Modes of Intervention
Various modes of intervention or assistance might be considered to address the spiritual concerns of patients. These include the following:
- Exploration by the physician or other health care provider within the context of usual medical care.
- Encouragement for the patient to seek assistance from his or her own clergy.
- Formal referral to a hospital chaplain.
- Referral to a religious or faith-based therapist.
- Referral to a range of support groups that are known to address spiritual issues.
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. This study also found that while providers perceived that a patient's desire for addressing 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  of physicians and end-of-life specialists suggested several guidelines for physicians who wish to respond to patients’ spiritual concerns:
- Respect the patient’s views and follow the patient’s lead.
- Make a connection by listening carefully and acknowledging the patient’s concerns, but avoid theological discussions or engaging in specific religious rituals.
- Maintain one's own integrity in relation to one's own religious beliefs and practices.
- Identify common goals for care and medical decisions.
- Mobilize other resources of support for the patient, such as referring the patient to a chaplain or encouraging contact with the patient’s own clergy.
Inquiring about religious or spiritual concerns by physicians or other health care professionals 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 of cancer outpatients, between 20% and 35% expressed a desire for religious and spiritual resources, help with talking about finding meaning in life, help with finding hope, talking about death and dying, and finding peace of mind.[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,[Level of evidence: II] there was considerable variation in whether spiritual concerns were addressed by medical staff, with about 50% reporting at least some support at three of the settings, in contrast to fewer than 15% reporting some support at the other four settings. Support received from the medical team predicted greater quality of life, greater likelihood of receiving hospice care at the end of life, and for patients who have high levels of religious coping, less aggressive care.
One trial,[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 the 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.|
|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.||“Whom do you have to talk to about this/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  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  found that patients 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 their opinions regarding the appropriateness of patient-practitioner prayer in the advanced-cancer setting. Results showed that 71% of advanced-cancer patients, 83% of oncology nurses, and 65% of physicians reported that it is occasionally appropriate for a practitioner to pray with a patient when the request to pray is initiated by the patient. 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.
The most important guideline is to remain sensitive to the patient’s preference; therefore, 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.
Traditional means of providing assistance to patients has generally been through the services of hospital chaplains.[10,11] Hospital chaplains can play a key role in addressing spiritual and religious issues; chaplains are trained to work with a wide range of issues as they arise for medical patients and to be sensitive to the diverse beliefs and concerns that patients may have. Chaplains are generally available in large medical centers, but they may not be available in smaller hospitals on a reliable basis. Chaplains are rarely available in the outpatient settings where most 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,[Level of evidence: II] only 46% of patients reported receiving pastoral care visits. While these visits were not associated with receipt of 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 is relatively easy to do, and many such resources exist; however, a breadth of resources covering all faith backgrounds of patients is highly desirable (refer to the Additional Resources section).
Support groups may provide a setting in which patients may explore spiritual concerns. If spiritual concerns are important to a patient, the health care provider may need to identify whether a locally available 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 [Level of evidence: I] compared the effects of a mind-body-spirit group to a standard group support program 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 were found to have lower levels of negative emotions, higher levels of perceived health self-efficacy, and higher functional well-being. 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 engagement in the religious and spiritual aspects of their lives.[Level of evidence: III]
One author  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, 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.
