National surveys consistently support the idea that religion and spirituality are important to most individuals in the general population. More than 90% of adults express a belief in God, and slightly more than 70% of individuals surveyed identified religion as one of the most important influences in their lives.[1] Yet even widely held beliefs, such as survival of the soul after death or a belief in miracles, vary substantially by gender, education, and ethnicity.[2]
Research indicates that both patients and family caregivers [3,4] commonly rely on spirituality and religion to help them deal with serious physical illnesses, with a desire to have specific spiritual and religious needs acknowledged or addressed by medical staff. These needs, although widespread, may take different forms between and within cultural and religious traditions.[5-7]
A survey of hospital inpatients found that 77% of them reported that physicians should take patients' spiritual needs into consideration, and 37% wanted physicians to address religious beliefs more frequently.[8] A large survey of cancer outpatients in New York City found that a slight majority felt it was appropriate for a physician to inquire about their religious beliefs and spiritual needs, although only 1% reported that this had occurred. Patients who reported that spiritual needs were not being met gave lower ratings to quality of care (P < .01) and reported lower satisfaction with care (P < .01).[7] A pilot study of 14 African American men with a history of prostate cancer found that most had discussed spirituality and religious beliefs with their physicians. They expressed a desire for their doctors and clergy to be in contact with each other.[9]
In addition, 61% of 57 inpatients with advanced cancer receiving end-of-life care in a hospital supported by the Catholic archdiocese reported spiritual distress when interviewed by hospital chaplains. The intensity of spiritual distress correlated with self-reports of depression but not with physical pain or perceived severity of illness.[10] Another study[11] of patients with advanced cancer (N = 230) in New England and Texas assessed spiritual needs. Almost half (47%) reported that their spiritual needs were not being met by a religious community, and 72% reported that these needs were not supported by the medical system. When such support existed, it was positively related to improved quality of life. Furthermore, having the medical care team address spiritual issues had more impact than did pastoral counseling on increasing hospice use and decreasing aggressive end-of-life measures.[12]
This summary will review the following topics:
Paying attention to the religious or spiritual beliefs of seriously ill patients has a long tradition within inpatient medical environments. Addressing such issues has been viewed as the domain of hospital chaplains or a patient’s own religious leader. In this context, systematic assessment has usually been limited to identifying a patient’s religious preference, while responsibility for management of apparent spiritual distress has fallen to the chaplain service.[13-15] Although health care providers may address such concerns themselves, they are generally very ambivalent about doing so,[16] and there has been relatively little systematic investigation addressing the physician’s role. These issues, however, are increasingly addressed in medical training.[17] Acknowledging the role of all health care professionals in spirituality, a multidisciplinary group from one cancer center developed a four-stage model that allows health care professionals to deliver spiritual care consistent with their knowledge, skills, and actions at one of four skill levels.[18]
Interest in and recognition of the function of religious and spiritual coping in adjustment to serious illness, including cancer, has been growing.[19-23] New ways to assess and address religious and spiritual concerns as part of overall quality of life are being developed and tested. Limited data support the possibility that spiritual coping is one of the most powerful means by which patients draw on their own resources to deal with a serious illness such as cancer. However, patients and their family caregivers may be reluctant to raise religious and spiritual concerns with their professional health care providers.[24-26] Increased spiritual well-being in a seriously ill population may be linked with lower anxiety about death,[27] but greater religious involvement may also be linked to an increased likelihood of desire for extreme measures at the end of life.[28] Given the importance of religion and spirituality to patients, integrating systematic assessment of such needs into medical care, including outpatient care, is crucial. The development of better assessment tools will make it easier to discern which aspects of religious and spiritual coping may be important in a particular patient’s adjustment to illness.
Of equal importance is the consideration of how and when to address religion and spirituality with patients and the best ways to do so in different medical environments.[29-31] Although addressing spiritual concerns is often considered an end-of-life issue, such concerns may arise at any time after diagnosis.[24] Acknowledging the importance of these concerns and addressing them, even briefly, at diagnosis may facilitate better adjustment throughout the course of treatment and create a context for richer dialogue later in the illness. One study of 118 patients seen in follow-up by one of four oncologists suggests that a semistructured inquiry into spiritual concerns related to coping with cancer is well accepted by patients and oncologists and is associated with positive perceptions of care and well-being.[32]
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.
