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Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients

Colleen S McClain MA, Dr Barry Rosenfeld PhD and William Breitbart MD
Department of Psychology, Fordham University

The importance of spirituality in coping with a terminal illness is becoming increasingly recognised. We aimed to assess the relation between spiritual well-being, depression, and end-of-life despair in terminally-ill cancer patients.

160 patients in a palliative care hospital with a life expectancy of less than 3 months were interviewed with a series of standardised instruments, including the functional assessment of chronic illness therapy—spiritual well-being scale, the Hamilton depression rating scale, the Beck hopelessness scale, and the schedule of attitudes toward hastened death. Suicidal ideation was based on responses to the Hamilton depression rating scale.

Significant correlations were seen between spiritual well-being and desire for hastened death (r=?0·51), hopelessness (r=?0·68), and suicidal ideation (r=?0·41). Results of multiple regression analyses showed that spiritual well-being was the strongest predictor of each outcome variable and provided a unique significant contribution beyond that of depression and relevant covariates. Additionally, depression was highly correlated with desire for hastened death in participants low in spiritual well-being (r=0·40, p<0·0001) but not in those high in spiritual well-being (r=0·20, p=0·06).

Spiritual well-being offers some protection against end-of-life despair in those for whom death is imminent. Our findings have important implications for palliative care practice. Controlled research assessing the effect of spirituality-based interventions is needed to establish what methods can help engender a sense of peace and meaning.

Source: Lancet. 2003 May 10;361(9369):1603-7

Spiritual Needs of Persons With Advanced Cancer

Diane M. Hampton, Dana E. Hollis, Dudley A. Lloyd, James Taylor, James A. Haley Susan C. McMillan
University of South Florida College of Nursing, Tampa, Florida; The Center for Hospice, Palliative Care, and End of Life Studies, University of South Florida, Tampa, Florida

Spiritual needs, spiritual distress, and spiritual well-being of patients with terminal illnesses can affect their quality of life. The spiritual needs of patients with advanced cancer have not been widely studied. This study assessed the spiritual needs of 90 patients with advanced cancer who were newly admitted to hospice home care. They completed a demographic data form and the Spiritual Needs Inventory shortly after hospice admission. Scores could range from a low of 17 to a high of 85; study scores were 23 to 83. Results showed great variability in spiritual needs. Being with family was the most frequently cited need (80%), and 50% cited prayer as frequently or always a need. The most frequently cited unmet need was attending religious services. Results suggest the importance of a focus on the spiritual more than the religious in providing care to patients at the end of life.

Key Words: hospice • cancer • spiritual needs

Source: American Journal of Hospice and Palliative Medicine, Vol. 24, No. 1, 42-48 (2007)

Spiritual life after cancer: connectedness and the will to meaning as an expression of self-help.

Edser SJ, May CG.
The Centre for Cancer Management and Psychology, Carrington, NSW 2294, Australia. Stuart.

This article uses a mixed quantitative/qualitative design to elicit the attitudes and experience of spirituality in a group of N = 11 heterogeneous cancer participants, who were interviewed regarding self-help practice. Part of this interview enquired about spirituality and was analysed separately from the larger body of data, becoming the Spiritual Interview. The authors argue for a conceptualisation of spirituality as a "will to meaning" and "connectedness." Further, they propose that it is the integration of spiritual life that is the crucial variable in assessing spirituality. Participants demonstrated a wide diversity of attitude and experience that supports the authors' contentions.

Source: J Psychosoc Oncol. 2007;25(1):67-85.

Religiousness and Spiritual Support Among Advanced Cancer Patients and Associations With End-of-Life Treatment Preferences and Quality of Life

Tracy A. Balboni, Lauren C. Vanderwerker, Susan D. Block, M. Elizabeth Paulk, Christopher S. Lathan, John R. Peteet, Holly G. Prigerson
Harvard Radiation Oncology Program; Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute; Department of Psychiatry, Brigham and Women’s Hospital; Department of Medical Oncology, Dana-Farber Cancer Institute; Harvard Medical School Center for Palliative Care, Harvard Medical School, Boston, MA; and Palliative Care Service, University of Texas Southwestern Medical Center, Dallas, TX

PURPOSE: Religion and spirituality play a role in coping with illness for many cancer patients. This study examined religiousness and spiritual support in advanced cancer patients of diverse racial/ethnic backgrounds and associations with quality of life (QOL), treatment preferences, and advance care planning.

METHODS: The Coping With Cancer study is a federally funded, multi-institutional investigation examining factors associated with advanced cancer patient and caregiver well-being. Patients with an advanced cancer diagnosis and failure of first-line chemotherapy were interviewed at baseline regarding religiousness, spiritual support, QOL, treatment preferences, and advance care planning.

RESULTS: Most (88%) of the study population (N = 230) considered religion to be at least somewhat important. Nearly half (47%) 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. Spiritual support by religious communities or the medical system was significantly associated with patient QOL (P = .0003). Religiousness was significantly associated with wanting all measures to extend life (odds ratio, 1.96; 95% CI, 1.08 to 3.57).

CONCLUSION: Many advanced cancer patients’ spiritual needs are not supported by religious communities or the medical system, and spiritual support is associated with better QOL. Religious individuals more frequently want aggressive measures to extend life.

