequency. RESULTS Most patients with advanced cancer had never received any form of spiritual care from their oncology nurses or physicians (87% and 94%, respectively; P for difference = .043). Majorities of patients indicated that SC is an important component of cancer care from nurses and physicians (86% and 87%, respectively; P = .1). Most nurses and physicians thought that SC should at least occasionally be provided (87% and 80%, respectively; P = .16). Majorities of patients, nurses, and physicians endorsed the appropriateness of eight examples of SC (averages, 78%, 93%, and 87%, respectively; P = .01). In adjusted analyses, the strongest predictor of SC provision by nurses and physicians was reception of SC training (odds ratio [OR] = 11.20, 95% CI, 1.24 to 101; and OR = 7.22, 95% CI, 1.91 to 27.30, respectively). Most nurses and physicians had not received SC training (88% and 86%, respectively; P = .83). CONCLUSION Patients, nurses, and physicians view SC as an important, appropriate, and beneficial component of EOL care. SC infrequency may be primarily due to lack of training, suggesting that SC training is critical to meeting national EOL care guidelines.
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Affiliation(s)
- Michael J Balboni
- Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA 02115, USA
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20
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Abstract
Social forces have continually framed how hospitals perceive their role in care of the dying. Hospitals were originally conceived as places of hospitality and spiritual care, but by the 18th century illness was an opponent, conquered through science. Medicalization transformed hospitals to places of physical cure and scientific prowess. Death was an institutional liability. Equipped with new technologies, increased public demand, and the establishment of Medicare in 1965, modern hospitals became the most likely place for Americans to die—increasing after the 1940s and spiking in the 1990s. Medicare’s 1983 hospice benefit began to reverse this trend. Palliative care has more recently proliferated, suggesting an institutional shift of alignment with traditional functions of care toward those facing death.
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Affiliation(s)
- Guenter B. Risse
- Affiliate Professor of Bioethics and Humanities, University of Washington School of Medicine; Department of Anthropology, History, and Social Medicine, University of California at San Francisco, CA, USA
| | - Michael J. Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
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21
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Epstein-Peterson Z, Sullivan A, Phelps AC, Balboni MJ, Vanderweele TJ, Balboni TA. Spiritual care provided by oncology physicians and nurses to advanced cancer patients. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.9116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9116 Background: For many patients facing a diagnosis of advanced cancer, religion and/or spirituality (R/S) play an important role in coping with illness. Data suggest that cancer patients receiving spiritual care (SC) have better quality of life and receive less futile, aggressive interventions at the end of life. National palliative care guidelines include SC as a key component of end-of-life care. However, current SC practices and the role clinicians should play in SC provision remain unclear. Methods: The Religion and Spirituality in Cancer Care (RSCC) study is a survey-based, cross-sectional study of oncology physicians and nurses and advanced cancer patients from five Boston-area institutions. The survey elicited respondents’ R/S beliefs/practices, their views on the appropriateness of SC in the advanced cancer care setting, and their experiences in giving or receiving SC (e.g., spiritual history, referrals to chaplains). In total, 68 patients, 204 physicians, and 114 nurses responded (response rates: patients = 73%; clinicians = 63%). Multivariable analyses (MVAs) were performed to determine predictors (e.g., clinician demographics, R/S, spiritual care training) of SC provision by clinicians. Results: All respondents reported a low frequency of SC provision, with only 9% of patients receiving SC from physicians, 20% from nurses, and physicians reporting performing SC during only 8% of interactions, nurses during 12% of interactions. In MVAs, prior training in spiritual care was significantly associated with SC provision (OR physicians 5.89, CI 2.14-16.22; OR nurses 10.42, CI 1.30-89.19), as was the provider identifying as being spiritual (OR 3.85 physicians CI, 2.12-6.98; OR 2.92 nurses CI, 1.15-7.42). Conclusions: These data highlight the current inadequacies of SC provision by clinicians, despite national palliative care guidelines, and underscore the central role of SC training for doctors and nurses, as this was the strongest predictor of SC provision. Given the important role that SC has in end-of-life care and the paucity of data guiding its provision, we hope this research will advance the understanding of how to integrate SC into end-of-life care, and ultimately improve patient outcomes at the end-of-life.
