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June 2012 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Puchalski, C. M. "Spirituality in the cancer trajectory." Annals of Oncology 23, suppl. 3 (April 2012): 49-55.


SUMMARY and COMMENT: Our featured article for June is not a report of a single study but rather a very research-minded overview by a physician leader in spirituality & health that should serve as a good entrée to the field for CPE summer interns. Christina Puchalski, MD, is the founder and Director of the George Washington Institute for Spirituality and Health (GWish), an extensive resource useful to all chaplains [--see Related Items of Interest, §I, below]. The article covers basic terms, the current medical perspective on spirituality in general, and particular issues related to cancer --a diagnosis that, according to a National Cancer Institute estimate, will be experienced by 41% of Americans born today [p. 50; and see the NCI source]. The author mentions chaplains at a number of points.

The opening paragraphs present a broad description of the relation of spirituality to cancer patients:

From initial diagnosis, through treatment, survivorship, recurrence, and dying, cancer patients’ understanding of their illness and their lives with their illness range from the physical, social, emotional, and spiritual. A diagnosis raises spirituality-related questions and concerns, both existential and religious. Diagnosis of cancer changes the lives of patients forever, the diagnosis often triggering deep questions of meaning and purpose, and with the journey through treatment, deep issues of hope and fulfillment. The uncertainties and myriad decisions may raise spirituality-related issues more often in persons diagnosed with cancer than with other long-term illnesses. Spirituality is also an important component of quality of life of patients with cancer. [p. 49]
The author then addresses the concept of spirituality, as defined (in the author's work elsewhere) as "the way people find meaning and purpose, and how they experience their connectedness to self, others, the significant, or sacred" [p. 49]. The research basis for statements in this article is immediately apparent by the copious references to studies, and the reader should be drawn to flip back and forth to the 91-item list of endnote citations. Of special note is the discussion of "spiritual distress" as a clinical diagnosis and a table of examples [--see p. 51]. A further section looks at the "biopsychosocialspiritual assessment and treatment plan" [--see pp. 52-53] and offers a case illustration and examples of spiritual care interventions [--see tables on p. 53]. The model for spiritual care here is guided by the "principle that all members of the healthcare team are responsible for attending to a patient’s spiritual issues, recognizing that the board-certified chaplain is the spiritual expert on the team" [p. 52]. The biopsychosocialspiritual model...
...recognize[s] that spirituality underlies all the dimensions of care.... In this model, spirituality is the essence of humanity as described by Viktor Frankl. The inner core of the person is not possible to understand, diagnose or treat. However, where spirituality interacts with the other domains is the area that is relevant for clinical care. So, physical pain may in fact be an expression or complication of spiritual distress. ...The biopsychosocialspiritual model recognizes the distinct dimensions--biological, psychological, social, and spiritual--of a person and the fact that no dimension can be left out when caring for the whole person. [p. 52]
A section on barriers providing spiritual care considers the quandary that "[d]espite evidence that spirituality plays an integral role in helping oncology professionals understand how a person defines quality of life in the context of his or her cancer experience, cancer patients report their psychosocialspiritual needs are not understood--and that healthcare professionals do not recognize, treat, or offer appropriate referrals to address their spiritual needs" [p. 52]. The author comments on physician reluctance and issues of education and communication, plus concerns about assessment and documentation systems as well as the complexities of ethics and confidentiality. Note: there is no discussion of barriers other than those related to caregivers, such as the many barriers brought to the clinical encounter by patients themselves.

The idea of "trajectory," while part of the title, is not explored in detail here [--but see Related Items of Interest, §II, below], yet the sense of a patient's process is implicit throughout: e.g., "From the moment of diagnosis of cancer through treatment, survivorship, recurrence, and dying, patients with cancer are faced with spiritual issues that may cause spiritual distress or may help them as they face their illness" [p. 53]. Also, "Evidence shows...that addressing spiritual distress and spiritual resources of strength are integral to care across the trajectory of illness," and "Attention to a patient’s spiritual well-being can help the individual find meaning and live life to the fullest from diagnosis through treatment, survivorship, and dying" [p. 51]. Trajectory allows for a varied course, including survivorship, but it is in practice a term rooted in palliative care as defined as "care span[ning] the time from diagnosis to eventual death" [p. 52].

Puchalski is certainly addressing physicians, and making a research-based case for the criticality of attending to spiritual needs in patient care, but for chaplains the article constitutes a brief and effective review of how medicine currently may see grounds for the work of chaplaincy across the full trajectory of illness/treatment.