Specific religious beliefs and practices should be distinguished from the idea of a universal capacity for spiritual and religious experiences. Although this distinction may not be salient or important on a personal basis, it is important conceptually for understanding various aspects of evaluation and the role of different beliefs, practices, and experiences in coping with cancer.
The most useful general distinction in this context is between religion and spirituality. There is no general agreement on definitions of either term, but there is general agreement on the usefulness of this distinction.[1-3]
In health care, concerns about spiritual or religious well-being have sometimes been viewed as an aspect of complementary and alternative medicine (CAM), but this perception may be more characteristic of providers than of patients. In one study,[5] virtually no patients but about 20% of providers said that CAM services were sought to assist with spiritual or religious issues.
Religion is highly culturally determined. Spirituality is considered a universal human capacity, usually—but not necessarily—associated with and expressed in religious practice. Most individuals consider themselves both spiritual and religious. Some may consider themselves religious but not spiritual; others, including some atheists (people who do not believe in the existence of God) or agnostics (people who believe that God cannot be shown to exist), may consider themselves spiritual but not religious. In a sample of 369 representative cancer outpatients in New York City (33% minority groups), 6% identified themselves as agnostic or atheist, 29% attended religious services weekly; and 66% represented themselves as spiritual but not religious.[6]
One effort to characterize individuals by types of spiritual and religious experience [7] identified the following three groups, using cluster analytic techniques:
Individuals in the third group were far more distressed about their illness and experienced worse adjustment than the other two groups. There is not yet consensus on the number or types of underlying dimensions of spirituality or religious engagement.
From the perspective of both the research and clinical literature on the relationships among religion, spirituality, and health, it is important to consider how investigators and authors define and use these concepts. Much of the epidemiological literature that indicates a relationship between religion and health is based on definitions of religious involvement such as:
Assessing specific beliefs or religious practices such as belief in God, frequency of prayer, or reading religious material is somewhat more complex. Individuals may engage in such practices or believe in God without necessarily attending services. Terminology also carries certain connotations. The term religiosity, for example, has a history of implying fervor and perhaps undue investment in particular religious practices or beliefs. The term religiousness may be a more neutral way to refer to the dimension of religious practice.
Spirituality and spiritual well-being are more challenging to define. Some definitions limit spirituality to mean profound mystical experiences. However, in effects on health and psychological well-being, the more helpful definitions focus on accessible feelings, such as:
This discussion assumes a continuum of meaningful spiritual experiences, from the common and accessible to the extraordinary and transformative. Both type and intensity of experience may vary. Other aspects of spirituality that have been identified by those working with patients include the following:
Low levels of these experiences may be associated with poorer coping.[3] For more information, see the Religion, Spirituality, and Living With Cancer section.
The definition of acute spiritual distress must be considered separately. Spiritual distress may result from the belief that cancer reflects punishment by God or may accompany a preoccupation with the question “Why me?” A cancer patient may also suffer a loss of faith.[8] Although many individuals may have such thoughts at some point after diagnosis, only a few become obsessed with these thoughts or score high on a general measure of religious and spiritual distress (such as the Negative subscale of the Religious Coping Scale).[8] High levels of spiritual distress may contribute to poorer health and psychosocial outcomes.[9,10] The tools for measuring these dimensions are described in the Screening and Assessment of Spiritual Concerns section.