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Affiliation(s)
| | - Adam Sullivan
- Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | - Andrea C. Phelps
- Center for Psychooncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, MA
| | - Michael J. Balboni
- Center for Psychooncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, MA
| | | | - Tracy A. Balboni
- Center for Psychooncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, MA
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22
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Vallurupalli M, Lauderdale K, Balboni MJ, Phelps AC, Block SD, Ng AK, Kachnic LA, Vanderweele TJ, Balboni TA. The role of spirituality and religious coping in the quality of life of patients with advanced cancer receiving palliative radiation therapy. J Support Oncol 2012; 10:81-7. [PMID: 22088828 PMCID: PMC3391969 DOI: 10.1016/j.suponc.2011.09.003] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 08/31/2011] [Accepted: 09/01/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVES National palliative care guidelines outline spiritual care as a domain of palliative care, yet patients' religiousness and/or spirituality (R/S) are underappreciated in the palliative oncology setting. Among patients with advanced cancer receiving palliative radiation therapy (RT), this study aims to characterize patient spirituality, religiousness, and religious coping; examine the relationships of these variables to quality of life (QOL); and assess patients' perceptions of spiritual care in the cancer care setting. METHODS This is a multisite, cross-sectional survey of 69 patients with advanced cancer (response rate = 73%) receiving palliative RT. Scripted interviews assessed patient spirituality, religiousness, religious coping, QOL (McGill QOL Questionnaire), and perceptions of the importance of attention to spiritual needs by health providers. Multivariable models assessed the relationships of patient spirituality and R/S coping to patient QOL, controlling for other significant predictors of QOL. RESULTS Most participants (84%) indicated reliance on R/S beliefs to cope with cancer. Patient spirituality and religious coping were associated with improved QOL in multivariable analyses (β = 10.57, P < .001 and β = 1.28, P = .01, respectively). Most patients considered attention to spiritual concerns an important part of cancer care by physicians (87%) and nurses (85%). LIMITATIONS Limitations include a small sample size, a cross-sectional study design, and a limited proportion of nonwhite participants (15%) from one US region. CONCLUSION Patients receiving palliative RT rely on R/S beliefs to cope with advanced cancer. Furthermore, spirituality and religious coping are contributors to better QOL. These findings highlight the importance of spiritual care in advanced cancer care.
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Winkelman WD, Lauderdale K, Balboni MJ, Phelps AC, Peteet JR, Block SD, Kachnic LA, VanderWeele TJ, Balboni TA. The relationship of spiritual concerns to the quality of life of advanced cancer patients: preliminary findings. J Palliat Med 2011; 14:1022-8. [PMID: 21767165 DOI: 10.1089/jpm.2010.0536] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Religion and/or spirituality (R/S) have increasingly been recognized as key elements in patients' experience of advanced illness. This study examines the relationship of spiritual concerns (SCs) to quality of life (QOL) in patients with advanced cancer. PATIENTS AND METHODS Patients were recruited between March 3, 2006 and April 14, 2008 as part of a survey-based study of 69 cancer patients receiving palliative radiotherapy. Sixteen SCs were assessed, including 11 items assessing spiritual struggles (e.g., feeling abandoned by God) and 5 items assessing spiritual seeking (e.g., seeking forgiveness, thinking about what gives meaning in life). The relationship of SCs to patient QOL domains was examined using univariable and multivariable regression analysis. RESULTS Most patients (86%) endorsed one or more SCs, with a median of 4 per patient. Younger age was associated with a greater burden of SCs (β = -0.01, p = 0.006). Total spiritual struggles, spiritual seeking, and SCs were each associated with worse psychological QOL (β = -1.11, p = 0.01; β = -1.67, p < 0.05; and β = -1.06, p < 0.001). One of the most common forms of spiritual seeking (endorsed by 54%)--thinking about what gives meaning to life--was associated with worse psychological and overall QOL (β = - 5.75, p = 0.02; β = -12.94, p = 0.02). Most patients (86%) believed it was important for health care professionals to consider patient SCs within the medical setting. CONCLUSIONS SCs are associated with poorer QOL among advanced cancer patients. Furthermore, most patients view attention to SCs as an important part of medical care. These findings underscore the important role of spiritual care in palliative cancer management.
