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Spirituality in Cancer Care (PDQ®)

Screening and Assessment of Spiritual Concerns

Raising spiritual concerns with patients can be accomplished by the following approaches:[1,2]

  • Waiting for the patient to bring up spiritual concerns.
  • Requesting that the patient complete a paper-and-pencil assessment.
  • Having the physician do a spiritual inquiry or assessment by indicating his or her openness to a discussion.

These approaches have different potential value and limitations. Patients may express reluctance to bring up spiritual issues, noting that they would 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 becoming available for physician use and training.[4]

Numerous assessment tools are pertinent to performing a religious and spiritual assessment. Table 1 summarizes a selection of assessment tools. Several factors should be considered before choosing an assessment tool:

  • Focus of the evaluation (religious practice or spiritual well-being/distress).
  • Purpose of the assessment (e.g., screening for distress vs. evaluation of all patients as part of care).
  • Modality of the assessment (interview or questionnaire).
  • Feasibility of the assessment (staff and patient burden).

The line between assessment and intervention is blurred, and simply inquiring about an area such as religious or spiritual coping may be experienced by the patient as an opening for further exploration and validation of the importance of this experience. Evidence suggests that such an inquiry will be experienced as intrusive and distressing by only a very small proportion of patients. Key assessment approaches are briefly reviewed below; pertinent characteristics are summarized in Table 1.

Standardized Assessment Measures

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 area for exploration and for ascertaining basic levels of religious engagement or spiritual well-being (or spiritual distress). Most also assume a belief in God and therefore 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.

  • Duke Religious Index (DRI). The DRI (or DUREL) [5][Level of evidence: II][6] is short (five items) and has reasonable psychometric properties [5] examined in cancer patients. It is best used as an indicator of religious involvement rather than spirituality and has low or modest correlations with psychological well-being.
  • Systems of Belief Inventory (SBI-15R). The SBI-15R [7][Level of evidence: II] has undergone careful psychometric development and measures two domains:
    1. Presence and importance of religious and spiritual beliefs and practices.
    2. Value of support from a religious/spiritual community.

    The questions are worded well and may provide a good initiation for further discussion and exploration.

  • Brief Measure of Religious Coping (RCOPE). The Brief RCOPE [8][Level of evidence: II] has two dimensions: positive religious coping and negative religious coping, with five items each. The second factor appears to uniquely identify a very important aspect of spiritual adjustment, i.e., the degree to which conflict, self-blame, or anger at God is present for an individual. A longer form of the scale, with additional dimensions, would be suitable for a more comprehensive assessment of religious/spiritual concerns. Psychometric development is high. While high scores in negative religious coping are unusual, they are particularly powerful in predicting poor adjustment to disease.[9]
  • Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp).[10] The FACIT-Sp is part of the widely used Functional Assessment of Cancer Therapy (FACT) quality-of-life battery.[11] It was developed with an ethnically diverse cancer population and contains 12 items and 2 factors (faith, and meaning and peace), with good to excellent psychometric properties; although some evidence suggests that inner meaning and inner peace can be identified as two separate factors, such identification does not appear to substantially improve associations with other indicators of well-being.[12] One characteristic of this scale is that the wording of items does not assume a belief in God. Therefore, it can be comfortably completed by an atheist or agnostic, yet it taps into both traditional religiousness dimensions (faith factor) and spiritual dimensions (meaning and peace factor). 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 generally 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 assessment of this dimension 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 advanced cancer patients. The linear scale (Spiritual Well-Being Linear Analogue Self-Assessment [SWB LASA]) was worded, “How would you describe your overall spiritual well-being?” and ratings ranged from 0 (as bad as it can be) to 10 (as good as it can be).[17]
  • Spiritual Transformation Scale (STS).[18] The STS is a 40-item measure of change in spiritual engagement following cancer diagnosis. It has two subscales: Spiritual Growth (SG) and Spiritual Decline (SD). The SG factor is highly correlated with the Positive RCOPE (r = .71) and the Post-traumatic Growth Inventory (r = .68), while the SD factor is correlated with the Negative RCOPE (r = .56) and the Center for Epidemiologic Studies Depression Scale (CES-D) (r = .40). Analyses show that the STS accounts for additional variance on depression, other measures of adjustment (Positive and Negative Affect Schedule [PANAS]), and the Daily Spiritual Experience Scale.[18] Individuals with later stage cancer (stage III or IV) had higher scores on SG, as did individuals with a recurrence rather than a new diagnosis. Individuals with higher scores on SD 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; wording on items is also generally appropriate for individuals who identify as spiritual rather than religious. Among the limitations of this scale is that development to date includes mostly observant Christians, with few minorities in the sample.

Interviewing Tools

The following are semistructured interviewing tools designed to facilitate an exploration, by the physician or other health care provider, of religious beliefs and spiritual experiences or issues. 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 for provision of 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 SPIRITual History.[19] The SPIRIT is an acronym for the six domains explored by this tool: S, spiritual belief system; P, personal spirituality; I, integration with a spiritual community; R, ritualized practices and restrictions; I, implications for medical care; T, terminal events planning. The 6 domains are covered by 22 items, which may be covered 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 to gaining an understanding of how patient religious beliefs may bear on patient care decisions.
  • Faith, Importance/Influence, Community, and Address (FICA) Spiritual History.[1,20] FICA is an acronym for Faith, Importance/Influence, Community, and Address, with a set of questions to explore each area (e.g., What is your faith? How important is it? Are you part of a religious community? How would you like me as your provider to address these issues in your care?). Although developed as a spiritual history tool for use in primary care settings, it would lend itself to any patient population. The relative simplicity of the approach has led to its adoption by many medical schools.
Table 1. Assessment of Religion and Spirituality in Cancer Patients
Tool Developer Purpose/ Focus/ Subscale (No.) Specific to Cancer Patients? Level of Psychometric Development Length/ Other Characteristics/ Comments
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.


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  • Updated: July 3, 2014