Overview of spirituality in palliative care
- Christina M Puchalski, MD, MS, FACP
Christina M Puchalski, MD, MS, FACP
- Director and Professor
- George Washington Institute for Spirituality and Health, School of Medicine and Health Sciences
- The George Washington University, Washington, DC
- Betty Ferrell, PhD, MA, FAAN, FPCN
Betty Ferrell, PhD, MA, FAAN, FPCN
- Director and Professor, Division of Nursing Research and Education
- City of Hope Medical Center
- Shirley Otis-Green, MSW, LCSW, ACSW, OSW-C
Shirley Otis-Green, MSW, LCSW, ACSW, OSW-C
- Collaborative Caring
- George Handzo, BCC, CSSBB
George Handzo, BCC, CSSBB
- Director of Health Services Research & Quality
- HealthCare Chaplaincy, New York, NY
Spirituality is a fundamental element of human experience. It encompasses the individual’s search for meaning and purpose in life and the experience of the transcendent . Spirituality also encompasses the connections one makes with others, his or herself, nature, and to the sacred realms, inside as well as outside of traditional religion . Viewed in this way, spirituality can be a key factor in how people cope with illness, experience healing, and achieve a sense of coherence .
The diagnosis of chronic or life-threatening illness can lead to spiritual struggles for patients. The turmoil may be short for some patients and protracted for others as individuals attempt to make sense of the reality of their diagnosis with what gives them value and meaning in life. The journey may result in growth and transformation for some people, distress and despair for others, and both for many people .
Spiritual care is an essential domain of palliative care . This topic will provide an overview of key spiritual issues in palliative care, describe approaches to spiritual assessment in the clinical setting, and propose a way to integrate treatment of spiritual distress into a palliative care treatment or care plan. Specific discussions on the incorporation of palliative care with regard to various religious traditions (eg, Catholicism, Christianity, Judaism, Buddhism, or Islam, among others ) are beyond the scope of this topic. For more information regarding their role in clinical care, the clinician is advised to seek input from their local and institutionally based chaplaincy services.
A discussion about the influence of spirituality and religiousness on outcomes (ie, healthcare decision making, quality of life) in palliative care patients is provided separately. (See "Influence of spirituality and religiousness on outcomes in palliative care patients".)
For purposes of this discussion, the following definitions will apply:
- Puchalski C, Ferrell B, Virani R, et al. Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference. J Palliat Med 2009; 12:885.
- Norris L, Walseman K, Puchalski CM. Communicating About Spiritual Issues with Cancer Patients. In: New Challenges in Communication with Cancer Patients, Surbone A, et al (Eds), Springer, New York 2012.
- Pargament KI, Koenig HG, Tarakeshwar N, Hahn J. Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: a two-year longitudinal study. J Health Psychol 2004; 9:713.
- National Consensus Project. Clinical Practice Guidelines for Quality Palliative Care www.nationalconsensusproject.org/Guidelines_Download2.aspx (Accessed on April 20, 2016).
- Puchalski C, Ferrel B, O'Donnel E. Spiritual Issues in Palliative Care. In: Oxford American Handbook of Hispice and Palliative Care, 2011. p.253.
- Balboni TA, Paulk ME, Balboni MJ, et al. 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.
- General Information About Spirituality. http://www.cancer.gov/cancertopics/pdq/supportivecare/spirituality/Patient/page1 (Accessed on February 24, 2014).
- Bolton D. What's the problem? A response to "secular humanism and scientific psychiatry". Philos Ethics Humanit Med 2006; 1:E6.
- American Nurses Association and Health Ministries Association. Faith and Community Nursing: Scope and Standards of Practice, American Nurses Association, Silver Spring, MD 2005.
- Cassell EJ. The nature of suffering: physical, psychological, social, and spiritual aspects. NLN Publ 1992; :1.
- Boudreau JD, Cassell EJ, Fuks A. A healing curriculum. Med Educ 2007; 41:1193.
- Sulmasy DP. A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist 2002; 42 Spec No 3:24.
- Lucchese FA, Koenig HG. Religion, spirituality and cardiovascular disease: research, clinical implications, and opportunities in Brazil. Rev Bras Cir Cardiovasc 2013; 28:103.