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Balboni MJ, Babar A, Dillinger J, Phelps AC, George E, Block SD, Kachnic L, Hunt J, Peteet J, Prigerson HG, VanderWeele TJ, Balboni TA. "It depends": viewpoints of patients, physicians, and nurses on patient-practitioner prayer in the setting of advanced cancer. J Pain Symptom Manage 2011; 41:836-47. [PMID: 21276700 PMCID: PMC3391979 DOI: 10.1016/j.jpainsymman.2010.07.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 07/19/2010] [Accepted: 07/29/2010] [Indexed: 11/19/2022]
Abstract
CONTEXT Although prayer potentially serves as an important practice in offering religious/spiritual support, its role in the clinical setting remains disputed. Few data exist to guide the role of patient-practitioner prayer in the setting of advanced illness. OBJECTIVES To inform the role of prayer in the setting of life-threatening illness, this study used mixed quantitative-qualitative methods to describe the viewpoints expressed by patients with advanced cancer, oncology nurses, and oncology physicians concerning the appropriateness of clinician prayer. METHODS This is a cross-sectional, multisite, mixed-methods study of advanced cancer patients (n=70), oncology physicians (n=206), and oncology nurses (n=115). Semistructured interviews were used to assess respondents' attitudes toward the appropriate role of prayer in the context of advanced cancer. Theme extraction was performed based on interdisciplinary input using grounded theory. RESULTS Most advanced cancer patients (71%), nurses (83%), and physicians (65%) reported that patient-initiated patient-practitioner prayer was at least occasionally appropriate. Furthermore, clinician prayer was viewed as at least occasionally appropriate by the majority of patients (64%), nurses (76%), and physicians (59%). Of those patients who could envision themselves asking their physician or nurse for prayer (61%), 86% would find this form of prayer spiritually supportive. Most patients (80%) viewed practitioner-initiated prayer as spiritually supportive. Open-ended responses regarding the appropriateness of patient-practitioner prayer in the advanced cancer setting revealed six themes shaping respondents' viewpoints: necessary conditions for prayer, potential benefits of prayer, critical attitudes toward prayer, positive attitudes toward prayer, potential negative consequences of prayer, and prayer alternatives. CONCLUSION Most patients and practitioners view patient-practitioner prayer as at least occasionally appropriate in the advanced cancer setting, and most patients view prayer as spiritually supportive. However, the appropriateness of patient-practitioner prayer is case specific, requiring consideration of multiple factors.
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Affiliation(s)
- Michael J Balboni
- Center for Psycho-Oncology and Palliative Care Research, Department of Psycho-Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts 02120, USA.