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

This is a well-crafted article that should engage CPE students, including summer interns or others new to the spirituality & health literature. Discussion could start with a general question: "What is the role and importance of research in making the case for spiritual care?" It is simply a nice way to make a case, or is it something more essential? Students might discuss how physicians may see spiritual care, and inviting an oncology physician (and/or a physician who sits on the CPE center's advisory committee) to join in the discussion could benefit students' thinking. How do students react to the statement, "Not addressing spirituality could result in poorer outcomes, increased non-compliance with the treatment plan, and failure to help patients find effective coping mechanisms" [p. 51]? Does it comport with their own sense of why they are interested in chaplaincy? And what about the author's definition of spirituality? The table of examples of spiritual distress [p. 51] could also be a thought-provoking list of "diagnoses" and key features. How does the wide-angle view of a trajectory of illness and patient experience strike students? Might it provide a broad context for specific clinical encounters? Finally, the article puts forward an integrated biopsychosocialspiritual model, but do students understand their work as truly integrated or somehow separate from the bio-psycho-social aspects of health care?


Related Items of Interest:

I. The George Washington Institute for Spirituality and Health offers a library of resources (including a handful of Dr. Puchalski's other articles) online through its SOERCE project, which is free but requires registration. GWish also provides authoritative information about the FICA Spiritual History Tool, developed by Puchalski. (An article evaluating the FICA tool was featured as our August 2010 Article-of-the-Month.)


II. For more on the idea of trajectories in the study of spirituality & health, see the November 2007 Article-of-the-Month, featuring the article, "Patterns of social, psychological, and spiritual decline toward the end of life in lung cancer and heart failure," by Murray, S. A., Kendall, M., Grant, E., Boyd, K., Barclay, S. and Sheikh, A. in The Journal of Pain and Symptom Management [vol. 34, no. 4 (October 2007): 393-402] but noting additional articles.


III. One of the references for a spiritual screening tool cited in our featured article [p. 52] that may be of special interest to CPE students is Fitchett, G. and Risk, J. L., "Screening for spiritual struggle," from The Journal of Pastoral Care & Counseling [vol. 63, nos. 1-2 (Spring-Summer 2009): 4-1-12]. (Abstract:) A growing body of research documents the harmful effects of religious or spiritual struggle among patients with a wide variety of diagnoses. We developed a brief screening protocol for use in identifying patients who may be experiencing religious/spiritual struggle, as well as patients who would like a visit from a chaplain. We describe the results of a pilot study in which non-chaplain healthcare colleagues administered the screening protocol to patients admitted to an acute medical rehabilitation unit. The protocol identified 7% of the patients as possibly experiencing religious/spiritual struggle. Follow up spiritual assessments by the chaplain confirmed religious/spiritual struggle in all but one of these patients and also identified additional cases of religious/spiritual struggled not identified by the protocol. In addition to areas for future research, the authors describe how using a protocol to screen patients for religious/spiritual can make important contributions to spiritual care.


IV. For more on the biopsychosocialspiritual model, see especially Daniel P. Sulmasy's now slightly old but still fine article, "A biopsychosocial-spiritual model for the care of patients at the end of life," published in Gerontologist [vol. 42, special issue no 3 (October 2002): 24-33]. (Abstract:) PURPOSE: This article presents a model for research and practice that expands on the biopsychosocial model to include the spiritual concerns of patients. DESIGNS AND METHODS: Literature review and philosophical inquiry were used. RESULTS: The healing professions should serve the needs of patients as whole persons. Persons can be considered beings-in-relationship, and illness can be considered a disruption in biological relationships that in turn affects all the other relational aspects of a person. Spirituality concerns a person's relationship with transcendence. Therefore, genuinely holistic health care must address the totality of the patient's relational existence-physical, psychological, social, and spiritual. The literature suggests that many patients would like health professionals to attend to their spiritual needs, but health professionals must be morally cautious and eschew proselytizing in any form. Four general domains for measuring various aspects of spirituality are distinguished: religiosity, religious coping and support, spiritual well-being, and spiritual need. A framework for understanding the interactions between these domains is presented. Available instruments are reviewed and critiqued. An agenda for research in the spiritual aspects of illness and care at the end of life is proposed. IMPLICATIONS: Spiritual concerns are important to many patients, particularly at the end of life. Much work remains to be done in understanding the spiritual aspects of patient care and how to address spirituality in research and practice.


V. Note the reference [p. 52] to the article, "Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference," by 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., published in the Journal of Palliative Medicine [vol. 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 (available from and another similar project, A National Framework and Preferred Practices for Palliative and Hospice Care (available from the Robert Word Johnson Foundation). [The article is available online from, and 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.]


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