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August 2022 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA


Balboni, T. A., VanderWeele, T. J., Doan-Soares, S. D., Long, K. N. G., Ferrell, B. R., Fitchett, G., Koenig, H. G., Bain, P. A., Puchalski, C., Steinhauser, K. E., Sulmasy, D. P. and Koh, H. K. "Spirituality in serious illness and health." JAMA 328, no. 2 (July 12, 2022): 184-197.


SUMMARY and COMMENT: This month's article is a milestone in the development of the Spirituality & Health literature, not only for its content -- from established leaders in the field -- and for its high-profile publication -- in the Journal of the American Medical Association -- but also as a signal that research in this area has now amassed enough high-quality evidence to suggest a well-founded and systematic strategy for patient care and outcomes in serious illness and health. This is an ambitious project, carried out with remarkable thoroughness, to which the 14-page article's 256-page appendix attests. Systematic reviews of this magnitude are critical to the progress of an empirically-informed discipline, and while the scope of this study goes beyond the practice of chaplaincy, it is surely essential reading for all chaplains. The present summary lines out only key points as a means of facilitating engagement of the original material.

After a brief introduction, the authors describe their methodology "to synthesize the highest-quality evidence available and identify evidence-based implications for health care" [p. 185, and see Related Items of Interest, §II, below],]. This involved a 5-step process, utilizing a multidisciplinary Delphi panel of experts [--see Related Items of Interest, §III, below], divided into two sub-panels: one group of 13 focusing on serious illness, and one group of 15 focusing on outcomes. The 5-step process is helpfully depicted in a figure on p. 185. In more detail:

Step 1 --
Electronic databases were searched for English-language articles published from January 2000 up through April 2022. "This time frame...was chosen to prioritize up-to-date research while permitting sufficient breadth and quantity of literature to identify evidence themes" [p. 185]. The inclusion criteria here are important to note. "For studies of serious illness, eligible studies met the following criteria: (1) examined populations of 100 or more persons with serious illness; (2) were prospective cohort studies, cross-sectional descriptive studies, meta-analyses (containing data not otherwise included), or randomized clinical trials; and (3) included validated measures of spirituality" [p. 185]. "For health outcomes, eligible studies met the following criteria: (1) prospectively examined the relationship between spirituality and health; (2) used data from prospective cohort studies, case-control studies, or meta-analyses (containing data not otherwise included) with sample sizes of 1000 or more or were randomized clinical trials (eg, public health interventions) with sample sizes of 100 or more; and (3) used validated measures of spirituality" [p. 185]. Studies were then categorized into 1 or more content areas: for serious illness, the categories were 1) the role of spirituality in illness, 2) spiritual needs, 3) spiritual care, 4) spirituality in medical decision-making, and 5) spiritual interventions; and for health outcomes, the categories were 1) all-cause mortality, 2) physical health, 3) health behaviors, 4) mental health, and 5) quality of life [--see p. 186].

Step 2 --
Over two months, Delphi panel members (which included 4 chaplains/community clergy) "independently reviewed the data tables and literature summaries and provided qualitative feedback on the content of the literature review, including suggestions on missing studies." and "qualitatively summarized the literature into evidence statements and provided implications for health care" [p. 186].

Step 3 --
The research team analyzed qualitative Delphi panel feedback to create a portfolio of evidence statements and suggested implications.

Step 4 --
Over eight weeks, the Delphi panel then reviewed the work of the research team regarding the panel's original input, and they evaluated (quantitatively) the strength of data supporting evidence statements and ranked the suggested implications of those statements for serious illness and health outcomes.

Step 5 --
The research team then quantitatively analyzed the Delphi panel's final qualitative assessments, in order to identify key evidence statements and implications of the extant research.