Religion and spirituality have been shown to be significantly associated with measures of adjustment to cancer and with management of cancer symptoms in patients. Religious and spiritual coping have been associated with lower levels of patient discomfort as well as reduced hostility, anxiety, and social isolation in patients with cancer [1-4] and family caregivers.[5] Specific characteristics of strong religious beliefs, including hope, optimism, freedom from regret, and life satisfaction, have also been associated with improved adjustment in individuals diagnosed with cancer.[6,7]
Type of religious coping may influence quality of life. In a multi-institutional cross-sectional study of 170 patients with advanced cancer, more use of positive religious coping methods (such as benevolent religious appraisals) was associated with better overall quality of life and higher scores on the existential and support domains of the McGill Quality of Life Questionnaire. In contrast, more use of negative religious coping methods (such as anger at God) was related to poorer overall quality of life and lower scores on the existential and psychological domains.[8,9] A study of 95 patients with cancer diagnosed within the past 5 years found that spirituality was associated with less distress and better quality of life regardless of perceived life threat, with existential well-being but not religious well-being as the major contributor.[10]
Spiritual well-being, particularly a sense of meaning and peace,[11] is significantly associated with an ability of cancer patients to continue to enjoy life despite high levels of pain or fatigue. Spiritual well-being and depression are inversely related.[12,13] Higher levels of a sense of inner meaning and peace have also been associated with lower levels of depression, whereas measures of religiousness were unrelated to depression.[14]
This relationship has been specifically demonstrated in the cancer setting. In a cross-sectional survey of 85 hospice patients with cancer, there was a negative correlation between anxiety and depression (as measured by the Hospital Anxiety and Depression Scale) and overall spiritual well-being (as measured by the Spiritual Well-Being Scale) (P < .0001). There was also a negative correlation between the existential well-being scores and the anxiety and depression scores but not with the religious well-being score (P < .001).[15] These patterns were also found in a large study of indigent survivors of prostate cancer; the patterns were consistent across ethnicity and metastatic status.[16]
In a large (N = 418) study of breast cancer patients, a higher level of meaning and peace was associated with a decline in depression over 12 months, whereas higher religiousness predicted an increase in depression, particularly if the sense of meaning/peace was lower.[17][Level of evidence: II] A second study with mixed gender/mixed cancer survivors (N = 165) found similar patterns. In both studies, high levels of religiousness were linked to increases in perceived cancer-related growth.[17][Level of evidence: II] In a convenience sample, 222 low-income men with prostate cancer were surveyed about spirituality and health-related quality of life. Low scores in spirituality, as measured by the peace/meaning and faith subscale of the Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp), were associated with significantly worse physical and mental health than were high scores in spirituality.[18]
A large national survey of 361 paired U.S. survivors (52% women) and caregivers (including spouses and adult children) found that for both survivors and caregivers, the peace factor of the FACIT-Sp was strongly related to mental health but negligibly or not at all related to physical well-being. The faith factor (“religiousness”) was unrelated to physical or mental well-being.[19] These findings support the value of the FACIT-Sp in separating people’s religious involvement from their sense of spiritual well-being and that it is this sense of spiritual well-being that seems to be most related to psychological adjustment.
Another large national survey study of female family caregivers (N = 252; 89% White) found that higher levels of spirituality, as measured by the FACIT-Sp, were associated with much less psychological distress (measured by the Pearlin Stress Scale). Participants with higher levels of spirituality actually had improved well-being even as the stress caused by caregiving increased, while those with lower levels of spirituality showed the opposite pattern. This finding suggests a strong stress-buffering effect of spiritual well-being and reinforces the need to identify low spiritual well-being when assessing the coping capacity of family caregivers as well as patients.[5]
Data from the National Quality of Life Survey for Caregivers were used to examine the effects of spirituality on caregiving motivation and satisfaction. Caregivers received a baseline survey to measure motivation 2 years after a family member’s cancer diagnosis and again at 5 years after diagnosis. Male caregivers were more likely to report internal/spiritual motives for caregiving, whereas the motives of female caregivers were not related to internal/spiritual reasons. However, both men and women who were able to identify a sense of spiritual peace in their caregiving efforts had better mental health after 5 years of caregiving. Evidence suggests that caregiver motivation affects long-term mental health and quality of life.[20][Level of evidence: II]
One author [21] found that cancer survivors who had drawn on spiritual resources reported substantial personal growth as a function of dealing with the trauma of cancer. This finding was echoed in a survey study of 100 well-educated, mostly married/partnered White women with early-stage breast cancer, recruited from an Internet website. The study found that increasing levels of spiritual struggle were related to poorer emotional adjustment, though not to other aspects of cancer-related quality of life.[22] Using path analytic techniques, a study of women with breast cancer found that at both prediagnosis and 6 months postsurgery, holding negative images of God was the strongest predictor of emotional distress and lower social well-being.[23] However, longitudinal analyses failed to find sustained effects for baseline positive or negative attitudes toward God at either 6 or 12 months. One possible explanation for these findings is that such attitudes are somewhat unstable during a period of uncertainty (e.g., at prediagnosis).[23]
