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January 2010 Article of the Month

This month's article was proposed by Chaplain George Fitchett, Director of Research and Spiritual Assessment at the Department of Religion, Health and Human Values at Rush University College of Health Sciences and Rush University Medical Center, Chicago, IL. Comments about the article are by Chaplain John Ehman, University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia, PA.


Balboni, T. A, Paulk, M. E., Balboni, M. J., Phelps, A. C., Loggers, E. T., Wright, A. A., Block, S. D., Lewis, E. F., Peteet, J. R. and Prigerson, H. G. "Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death." Journal of Clinical Oncology, 28, no. 3 (January 20, 2010): 445-452.


SUMMARY and COMMENT: This month's article, by an impressive group of researchers (eight of the ten being MDs, and one--Michael J. Balboni--having MDiv, PhD credentials), presents "the first study demonstrating prospective associations of spiritual care with medical care and QoL [Quality of Life] near death…" [p. 449]. The findings suggest that "chaplains and other members of the medical team" have "complementary roles in providing spiritual care" [p. 451]. "Chaplains play an essential role as professional providers of spiritual care; other medical providers also have a crucial role, including by performing spiritual assessments, recognizing spiritual needs, and making pastoral care referrals" [p. 451]. Moreover, the authors see their work as bolstering the recommendations of "existing national spiritual care guidelines" [p. 451; and see Related Items of Interest, §I, below].

Data were analyzed from 343 advanced cancer patients from multiple sites who were recruited between 2002-2008 and followed until death. Measures included patient reports of spiritual support, the Brief RCOPE questionnaire, the McGill QoL questionnaire, and postmortem interviews with caregivers. Questions about spiritual care are given in Table 1 [--see p. 446], and three other tables and two figures offer detailed information about results. The article contains a very thorough methodology section [--see pp. 446-447].

Among the findings: "The majority (60%) reported their spiritual needs were minimally or not at all supported, and 54% had not received pastoral care visits" --this for a sample that "died a median of 116 days (interquartile range, 5 to 255 days) after the baseline interview" [p. 447].

…[P]atients with advanced cancer whose spiritual needs are met by the medical team have more than three-fold greater odds of receiving hospice care at the EoL [End of Life] in comparison with those not supported. High religious coping patients receiving full support of their spiritual needs had near five-fold greater odds of receiving hospice care and more than five-fold decreased odds of receiving aggressive care at EoL as compared with those not supported. These associations were over and above established predictors of EoL care, such as race and EoL care preferences. Additionally, spiritual care was found to be associated with better patient QoL at the EoL. Near-death QoL scores were increased 28% on average among patients receiving either pastoral care services or spiritual support from the medical team in comparison with those receiving no spiritual care. The associations of spiritual care with patient QoL near death are notable given adjustment for multiple potential confounds, such as baseline QoL, the patient-physician relationship, and care received at EoL. [pp. 448-449]

The authors speculate on causal possibilities:

Spiritual support may facilitate patients’ facing spiritual issues and finding spiritual peace at EoL, thereby creating more receptivity to a transition away from aggressive care. Furthermore, discussion regarding the role of R/S [Religious/Spiritual] beliefs in medical decision making may help patients more fully recognize EoL care options that are consistent with their R/S beliefs. Interestingly, the association of spiritual support with EoL care was present for spiritual support from the medical team, but not for receipt of pastoral care services. Caregivers such as doctors and nurses are generally the individuals providing counsel regarding medical decision making. Their acknowledgment of the R/S components of illness may be of particular importance in helping patients face the spiritual issues most directly impacting their care decisions. [p. 450]
This latter point about the effect of spiritual support from the medical team (e.g., doctors and nurses) is interesting indeed. The study found no association between pastoral care services and either receipt of hospice or aggressive care at the end of life [--see p. 448]. That does not seem to diminish the role of chaplains in the eyes of Baboni and her colleagues; rather, it appears to speak to the "complementary" [p. 451] nature of the various roles of pastoral and medical caregivers. The authors conclude: "These findings underscore the need to educate medical caregivers in their appropriate roles in providing patient-centered spiritual care and the importance of integrating pastoral care into multidisciplinary medical teams" [p. 451]. For this reader, there is here an opening for chaplains to make the case not just for their involvement in patient care but in education for medical caregivers about how they may incorporate spiritual support into their practice.


Suggestions for the Use of the Article for Discussion in CPE: 

The very thorough methodology section of this month's article recommends it to any CPE group interested in research, and the outline of the spiritual care questions used in the interview process (given in Table 1 [--see p. 446]) should be intriguing to students exploring methods of collecting quantitative data about spirituality from an interview process. However, for a general discussion, the article holds much to engage students in particular findings and regarding the basic subject of unmet spiritual needs. The results regarding the effect on End of Life care of spiritual support by the medical team, as opposed to support from chaplains [--see p. 450, and also p. 448], is worth some consideration. What do students think about the relative value of this finding about hospice care or aggressive care vis-ŕ-vis the value of affecting Quality of Life (--for example: Which of the two types of outcomes have more economic and institutional implications?). Students might further discuss how they see the spiritual support they provide, in relation to that potentially provided by the medical team, as complementary. [See Related Items of Interest, §IV, below.]