Among the results, this project gives a sense of what percentage of studies appear to avoid a high risk of bias (i.e., anything that could skew the data) and thereby undercut the integrity of the empirical findings. The authors sought to work with just those studies that were assessed to have only low to moderate risk of bias, and that came out to 76.9% of the sample. Regarding the five categories into which the trove of total articles was sorted: for articles about serious illness, that amounted to 74% for the role of spirituality, 78.7% for spiritual needs, 73.2% for spiritual care, 84.2% for medical decision-making, and 93.8% for interventions; and for articles about outcomes, that amounted to 81.3% for all-cause mortality, 65.6% for physical health, 63.6% for health behaviors, 64.4% for mental health, and 62% for quality of life [--see p. 188]. Such percentages show where this area of inquiry is still lacking, but also indicates strides in moving toward methodological integrity in recent decades --no small feat for a field still quite young in its overall development and one contending with many practical challenges to quantitative exploration.

The principal results, however, are the identification of evidence statements and ranked implications for Spirituality & Health. These are as follows:

"Spirituality in SERIOUS ILLNESS yielded 8 evidence synthesis statements...
  1. spirituality is important to most patients with serious illness (eg, literature estimates ranged from 71%-99%);
  2. spiritual needs are common in that setting (eg, estimates ranged from 23%-98%);
  3. spiritual care is frequently desired by patients with serious illness (eg, estimates ranged from 50%- 96%);
  4. ...spirituality can influence medical decision-making in serious illness.
  5. ...spiritual needs of patients with serious illness are frequently unaddressed within medical care
  6. ...spiritual care is infrequent in the care of such patients (eg, estimates of patients not receiving spiritual care ranged from 49%-91%).
  7. ...the provision of spiritual care in the medical care of patients with serious illness was associated with better end-of-life outcomes,
  8. [and] ...unaddressed spiritual needs can be associated with poorer patient quality of life." [p. 194]

The top three implications for SERIOUS ILLNESS were then identified:

  1. ...[T]he standard inclusion of spiritual care...[in medical care was the Delphi panel's] suggested implication in serious illness. Doing so could improve the quality of life of patients and their families and may also influence medical decision-making to advance patient-centered care. Conversely, although patient spirituality is often associated with better quality of life among patients with serious illness, unmet spiritual needs are also frequent in this setting and can be associated with reduced patient well-being. Raising issues of spirituality can also be a source of distress in serious illness. ...Raising issues of spirituality can also be a source of distress in serious illness. ...Attention to both the positive and negative associations of spirituality can shape person-centered, quality-of-life-focused care in serious illness." [p. 194]

  2. "The second highest-ranked suggested implication is that all members of the multidisciplinary care team should receive training in spiritual care provision. Achieving competence in history taking in accordance with the generalist-specialist model requires only time-limited training and resources; guides for integrating validated spiritual history tools are readily available for clinicians." [p. 194]

  3. "[The] third highest-ranked suggested implication highlights the need to involve spiritual care professionals (eg, chaplains) in the care of patients with serious illness. Such professionals [would be] trained to address spiritual needs in a manner sensitive to the patient's particular spirituality...." [p. 194]

Turning to the question of OUTCOMES, "...[t]he "Delphi panel review...yielded 8 evidence statements supported by the data...:

  1. frequent service attendance was associated with lower risk of mortality,
  2. ...dose-response association between attendance and lower risk of mortality.
  3. ...less smoking and less alcohol, marijuana, and illicit drug use compared with adults with less frequent or no attendance;
  4. better measures of quality of life (eg, life satisfaction);
  5. better mental health;
  6. fewer depressive symptoms;
  7. fewer suicidal behaviors
  8. [and] ...among adolescents, frequent attendance was associated with less risky sexual behaviors, less smoking, and reduced use of alcohol, marijuana, and illicit drugs." [p. 195]

The top three implications for OUTCOMES were then identified:

  1. "[The] top-ranked suggested implication for health outcomes was that health care professionals recognize and consider the benefits of spiritual community as a part of efforts to improve well-being. ...However, this consideration needs to be highly individualized and delivered with respect for each person's values and beliefs." [p. 195]

  2. "[The] second highest-ranked suggested implication was for education of public health professionals and students regarding spirituality and health outcomes...." [p. 195]

  3. "[The] third highest-ranked suggested implication was to recognize spirituality as a social factor associated with health --joining other social factors such as social integration, healthy work conditions, economic supports, protection from discrimination, access to healthy foods, and safe environments." There is potential here in "opening collaborations leveraging the strengths of spiritual communities in addressing health needs, particularly for the communities most vulnerable and at risk of chronic health challenges." [p. 195]