Engaging in prayer is often cited as an adaptive tool,[24] but qualitative research [25] found that for about one-third of cancer patients interviewed, concerns about how to pray effectively or the questions raised about the effectiveness of prayer also caused inner conflict and mild distress. In another study, of 123 patients hospitalized on a palliative care unit, 26.8% reported having used spiritual healing and prayer for curative purposes, 35% for improving survival, and 36.6% for improving symptoms (note: these percentages overlap). Higher levels of faith on the FACIT-Sp were associated with greater use of complementary and alternative medicine techniques in general and with interest in future use, whereas the level of meaning/peace was not. The study also looked at the general use of complementary therapies.[26] A useful discussion of how patients with cancer use prayer and how clinicians might conceptualize prayer has been published.[27]
Ethnicity and spirituality were investigated in a qualitative study of 161 breast cancer survivors.[28] In individual interviews, most participants (83%) spoke about some aspect of their spirituality. A higher percentage of African American, Latina, and Christian participants felt comforted by God than did those in other groups. Seven themes were identified:
One meta-analysis showed that positive religious involvement and spirituality appeared to be associated with better health and longer life expectancy, even after researchers controlled for other variables, such as health behaviors and social support.[29] Although little of this research is specific to cancer patients, one study of 230 patients with advanced cancer (expected prognosis <1 year) investigated a variety of associations between religiousness and spiritual support.[30] Most study participants (88%) considered religion either very important (68%) or somewhat important (20%), and more African American and Hispanic individuals than White individuals reported religion to be very important. Spiritual support by religious communities or the medical system was associated with better patient quality of life. Age was not associated with religiousness. At the time of recruitment, increasing self-reported distress was associated with increasing religiousness, and private religious or spiritual activities were performed by a larger percentage of patients after their diagnosis (61%) than before (47%). Regarding spiritual support, 38% reported that their spiritual needs were supported by a religious community “to a large extent or completely,” while 47% reported receiving support from a religious community “to a small extent or not at all.” Finally, religiousness was also associated with preference of “wanting all measures taken to extend life” at the end of life.
Another study [31] found that helper and cytotoxic T-cell counts were higher among women with metastatic breast cancer who reported greater importance of spirituality. Other investigators [32] found that attendance at religious services was associated with better immune system functioning. Still other research [33,34] suggests that religious distress negatively affects health status. These associations, however, have been criticized as weak and inconsistent.[35]
Several randomized trials with cancer patients have suggested that group support interventions benefit survival.[36,37] These studies must be interpreted cautiously, however. First, the treatments focused on general psychotherapeutic issues and psychosocial support. Although spiritually relevant issues undoubtedly arose in these settings, they were not the focus of the groups. Second, there has been difficulty replicating these effects.[38]
Raising spiritual concerns with patients can be accomplished by the following approaches:[1,2]
These approaches have different potential value and limitations. Patients may be reluctant to bring up spiritual issues and prefer to wait for the provider to broach the subject. Standardized assessment tools vary, have generally been designed for research purposes, and need to be reviewed and utilized appropriately by the provider. Physicians, unless trained specifically to address such issues, may feel uncomfortable raising spiritual concerns with patients.[3] However, an increasing number of models are available for physician use and training.[4]
Table 1 summarizes a selection of tools to assess religion and spirituality. Several factors should be considered before choosing an assessment tool:
The line between assessment and intervention is blurred, and simply inquiring about an area such as religious or spiritual coping may prompt the patient's desire to further explore and validate this experience. Evidence suggests that only a small proportion of patients view such an inquiry as intrusive and distressing. Key assessment approaches are briefly reviewed below; pertinent characteristics are summarized in Table 1.
One of several paper-and-pencil measures can be given to patients to assess religious and spiritual needs. These measures have the advantage of being self-administered; however, they were mostly designed as research tools, and their role for clinical assessment purposes is not as well understood. These measures may be helpful in opening up the topic for exploration and for ascertaining basic levels of religious engagement or spiritual well-being (or spiritual distress). Most tools assume a belief in God and may seem inappropriate for an atheist or agnostic patient, who may still be spiritually oriented. All of the measures have undergone varying degrees of psychometric development, and most are being used in investigations of the relationship between religion or spirituality, health indices, and adjustment to illness.
The questions are worded well and may provide a good initiation for further discussion and exploration.