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 improvement in spirituality, stress, depression, and anger was significantly larger for the mindfulness-based stress reduction group.[Level of evidence: II]
- Kristeller JL, Zumbrun CS, Schilling RF: 'I would if I could': how oncologists and oncology nurses address spiritual distress in cancer patients. Psychooncology 8 (5): 451-8, 1999 Sep-Oct. [PUBMED Abstract]
- Ben-Arye E, Bar-Sela G, Frenkel M, et al.: Is a biopsychosocial-spiritual approach relevant to cancer treatment? A study of patients and oncology staff members on issues of complementary medicine and spirituality. Support Care Cancer 14 (2): 147-52, 2006. [PUBMED Abstract]
- Lo B, Ruston D, Kates LW, et al.: Discussing religious and spiritual issues at the end of life: a practical guide for physicians. JAMA 287 (6): 749-54, 2002. [PUBMED Abstract]
- Astrow AB, Wexler A, Texeira K, et al.: Is failure to meet spiritual needs associated with cancer patients' perceptions of quality of care and their satisfaction with care? J Clin Oncol 25 (36): 5753-7, 2007. [PUBMED Abstract]
- 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 28 (3): 445-52, 2010. [PUBMED Abstract]
- Kristeller JL, Rhodes M, Cripe LD, et al.: Oncologist Assisted Spiritual Intervention Study (OASIS): patient acceptability and initial evidence of effects. Int J Psychiatry Med 35 (4): 329-47, 2005. [PUBMED Abstract]
- King DE, Bushwick B: Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract 39 (4): 349-52, 1994. [PUBMED Abstract]
- Hebert RS, Jenckes MW, Ford DE, et al.: Patient perspectives on spirituality and the patient-physician relationship. J Gen Intern Med 16 (10): 685-92, 2001. [PUBMED Abstract]
- Balboni MJ, Babar A, Dillinger J, et al.: "It depends": viewpoints of patients, physicians, and nurses on patient-practitioner prayer in the setting of advanced cancer. J Pain Symptom Manage 41 (5): 836-47, 2011. [PUBMED Abstract]
- Fitchett G, Meyer PM, Burton LA: Spiritual care in the hospital: who requests it? Who needs it? J Pastoral Care 54 (2): 173-86, 2000 Summer. [PUBMED Abstract]
- Handzo G: Where do chaplains fit in the world of cancer care? J Health Care Chaplain 4 (1-2): 29-44, 1992. [PUBMED Abstract]
- Association of Professional Chaplains, Association for Clinical Pastoral Education, Canadian Association for Pastoral Practice and Education, et al.: A White Paper. Professional chaplaincy: its role and importance in healthcare. J Pastoral Care 55 (1): 81-97, 2001 Spring. [PUBMED Abstract]
- Targ EF, Levine EG: The efficacy of a mind-body-spirit group for women with breast cancer: a randomized controlled trial. Gen Hosp Psychiatry 24 (4): 238-48, 2002 Jul-Aug. [PUBMED Abstract]
- Shaw B, Han JY, Kim E, et al.: Effects of prayer and religious expression within computer support groups on women with breast cancer. Psychooncology 16 (7): 676-87, 2007. [PUBMED Abstract]
- Antle B, Collins WL: The impact of a spirituality-based support group on self-efficacy and well-being of African American breast cancer survivors: a mixed methods design. Social Work and Christianity 36 (3): 286-300, 2009.
- Cunningham AJ: Group psychological therapy: an integral part of care for cancer patients. Integrative Cancer Therapies 1(1): 67-75, 2002.
- Cunningham AJ, Edmonds CV, Phillips C, et al.: A prospective, longitudinal study of the relationship of psychological work to duration of survival in patients with metastatic cancer. Psychooncology 9 (4): 323-39, 2000 Jul-Aug. [PUBMED Abstract]
- Breitbart W: Spirituality and meaning in supportive care: spirituality- and meaning-centered group psychotherapy interventions in advanced cancer. Support Care Cancer 10 (4): 272-80, 2002. [PUBMED Abstract]
- Cole B, Pargament K: Re-creating your life: a spiritual/psychotherapeutic intervention for people diagnosed with cancer. Psychooncology 8 (5): 395-407, 1999 Sep-Oct. [PUBMED Abstract]
- Spiegel D, Bloom JR, Kraemer H, et al.: Psychological support for cancer patients. Lancet 2 (8677): 1447, 1989. [PUBMED Abstract]
- Garland SN, Carlson LE, Cook S, et al.: A non-randomized comparison of mindfulness-based stress reduction and healing arts programs for facilitating post-traumatic growth and spirituality in cancer outpatients. Support Care Cancer 15 (8): 949-61, 2007. [PUBMED Abstract]