The authors acknowledge that one of the limits of this study is that "the weight of evidence was largely driven by North American samples" [p. 196], but they observe a trend in the literature for greater diversity in research populations. They also note that the data for the study do not fully address the COVID-19 pandemic [--see p. 196], though that fact is obviously a function of how this major event is too recent at this point to be sufficiently represented in the literature. The authors encourage future research that would "explore the dimensions of and mechanisms by which spirituality may influence health and well-being," that involve "standardized measures [for] ...more consistent, multidimensional assessment of spirituality," and "inform best practices, as well as potential harms, to ensure optimal person- and community-centered attention to spiritual health" [p. 196].

The article contains a very helpful box of basic definitions of terms [p. 186] and 5 useful tables, though by far the bulk of the supporting information for the study is provided in the massive appendix, available online. Only 41 references appear in the article itself, though they are vital to substantiating the text immediately at hand.

This reader has one serious concern related to this article: namely, that chaplains might not be taken by the idea of a "review," or they may not see the results as captivatingly dramatic, or they may not appreciate the importance of the methodology utilized. While the text is written in a somewhat cautious and technical style, this article is a critical clarification of empirical knowledge about Spirituality & Health at an opportune time for advancement in the field. The authors comment that their findings "could aid in furthering the National Academy of Medicine's goals for improving health care quality in the 21st century, calling for more attention to patients' values, often shaped by spiritual views, in health care" [p. 196, and see Related Items of Interest, §V, below]. The first challenge for chaplains is to read this article closely, then to think of how to use the findings at their local institutions, how to lift up the evidence statements and implications set forth here, and how to build upon them through further writing and research. This would be a fine selection for a multidisciplinary health care journal club discussion as well as a core article for chaplaincy training curricula. And, while the currency of bibliographies is fleeting, the appendix is worth every chaplain keeping as a database of studies that is as well-curated as it is extensive, and research chaplains should find here a most exciting resource.


Suggestions for Use of the Article for Student Discussion: 

As noted at the outset (above), this month's article is surely essential reading for all chaplains, and the main results should be of interest even to first-unit CPE students. However, as is sometimes the case with students newer to research, they might feel bogged down in the Methods and Results sections. So, at least for newer students, there might be some guidance on how to tackle the article: skipping from the introductory paragraphs to the Discussion section, then looping back to the Methods and Results sections (to reinforce the justification of the results). The one piece of information that could be provided in advance is an explanation of a Delphi panel as -- to put it most simply -- a select group of experts that assesses material in a series of rounds of analysis which progressively refine the insights of the group into a kind of consensus of wisdom. Of course, students who are even modestly familiar with research should be able to move through the article in a more proper order. Discussion could begin with a look at the Evidence Statements for serious illness and outcomes. Which statements stand out to the students? Any surprises to them here? How might the empirically-based assertions of these statements be useful to them? Then, the group could turn to the ranked Implications. Which ones seem especially practical for the students' sense of their own work/careers? Does the prospect of building greater working relationships with other disciplines and with community resources have strong appeal? If the group is not aware of the generalist-specialist model of spiritual care [--see p. 194, plus Related Items of Interest §IV, below], that point may deserve some attention. Can they conceptualize their own work as part of a broad development of the field of Spirituality & Health? Finally, since the authors give emphasis to the their 5-step process with the Delphi panel, the group could be challenged to consider how this process works, as crucial to the strength of the findings. For students with special interests in research, they could be directed to the Appendix section, "eAppendix 2 -- Table 1, Table 2," regarding the assessment of studies for bias.


Related Items of Interest:

I.  This month's article is the subject of a Harvard press release, Spirituality linked with better health outcomes, patient care and a Psychology Today post, "Why spirituality matters in medicine," among other notices. In addition, the study will be the focus of a Transforming Chaplaincy webinar, "'Spirituality in Serious Illness and Health': Becoming familiar with this important new systematic review from JAMA," on August 31, 2022 at 1:00 PM EDT. Registration is free.