The meaning and peace factor has been shown to have particularly strong associations with psychological adjustment, in that individuals who score high on this scale are much more likely to report enjoying life despite fatigue or pain, are less likely to desire a hastened death at the end of life,[13][Level of evidence: II] report better disease-specific and psychosocial adjustment,[14-16] and report lower levels of helplessness/hopelessness.[16] These associations have been shown to be independent of other indicators of adjustment, supporting the value of adding religious and spiritual assessment to standard quality-of-life evaluations.[10,16] Total scores on the FACIT-Sp correlated highly over time (27 weeks) with a 10-point linear analogue scale of spiritual well-being in a sample of patients with advanced cancer. The linear scale (Spiritual Well-Being Linear Analogue Self-Assessment ) was worded, “How would you describe your overall spiritual well-being?” Ratings ranged from 0 (as bad as it can be) to 10 (as good as it can be).[17]
Analyses show that the STS accounts for additional variance on depression, other measures of adjustment (Positive and Negative Affect Schedule), and the Daily Spiritual Experience Scale.[18] Individuals with stage III or IV cancer had higher SG scores, as did individuals with a recurrence rather than a new diagnosis. Individuals with higher SD scores were more likely to have not graduated from high school. A unique strength of this scale is that it is specific to change in spirituality since diagnosis; the wording of items is also generally appropriate for individuals who identify as spiritual rather than religious. Among the limitations is that development to date includes mostly observant Christians, with few minority individuals in the sample.
The following semistructured interviewing tools are designed to facilitate an exploration of religious beliefs and spiritual experiences or issues by the physician or other health care provider. The tools take the spiritual history approach and have the advantage of engaging the patient in dialogue, identifying possible areas of concern, and indicating the need to provide for further resources such as referral to a chaplain or support group. These approaches, however, have not been systematically investigated as empirical measures or indices of religiousness or of spiritual well-being or distress.
The six domains cover 22 items, which may be explored in as little as 10 or 15 minutes or integrated into general interviewing over several appointments. A strength of this tool is the number of questions pertinent to managing serious illness and understanding how patient religious beliefs may affect patient care decisions.
| Tool | Developer | Purpose/ Focus/ Subscale (No.) | Specific to Cancer Patients? | Level of Psychometric Development | Length/ Other Characteristics/ Comments |
|---|---|---|---|---|---|
| DRI/DUREL = Duke Religious Index; FACIT-Sp = Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being; FACT-G = Functional Assessment of Cancer Therapy–General; FICA = Faith, Importance/Influence, Community, and Address Spiritual History; RCOPE = Brief Measure of Religious Coping; SPIRIT = The SPIRITual History. | |||||
| Systems of Belief Inventory (SBI-15R) [7] | Holland et al. | Two factors: Beliefs/experience (10); religious social support (5) | Yes | High | Four items assume belief in God |
| DRI/DUREL [5] | Sherman et al. | Religious involvement (5) | Yes | Moderate | |
| FACIT-Sp [10,15] | Brady et al.; Peterman | Two factors: Meaning & peace (8), faith (4) | Yes | High. Limited cross-validation data. | Part of FACT-G quality-of-life battery [11] |
| Brief RCOPE [8] | Pargament et al. | Two factors: Positive coping; negative coping/distress | No | Very High | |
| Fetzer Multidimensional Scale [21] | Fetzer | Multiple subscales | No | High. Under development. | |
| FICA: Spiritual history [1] | Puchalski et al. | Brief spiritual history | No | Low | MD interview assessment |
| SPIRIT [19] | Maugans | In-depth interview with guided questions | No | Low | MD interview assessment |
| Spiritual Transformation Scale (STS) [18] | Cole et al. | Two factors: Spiritual Growth and Spiritual Decline | Yes | Moderate | Forty items. Unique to assessing change in spiritual experience post–cancer diagnosis. |
Various modes of intervention or assistance might be considered to address the spiritual concerns of patients, including the following:
Two survey studies [1,2] found that physicians consistently underestimate the degree to which patients want spiritual concerns addressed. An Israeli study found that patients expressed the desire that 18% of a hypothetical 10-minute visit be spent addressing such concerns, while their providers estimated that 12% of the time should be spent in this way.[2] This study also found that while providers perceived that a patient's desire to address spiritual concerns related to a broader interest in complementary and alternative medicine (CAM) modalities, patients viewed CAM-related issues and spiritual/religious concerns as quite separate.
A task force [3] of physicians and end-of-life specialists suggested several guidelines for physicians who wish to respond to patients’ spiritual concerns:
Inquiring about religious or spiritual concerns may provide valuable and appreciated support to patients. Most cancer patients appear to welcome a dialogue about such concerns, regardless of diagnosis or prognosis. In a large survey, 20% to 35% of outpatients with cancer expressed the following:[4][Level of evidence: II]
It is appropriate to initiate such an inquiry once initial diagnosis and treatment issues have been discussed and considered by the patient (approximately a month after diagnosis or later). In a large, multisite, longitudinal study of patients with advanced cancer,[5][Level of evidence: II] there was considerable variation in whether medical staff addressed spiritual concerns, with about 50% reporting at least some support at three of the settings, in contrast with fewer than 15% reporting some support at the other four settings.