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Alcorn SR, Balboni MJ, Prigerson HG, Reynolds A, Phelps AC, Wright AA, Block SD, Peteet JR, Kachnic LA, Balboni TA. "If God wanted me yesterday, I wouldn't be here today": religious and spiritual themes in patients' experiences of advanced cancer. J Palliat Med 2010; 13:581-8. [PMID: 20408763 DOI: 10.1089/jpm.2009.0343] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This study sought to inductively derive core themes of religion and/or spirituality (R/S) active in patients' experiences of advanced cancer to inform the development of spiritual care interventions in the terminally ill cancer setting. METHODS This is a multisite, cross-sectional, mixed-methods study of randomly-selected patients with advanced cancer (n = 68). Scripted interviews assessed the role of R/S and R/S concerns encountered in the advanced cancer experience. Qualitative and quantitative data were analyzed. Theme extraction was performed with interdisciplinary input (sociology of religion, medicine, theology), utilizing grounded theory. Spearman correlations determined the degree of association between R/S themes. Predictors of R/S concerns were assessed using linear regression and analysis of variance. RESULTS Most participants (n = 53, 78%) stated that R/S had been important to the cancer experience. In descriptions of how R/S was related to the cancer experience, five primary R/S themes emerged: coping, practices, beliefs, transformation, and community. Most interviews (75%) contained two or more R/S themes, with 45% mentioning three or more R/S themes. Multiple significant subtheme interrelationships were noted between the primary R/S themes. Most participants (85%) identified 1 or more R/S concerns, with types of R/S concerns spanning the five R/S themes. Younger, more religious, and more spiritual patients identified R/S concerns more frequently (beta = -0.11, p < 0.001; beta = 0.83, p = 0.03; and beta = 0.89, p = 0.04, respectively). CONCLUSIONS R/S plays a variety of important and inter-related roles for most advanced cancer patients. Future research is needed to determine how spiritual care can incorporate these five themes and address R/S concerns.
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Affiliation(s)
- Sara R Alcorn
- Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Massachusetts 01225, USA
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Balboni TA, Balboni MJ, Prigerson HG. Reply to H.W.M. van Laarhoven et al. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.5536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Tracy A. Balboni
- Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, MA
| | - Michael J. Balboni
- Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute; and Boston University, Boston, MA
| | - Holly G. Prigerson
- Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute; and Harvard Medical School Center for Palliative Care, Boston, MA
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Balboni TA, Paulk ME, Balboni MJ, Phelps AC, Loggers ET, Wright AA, Block SD, Lewis EF, Peteet JR, Prigerson HG. Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. J Clin Oncol 2010; 28:445-52. [PMID: 20008625 PMCID: PMC2815706 DOI: 10.1200/jco.2009.24.8005] [Citation(s) in RCA: 297] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Accepted: 08/13/2009] [Indexed: 01/23/2023] Open
Abstract
PURPOSE To determine whether spiritual care from the medical team impacts medical care received and quality of life (QoL) at the end of life (EoL) and to examine these relationships according to patient religious coping. PATIENTS AND METHODS Prospective, multisite study of patients with advanced cancer from September 2002 through August 2008. We interviewed 343 patients at baseline and observed them (median, 116 days) until death. Spiritual care was defined by patient-rated support of spiritual needs by the medical team and receipt of pastoral care services. The Brief Religious Coping Scale (RCOPE) assessed positive religious coping. EoL outcomes included patient QoL and receipt of hospice and any aggressive care (eg, resuscitation). Analyses were adjusted for potential confounders and repeated according to median-split religious coping. RESULTS Patients whose spiritual needs were largely or completely supported by the medical team received more hospice care in comparison with those not supported (adjusted odds ratio [AOR] = 3.53; 95% CI, 1.53 to 8.12, P = .003). High religious coping patients whose spiritual needs were largely or completely supported were more likely to receive hospice (AOR = 4.93; 95% CI, 1.64 to 14.80; P = .004) and less likely to receive aggressive care (AOR = 0.18; 95% CI, 0.04 to 0.79; P = .02) in comparison with those not supported. Spiritual support from the medical team and pastoral care visits were associated with higher QOL scores near death (20.0 [95% CI, 18.9 to 21.1] v 17.3 [95% CI, 15.9 to 18.8], P = .007; and 20.4 [95% CI, 19.2 to 21.1] v 17.7 [95% CI, 16.5 to 18.9], P = .003, respectively). CONCLUSION Support of terminally ill patients' spiritual needs by the medical team is associated with greater hospice utilization and, among high religious copers, less aggressive care at EoL. Spiritual care is associated with better patient QoL near death.
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Affiliation(s)
- Tracy Anne Balboni
- Departments of Psycho-Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA 01225, USA.
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