II.  The RAND/UCLA Appropriateness Method User's Manual (2001), cited in our article [--see p. 185], is available online from the Rand Corporation (as well as other online sources). For a further example of research citing this method, see:

Bond, K., Ospina, M. B., Hooton, N., Bialy, L., Dryden, D. M., Buscemi, N., Shannahoff-Khalsa, D., Dusek, J. and Carlson, L. E. "Defining a complex intervention: The development of demarcation criteria for 'meditation.'" Psychology of Religion and Spirituality 1. No. 2 (2009): 129-137. [(Abstract:) The authors used a 5-round Delphi study with a panel of 7 experts in meditation research to achieve agreement on a set of criteria for a working definition of "meditation" for use in a comprehensive systematic review of the therapeutic use of meditation. Participants agreed that essential to a meditation practice is its use of (a) a defined technique, (b) logic relaxation, and (c) a self-induced state. Participants also agreed that a meditation practice may (d) involve a state of psychophysical relaxation somewhere in the process; (e) use a self-focus skill or anchor; (f) involve an altered state/mode of consciousness, mystic experience, enlightenment or suspension of logical thought processes; (g) be embedded in a religious/spiritual/philosophical context; or (h) involve an experience of mental silence. The results of this study provide insight into the challenges faced by researchers who want to demarcate meditative practices from nonmeditative practices, and they describe an approach to this problem that may prove useful for researchers trying to operationalize meditation in the context of comparative research.]


III.  The Delphi method, on which the RAND/UCLA Appropriateness Method was based, was also developed by the RAND Corporation. Core to this approach to achieving a convergence of opinion among experts are so-called Delphi panels whose work is carried out in progressive rounds. (NOTE: Modification of the Delphi process found in the RAND/UCLA Appropriateness Method lies in the opportunity for the Delphi panelists to discuss their assessments between rounds.) The Delphi method has had limited application in chaplaincy studies, but see the following:

Grossoehme, D. H. "Development of a spiritual screening tool for children and adolescents." Journal of Pastoral Care and Counseling 62, nos. 1-2 (Spring-Summer 2008): 71-85. [(Abstract:) A chaplain's ability to provide care where it is most needed depends upon some method of pastoral triage. Screening for spiritual needs of children and adolescents has been a largely neglected area. A Delphi panel developed elements to be included in a tool to screen 10-18 year olds' spiritual needs and resources. The Delphi panelists were informed of survey results of school-aged children and adolescents' opinions on spiritual issues important to them if they were hospitalized. A case study of the tool's use was conducted with a convenient sample of children and adolescents. Subsequent pilot use of the tool by five pediatric chaplains demonstrated the tool's utility in identifying patients' spiritual issues, ability to serve as a springboard to deeper discussion, and as a basis for initiating discussion of spiritual concerns with other disciplines on the healthcare team. Feedback indicates the potential clinical usefulness of this tool for hospitalized children and adolescents.]

Roberts D. L. and Kovacich, J. "Male chaplains and female soldiers: Are there gender and denominational differences in military pastoral care?" Journal of Pastoral Care and Counseling 74, no. 2 (June 2020): 133-140. [(Abstract:) In this study, 15 United States Army chaplain men described the practices they engaged in when providing pastoral support to women soldiers. Many engaged in creating safe spaces for women and themselves, particularly in regard to avoiding perceptions of impropriety. Other clergy did not consider gender a factor in counseling. Some chaplains placed limitations on the amount of support they would give. This study did not determine the degree to which chaplain men were effective.]

Roberts D. L. and Kovacich, J. "Modifying the qualitative Delphi technique to develop the Female Soldier Support Model." The Qualitative Report 23, no. 1 (2018): 158-167. [(Abstract:) The U.S. Army chaplaincy did not have a gender specific model for providing emotional and spiritual support to women soldiers. Such a model was needed because women often experience the military differently than men. The Comprehensive Female Soldier Support (CFS2) model was developed using a modified Delphi technique and a feminist theoretical framework. This study altered the Delphi design by using two successive panels of experts. The first panel, consisting of 10 wounded female soldiers, developed a list of pastoral needs experienced by the women. The second panel, composed of 11 female chaplains, provided solutions for those needs. The implication is that specific modifications used in this study are useful when the support needs of a population group are unknown, but once identified, the appropriate experts can solve these needs. Human services practitioners, social workers, and spiritual support providers may find the techniques invaluable.] [This article is available online.]