Support from the medical team predicted the following:
One trial,[6][Level of evidence: II] with a sample of 115 mixed-diagnosis patients (54% under active treatment), evaluated a 5-minute semistructured inquiry into spiritual and religious concerns. The four physicians’ personal religious backgrounds included two Christians, one Hindu, and one Sikh; 81% of patients were Christian. Unlike the history-oriented interviews noted above, this inquiry was informed by brief patient-centered counseling approaches that view the physician as an important source of empowerment to help patients identify and address personal concerns (see Table 2 below for the content). After 3 weeks, the intervention group had larger reductions in depression, had more improvement in quality of life, and rated their relationship with the physician more favorably. Effects for quality of life remained after statistically adjusting for change in other variables. More improvement was also seen in patients who scored lower in spiritual well-being, as measured by the Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp) at baseline. Acceptability was high, with physicians rating themselves as “comfortable” in providing the intervention during 85% of encounters. Seventy-six percent of patients characterized the inquiry as “somewhat” to “very” useful. Physicians were twice as likely to underestimate the usefulness of the inquiry to patients rather than to overestimate it, in relation to patient ratings.
The statements in Table 2 may be used to initiate a dialogue between health care provider and patient.
| Health Care Provider Inquiry | Question for Patient |
|---|---|
| aAdapted from Kristeller et al.[6] | |
| Introduce issue in neutral inquiring manner. | “When dealing with a serious illness, many people draw on religious or spiritual beliefs to help cope. It would be helpful to me to know how you feel about this.” |
| Inquire further, adjusting inquiry to patient’s initial response. | Positive-Active Faith Response: “What have you found most helpful about your beliefs since your illness?” |
| Neutral-Receptive Response: “How might you draw on your faith or spiritual beliefs to help you?” | |
| Spiritually Distressed Response (e.g., expression of anger or guilt): “Many people feel that way…what might help you come to terms with this?” | |
| Defensive/Rejecting Response: “It sounds like you’re uncomfortable I brought this up. What I’m really interested in is how you are coping…can you tell me about that?” | |
| Continue to explore further as indicated. | “I see. Can you tell me more (about…)?” |
| Inquire about ways of finding meaning and a sense of peace. | “Is there some way in which you are able to find a sense of meaning or peace in the midst of this?” |
| Inquire about resources. | "Who can you talk to about these concerns?" |
| Offer assistance as appropriate and available. | “Perhaps we can arrange for you to talk to someone/There’s a support group I can suggest/There are some reading materials in the waiting room.” |
| Bring inquiry to a close. | “I appreciate you discussing these issues with me. May I ask about it again?” |
A common concern is whether to offer to pray with patients. Although one study [7] found that more than one-half of the patients surveyed expressed a desire to have physicians pray with them, a large proportion did not express this preference. A qualitative study of cancer patients [8] found that they were concerned that physicians are too busy, not interested, or even prohibited from discussing religion. At the same time, patients generally wanted their physicians to acknowledge the value of spiritual and religious issues. A suggestion was made that physicians might raise the question of prayer by asking, “Would that comfort you?”
In a study of 70 patients with advanced cancer, 206 oncology physicians, and 115 oncology nurses, all participants were interviewed about the appropriateness of patient-practitioner prayer in the advanced-cancer setting. Results showed that 71% of patients, 83% of nurses, and 65% of physicians reported that it is occasionally appropriate for a practitioner to pray with a patient when the patient initiates the request. Similarly, 64% of patients, 76% of nurses, and 59% of physicians reported that they consider it appropriate for a religious/spiritual health care practitioner to pray for a patient.[9]
The most important guideline is to remain sensitive to the patient’s preference. Asking patients about their beliefs or spiritual concerns in the context of exploring how they are coping in general is the most viable approach in exploring these issues.