- Sun V, Kim JY, Irish TL, et al. Palliative care and spiritual well-being in lung cancer patients and family caregivers. Psychooncology 2015.
- Hermann CP. Spiritual needs of dying patients: a qualitative study. Oncol Nurs Forum 2001; 28:67.
- Ross L, Austin J. Spiritual needs and spiritual support preferences of people with end-stage heart failure and their carers: implications for nurse managers. J Nurs Manag 2015; 23:87.
- Murray SA, Kendall M, Boyd K, et al. Exploring the spiritual needs of people dying of lung cancer or heart failure: a prospective qualitative interview study of patients and their carers. Palliat Med 2004; 18:39.
- Silvestri GA, Knittig S, Zoller JS, Nietert PJ. Importance of faith on medical decisions regarding cancer care. J Clin Oncol 2003; 21:1379.
- Balboni T, Balboni M, Paulk ME, et al. Support of cancer patients' spiritual needs and associations with medical care costs at the end of life. Cancer 2011; 117:5383.
- McCord G, Gilchrist VJ, Grossman SD, et al. Discussing spirituality with patients: a rational and ethical approach. Ann Fam Med 2004; 2:356.
- Puchalski CM. Spiritual assessment in clinical practice. Psychiat Ann 2006; 36:150.
- Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician 2001; 63:81.
- Ehman JW, Ott BB, Short TH, et al. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999; 159:1803.
- Astrow AB, Puchalski CM, Sulmasy DP. Religion, spirituality, and health care: social, ethical, and practical considerations. Am J Med 2001; 110:283.
- Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med 2000; 3:129.
- Vallurupalli M, Lauderdale K, Balboni MJ, et al. 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.
- Hills J, Paice JA, Cameron JR, Shott S. Spirituality and distress in palliative care consultation. J Palliat Med 2005; 8:782.
- Tarakeshwar N, Vanderwerker LC, Paulk E, et al. Religious coping is associated with the quality of life of patients with advanced cancer. J Palliat Med 2006; 9:646.
- Thuné-Boyle IC, Stygall JA, Keshtgar MR, Newman SP. Do religious/spiritual coping strategies affect illness adjustment in patients with cancer? A systematic review of the literature. Soc Sci Med 2006; 63:151.
- Johnson ME, Piderman KM, Sloan JA, et al. Measuring spiritual quality of life in patients with cancer. J Support Oncol 2007; 5:437.
- Gall TL, Cornblat MW. Breast cancer survivors give voice: a qualitative analysis of spiritual factors in long-term adjustment. Psychooncology 2002; 11:524.
- Ferrell BR, Grant MM, Funk BM, et al. Quality of life in breast cancer survivors: implications for developing support services. Oncol Nurs Forum 1998; 25:887.
- Cancer Institute. Facing Forward: Life after cancer treatment. National Cancer Institute, Bethesda, MD. http://www.cancer.gov/cancertopics/coping/life-after-treatment (Accessed on November 01, 2011).
- O'Brien MR, Clark D. Spirituality and/or religious faith: A means for coping with the effects of amyotrophic lateral sclerosis/motor neuron disease? Palliat Support Care 2015; 13:1603.
- Harrison MO, Edwards CL, Koenig HG, et al. Religiosity/spirituality and pain in patients with sickle cell disease. J Nerv Ment Dis 2005; 193:250.
- Somlai AM, Kelly JA, Kalichman SC, et al. An empirical investigation of the relationship between spirituality, coping, and emotional distress in people living with HIV infection and AIDS. J Pastoral Care 1996; 50:181.
- Beuscher L, Beck C. A literature review of spirituality in coping with early-stage Alzheimer's disease. J Clin Nurs 2008; 17:88.
- Wirth AG, Büssing A. Utilized Resources of Hope, Orientation, and Inspiration in Life of Persons with Multiple Sclerosis and Their Association with Life Satisfaction, Adaptive Coping Strategies, and Spirituality. J Relig Health 2016; 55:1359.
- Bekelman DB, Dy SM, Becker DM, et al. Spiritual well-being and depression in patients with heart failure. J Gen Intern Med 2007; 22:470.
- Lin HR, Bauer-Wu SM. Psycho-spiritual well-being in patients with advanced cancer: an integrative review of the literature. J Adv Nurs 2003; 44:69.