Roze des Ordons, A. L., Sinclair, S., Sinuff, T., Grindrod-Millar, K. and Stelfox, H. T. "Development of a clinical guide for identifying spiritual distress in family members of patients in the Intensive Care Unit." Journal of Palliative Medicine 23, no. 2 (February 2020): 171-178. [(Abstract:) Background: Spirituality is important for many family members of patients in the intensive care unit (ICU). Clinicians without training in spiritual care experience difficulty identifying when family members are experiencing distress of a spiritual nature. Objective: The purpose of this study was to develop a guide to help clinicians working in the ICU identify family members who may benefit from specialized spiritual support. Design: Cross-sectional study. Setting/Subjects: A national sample of spiritual health practitioners, family members, and ICU clinicians. Subjects: A panel of 21 spiritual health practitioners participated in a modified Delphi process to achieve consensus on items that suggest spiritual distress among family members of patients in the ICU through three rounds of remote review followed by an in-person conference and a final round of panelist feedback. Feedback on the final set of items was obtained from an end-user group of four family members and six ICU clinicians. Measurements: Quantitative data were summarized with descriptive statistics. Content analysis was used to analyze written comments. Results: A total of 220 items were iteratively reviewed and rated by panelists. Forty-six items were identified as essential for inclusion and developed into a clinical guide, including an introduction (n = 1), definitions (n = 2), risk factors (n = 10), expressed concerns (n = 12), emotions (n = 7) and behaviors (n = 7) that may suggest spiritual distress, questions to identify spiritual needs (n = 6), and introducing spiritual support (n = 1). Conclusions: We have developed an evidence-informed clinical guide that may help clinicians in the ICU identify family members experiencing spiritual distress.] [This was our February 2020 Article-of-the-Month.]

Also, readers may find thought-provoking this brief editorial regarding the use of Delphi panels vis-a-vis standardized controlled trials:

Hohmann, E., Brand, J. C., Rossi, M. J. and Lubowitz, J. H. "Expert opinion is necessary: Delphi panel methodology facilitates a scientific approach to consensus." Arthroscopy: The Journal of Arthroscopic and Related Surgery 34, no 2 (February 2018): 349-351. [(Abstract:) Our current trend and focus on evidence-based medicine is biased in favor of randomized controlled trials, which are ranked highest in the hierarchy of evidence while devaluing expert opinion, which is ranked lowest in the hierarchy. However, randomized controlled trials have weaknesses as well as strengths, and no research method is flawless. Moreover, stringent application of scientific research techniques, such as the Delphi Panel methodology, allows survey of experts in a high quality and scientific manner. Level V evidence (expert opinion) remains a necessary component in the armamentarium used to determine the answer to a clinical question.]


IV.  In "Spiritual care: Whose job is it anyway? [Southern Medical Journal 97, no. 12 (December 2004): 1242-1244], George Handzo and Harold G. Koenig wrote, "In examining the relative roles of the physician and the chaplain in spiritual care giving, it may be most helpful to use the model of the general practitioner and the specialist" [p. 1243]. The Generalist-Specialist model for spiritual care was soon thereafter explicated by chaplains Mary R. Robinson and Mary Martha Thiel, et al., in "Matters of spirituality at the end of life in the pediatric intensive care unit" [Pediatrics 118, no. 3 (September 2006): e719-729], which was our November 2006 Article-of-the-Month. This latter article included tables for "Roles and Tasks of Spiritual Care Generalists and Specialists" [p. 726] and "When a Spiritual Generalist Should Consult A Chaplain" [p. 727].


V.  Our authors mention "the National Academy of Medicine's goals for improving health care quality in the 21st century, calling for more attention to patients' values, often shaped by spiritual views, in health care" [p. 195]. The work only makes minor references to spirituality/religion, but any discussion of patient values surely must recognize the potential significance of spirituality for ways many people understand and act within their world; and any Spirituality & Health initiative could be served by awareness of broad goals in healthcare planning. The document is available for download from the National Academies Press.



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