Traditionally, hospital chaplains deliver religious or spiritual assistance to patients.[10,11] Hospital chaplains can play a key role because they are trained to work with a wide range of issues as they arise for patients and to be sensitive to patients' diverse beliefs and concerns.[12] Chaplains are generally available in large medical centers but may not be reliably available in smaller hospitals. Chaplains are rarely available in outpatient settings where most cancer care is now delivered (especially early in the course of cancer treatment, when these issues may first arise). In a large, multisite, longitudinal study of patients with advanced cancer,[5][Level of evidence: II] only 46% of patients reported receiving pastoral care visits. While these visits were not associated with receiving end-of-life care (either hospice or aggressive measures), they were associated with better quality of life near death.
Another traditional approach in outpatient settings is having spiritual/religious resources available in waiting rooms. This activity is relatively easy to do, and many resources exist. A breadth of resources covering all faith backgrounds of patients is highly desirable. For more information, see the Additional Resources section.
Support groups may provide a setting where patients may explore spiritual concerns. The health care provider may need to identify whether an in-person or online group addresses these issues. The published data on the specific effects of support groups on assisting with spiritual concerns is relatively sparse, partly because this aspect of adjustment has not been systematically evaluated. A randomized trial [13][Level of evidence: I] compared the effects of a mind-body-spirit group to a standard support group for women with breast cancer. Both groups showed improvement in spiritual well-being, although there were appreciably more differential effects for the mind-body-spirit group in the area of spiritual integration.
A study of 97 lower-income women with breast cancer who were participating in an online support group examined the relationship between a variety of psychosocial outcomes and religious expression (as indicated by the use of religious words such as faith, God, pray, holy, or spirit). Results showed that women who communicated a deeper religiousness in their online writing to others had lower levels of negative emotions, higher levels of perceived health self-efficacy, and higher functional well-being.[14] An exploratory study of a monthly spirituality-based support group program for African American women with breast cancer suggested high levels of satisfaction in a sample that already had high levels of religious and spiritual engagement.[15][Level of evidence: III]
One author [16] presents a well-developed model of adjuvant psychological therapy that uses a large group format and addresses both basic coping issues and spiritual concerns and healing, using a combination of group exploration, meditation, prayer, and other spiritually oriented exercises. In a carefully conducted, longitudinal, qualitative study of 22 patients enrolled in this type of intervention,[17] researchers found that patients who were more psychologically engaged with the issues presented were more likely to survive longer. Other approaches are available but have yet to be systematically evaluated,[18,19] have not explicitly addressed religious and spiritual issues, or have failed to evaluate the effects of the intervention on spiritual well-being.[20]
Other therapies may also support spiritual growth and post-traumatic benefit finding. For example, in a nonrandomized comparison of mindfulness-based stress reduction (n = 60) and a healing arts program (n = 44) in cancer outpatients with a variety of diagnoses, both programs significantly improved facilitation of positive growth in participants, although improvements in spirituality, stress, depression, and anger were significantly larger for the mindfulness-based stress reduction group.[21][Level of evidence: II]
Many health care providers may regard spirituality, religion, death, and dying as a taboo subject. The meaning of illness and the possibility of death are often difficult to address. The assessment resources noted above may help introduce the topic of spiritual concerns, death, and dying to a patient in a supportive manner. In addition, reading clinical accounts by other health care providers can be helpful. For example, a qualitative study using an autoethnographic approach to explore spirituality in members of an interdisciplinary palliative care team. Findings from this work yielded a collective spirituality that emerged from the common goals, values, and belonging shared by team members. Participants' reflections offer insights into patient care for other health care professionals.[1]
Although a considerable number of anecdotal accounts suggest that prayer, meditation, imagery, or other religious activity can have healing power, the empirical evidence is extremely limited and inconsistent.[1] On the basis of current evidence, it is questionable whether any patient with cancer should be encouraged to seek such resources as a means to heal or to limit the physical effects of disease. However, the psychological value of support and spiritual well-being is increasingly well documented, and evidence that spiritual distress can have a negative impact on health is growing. Health care providers need to frame these resources in terms of self-understanding, clarifying questions of belief with an appropriate spiritual or religious leader, or seeking a sense of inner peace or awareness.
These reference citations are included for informational purposes only. Their inclusion should not be viewed as an endorsement by the PDQ Supportive and Palliative Care Editorial Board or the National Cancer Institute.
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This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about religious and spiritual coping in cancer care. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.
This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewer for Spirituality in Cancer Care is:
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The preferred citation for this PDQ summary is:
PDQ® Supportive and Palliative Care Editorial Board. PDQ Spirituality in Cancer Care. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/coping/day-to-day/faith-and-spirituality/spirituality-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389436]
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