- Brady MJ, Peterman AH, Fitchett G, et al. A case for including spirituality in quality of life measurement in oncology. Psychooncology 1999; 8:417.
- Breitbart W, Gibson C, Tremblay A. The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics 2002; 43:183.
- Greenstein M, Breitbart W. Cancer and the experience of meaning: a group psychotherapy program for people with cancer. Am J Psychother 2000; 54:486.
- Chang BH, Stein NR, Skarf LM. Spiritual distress of military veterans at the end of life. Palliat Support Care 2015; 13:635.
- Puchalski CM, Ferrell B. Making Health Care Whole: Integrating Spirituality Into Patient Care, Templeton Press, West Conshohocken 2010. p.99.
- Delgado-Guay MO, Chisholm G, Williams J, et al. Frequency, intensity, and correlates of spiritual pain in advanced cancer patients assessed in a supportive/palliative care clinic. Palliat Support Care 2016; 14:341.
- Borneman T, Ferrell B, Puchalski CM. Evaluation of the FICA Tool for Spiritual Assessment. J Pain Symptom Manage 2010; 40:163.
- The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL. The Joint Commission, 2010. http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf (Accessed on July 25, 2012).
- Maugans TA. The SPIRITual history. Arch Fam Med 1996; 5:11.
- Puchalski CM, Ferrell B. Making Health Care Whole: Integrating Spirituality into Patient Care, Templeton Press, West Conshohocken 2010. p.76.
- Nelson CJ, Rosenfeld B, Breitbart W, Galietta M. Spirituality, religion, and depression in the terminally ill. Psychosomatics 2002; 43:213.
- McClain CS, Rosenfeld B, Breitbart W. Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients. Lancet 2003; 361:1603.
- Whitford HS, Olver IN, Peterson MJ. Spirituality as a core domain in the assessment of quality of life in oncology. Psychooncology 2008; 17:1121.
- Munoz AR, Salsman JM, Stein KD, Cella D. Reference values of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being: a report from the American Cancer Society's studies of cancer survivors. Cancer 2015; 121:1838.
- McCoubrie RC, Davies AN. Is there a correlation between spirituality and anxiety and depression in patients with advanced cancer? Support Care Cancer 2006; 14:379.
- Paloutzian RF, Ellison CW. Loneliness, spiritual wellbeing, and the quality of life. In: Loneliness: a source book of current theory, research, and therapy, Peplau LA, Perlman D. (Eds), Wiley, New York 1982. p.224-237.
- Fitchett G, Canada AL. The Role of Religion/Spirituality in Coping with Cancer: Evidence, Assessment, and Intervention. In: Psycho-oncology, 2nd ed, Holland JC. (Ed), Oxford University Press, New York 2010.
- Shields M, Kestenbaum A, Dunn LB. Spiritual AIM and the work of the chaplain: a model for assessing spiritual needs and outcomes in relationship. Palliat Support Care 2015; 13:75.
- Bryson K. Guidelines for conducting a spiritual assessment. Palliat Support Care 2015; 13:91.
- Puchalski CM, Guenther M. Restoration and re-creation: spirituality in the lives of healthcare professionals. Curr Opin Support Palliat Care 2012; 6:254.
- Block SD. Perspectives on care at the close of life. Psychological considerations, growth, and transcendence at the end of life: the art of the possible. JAMA 2001; 285:2898.
- Lo B, Ruston D, Kates LW, et al. Discussing religious and spiritual issues at the end of life: a practical guide for physicians. JAMA 2002; 287:749.
- INFLUENCE OF SPIRITUALITY IN PALLIATIVE CARE
- Spiritual needs
- Spirituality and healthcare decision making
- Spiritual coping and support
- Spiritual well-being and quality of life
- Spiritual distress
- SPIRITUAL STRENGTH
- INTEGRATING SPIRITUALITY INTO PALLIATIVE CARE
- Spiritual screening
- Spiritual history
- - The FICA spiritual history tool
- Spiritual assessment
- APPROACHING SPIRITUAL DISTRESS
- The biopsychosocial and spiritual assessment and treatment plan
- Interdisciplinary collaboration
- Importance of the patient's community
- ADDRESSING SPIRITUALITY WITH PATIENTS
- SPIRITUALITY AT THE END OF LIFE
- SUMMARY AND RECOMMENDATIONS