Related Items of Interest:

I. Balboni, et al., note that "spiritual care--care that recognizes patient R/S [Religion/Spirituality] and attends to spiritual needs--has been incorporated into national care guidelines" [p. 445]. Two sources for such guidelines are cited: The Joint Commission for the Accreditation of Healthcare Organizations (specifically the JCAHO statements on spiritual assessment [available via] and the National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care [--downloadable via]. Readers may also be interested in:

Puchalski, C., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., Bull, J., Chochinov, H., Handzo, G., Nelson-Becker, H., Prince-Paul, M., Pugliese, K. and Sulmasy, D. "Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference." Journal of Palliative Medicine 12, no. 10 (October 2009): 885-904. [This report is from a conference held on February 17-18, 2009 in Pasadena, CA. The document seeks to build upon the National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care (cited in our Article-of-the-Month) and another similar project, A National Framework and Preferred Practices for Palliative and Hospice Care (available from the Robert Word Johnson Foundation). A larger version of the report has been published as a book: Puchalski, M. and Ferrell, B., Making Health Care Whole: Integrating Spirituality into Patient Care, Templeton Press, 2010.

II. The authors of this month's article note that spiritual care "remains notably absent for most patients at the EoL" [p. 446, and see also p. 451]. For more on this, see:

Balboni, T. A., Vanderwerker, L. C., Block, S. D., Paulk, M. E., Lathan, C. S., Peteet, J. R. and Prigerson, H. G. "Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life." Journal of Clinical Oncology 25, no. 5 (February 10, 2007): 555-560. [In that study, "Nearly half (47% [of 230 participants]) reported that their spiritual needs were minimally or not at all supported by a religious community, and 72% reported that their spiritual needs were supported minimally or not at all by the medical system" (--from the abstract). (This article is cited in our Article-of-the-Month.)]

Flannelly, K. J., Galek, K. and Handzo, G. F. "To what extent are the spiritual needs of hospital patients being met?" International Journal of Psychiatry in Medicine 35, no. 3 (2005): 319-323. [(Abstract:) Although a substantial number of studies have documented the spiritual needs of hospitalized patients, few have examined the prevalence of these needs and even fewer have attempted to measure the extent to which they are being met. Since chaplains are the primary providers of spiritual care, chaplains' visits to patients would appear to provide a reasonable proxy for the latter. Based on the limited data available, we estimated the proportion of hospitalized patients who are visited by chaplains. Our analyses yielded a point estimate of 20% (+/- 10%), depending on a number of factors.]

Hermann, C. P. "The degree to which spiritual needs of patients near the end of life are met." Oncology Nursing Forum 34, no. 1 (January 2007): 70-78. [This study of 100 hospice patients (both inpatient and outpatient), assessed perception of 17 spiritual needs (with spirituality conceived very broadly) and perception of whether each type of need was met or unmet. Among the findings: 79% said that talking to someone about spiritual issues was a need, and 75% said that this need had been met; 88% said that being with people who shares the same spiritual beliefs was a need, and 74% said that this need had been met; and 85% said that going to religious services was a need, and 30% said that this need had been met. (This article is cited in our Article-of-the-Month.)]

III. Our featured article bolsters the idea of medical professionals providing spiritual support to patients. The role of spirituality in the physician-patient relationship in particular has been explored in our September 2004 Article-of-the-Month, but readers may be interested in the following new article:

Tanyi, R. A., McKenzie, M. and Chapek, C. "How family practice physicians, nurse practitioners, and physician assistants incorporate spiritual care in practice." Journal of the American Academy of Nurse Practitioners 21, no. 12 (December 2009): 690-697. [(Abstract:) PURPOSE: To investigate how primary care family practice providers incorporate spirituality into their practices in spite of documented barriers. DATA SOURCES: A phenomenological qualitative design was used. Semi-structured interviews were conducted with three physicians, five nurse practitioners, and two physician assistants. CONCLUSIONS: Five major theme clusters emerged: (1) discerning instances for overt spiritual assessment; (2) displaying a genuine and caring attitude; (3) encouraging the use of existing spiritual practices; (4) documenting spiritual care for continuity of care; (5) managing perceived barriers to spiritual care. IMPLICATIONS FOR PRACTICE: Findings support that patients' spiritual needs can be addressed in spite of documented barriers. Techniques to assist providers in providing spiritual care are discussed and directions for future research are suggested.]

IV. What might chaplains think of members of the medical team having a role in the spiritual support of patients? One study, featured for our March 2007 Article-of-the-Month investigated how chaplains viewed nurses as spiritual care providers. See:

Cavendish, R., Edelman, M., Naradovy, L., McPartlan Bajo, M., Perosi, I. and Lanza, M. [City University of New York: College of Staten Island, Kingsborough Community College, and New York City College of Technology]. "Do pastoral care providers recognize nurses as spiritual care providers?" Holistic Nursing Practice 21, no. 2 (March/April 2007): 89-98.

V. Readers should recall our April 2009 Article-of-the-Month, by a number of the same authors as this month's article. Both studies emerged from the Coping with Cancer research initiative out of the Dana Farber Cancer Institute.

Phelps, A. C., Maciejewski, P. K., Nilsson, M., Balboni, T. A., Wright, A. A., Paulk, E. M., Trice, E., Schrag, D., Peteet, J. R., Block, S. D. and Prigerson, H. G. "Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer." JAMA 301, no. 11 (March 18, 2009): 1140-1147.


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