Source: Journal of Clinical Oncology, Vol 25, No 5 (February 10), 2007: pp. 555-560

Quality of Life of Long-Term Survivors of Breast Cancer and Lymphoma Treated With Standard-Dose Chemotherapy or Local Therapy

Tim A. Ahles, Andrew J. Saykin, Charlotte T. Furstenberg, Bernard Cole, Leila A. Mott, Linda Titus-Ernstoff, Karen Skalla, Marie Bakitas, Peter M. Silberfarb
From the Department of Psychiatry and Center for Psycho-Oncology Research, and Department of Psychiatry (Neuropsychology Program), Community and Family Medicine and the Norris Cotton Cancer Center; Dartmouth-Hitchcock Medical Center; Lebanon; and New Hampshire Hospital, Concord, NH

PURPOSE: This study compared the quality of life (QOL) of long-term survivors of breast cancer and lymphoma who had been treated with standard-dose systemic chemotherapy or local therapy only.

PATIENTS AND METHODS: Long-term survivors (mean, 10.0 ± 5.3 years after treatment) of breast cancer or lymphoma who had been treated with systemic chemotherapy (breast, n = 141, age = 57.0 ± 10.1 years; lymphoma, n = 66, age = 55.8 ± 13.5 years) or local therapy only (breast, n = 294, age = 65.8 ± 9.1 years; lymphoma, n = 37, age = 50.4 ± 12.8 years) were interviewed by phone using the Quality of Life–Cancer Survivors Tool.

RESULTS: Multivariate analysis of covariance, controlling for sex, age, education, stage of disease, and time since last treatment, revealed that survivors who had been treated with systemic chemotherapy scored significantly lower on overall QOL compared with survivors treated with local therapy only (P = .04). Analysis of covariance on the subscale scores revealed that, compared with survivors who received local therapy, survivors treated with chemotherapy scored significantly lower on the Social subscale (P < .0001), but no differences emerged on the Psychological or Spiritual subscales. There was a statistically significant interaction between treatment and diagnosis (P = .01), as measured by the Physical subscale, indicating that lymphoma survivors treated with chemotherapy scored worse than all other groups.

CONCLUSION: Important QOL differences emerged between the chemotherapy and local therapy groups, suggesting that long-term QOL may vary depending on the type of treatment and diagnosis.

Source: Journal of Clinical Oncology, Vol 23, No 19 (July 1), 2005: pp. 4399-4405

Anxiety and quality of life of women who receive radiation or chemotherapy for breast cancer.

Schreier AM,
Williams SA.
School of Nursing, East Carolina University, Greenville, NC, USA.

PURPOSE/OBJECTIVES: To examine quality of life (QOL) and anxiety in a sample of women receiving radiation or chemotherapy for breast cancer. DESIGN: Longitudinal, descriptive. SETTING: A cancer center in the southeastern United States.

SAMPLE: 48 women participated; 17 received radiation and 31 received chemotherapy. METHODS: The Ferrans and Powers Quality of Life Index (QLI) and Speilberger's State-Trait Anxiety Inventory (STAI) were administered. The QLI was administered at the start of treatment and one year later. The STAI was administered at the start of treatment. The state portion of the STAI also was administered 4 weeks and 12 weeks after the start of treatment.


FINDINGS: Total QOL improved significantly over time for the entire sample, as did scores on the health/functioning, psychological/spiritual, and family subscales of the QLI. No significant differences existed for total QOL or any subscales by treatment. Trait anxiety was significantly higher for women receiving chemotherapy, and state anxiety was significantly higher at all three measurement times for the women. State anxiety did not decrease significantly over the course of the treatment for either group. Trait anxiety and state anxiety at the start of treatment were significantly negatively correlated with total QLI score and the psychological/spiritual subscale. State anxiety at the start of treatment also was significantly negatively correlated with total QOL and the health/functioning and psychological/spiritual QLI subscales both at the start of treatment and one year later.

CONCLUSIONS: QOL improves over time for women who have received radiation or chemotherapy. Women receiving chemotherapy have higher anxiety scores, and higher anxiety at the start of treatment is associated with decreased QOL at the start of treatment and postdiagnosis.

IMPLICATIONS FOR NURSING: Nursing interventions to reduce anxiety at the start of treatment, especially for chemotherapy recipients, are indicated. Research also should target methods to reduce anxiety at the start of treatment.

Source: Oncol Nurs Forum. 2004 Jan-Feb;31(1):127-30

Ending treatment: the course of emotional adjustment and quality of life among breast cancer survivors immediately following radiation therapy

Teresa Deshields, Tiffany Tibbs, Ming-Yu Fan, Laura Bayer, Marie Taylor and Edwin Fisher

Goal of work This study investigated changes in psychological adjustment and quality of life among breast cancer patients following completion of radiation therapy.

Patients and methods Ninety-four patients completed measures of depressed mood, anxiety, and quality of life via interview at five time points: the end of radiation therapy, 2 weeks posttreatment, the first radiation oncology follow-up appointment (4–6 weeks after treatment), 3 months posttreatment, and 6 months posttreatment.

Main results At the conclusion of radiation treatment, participants reported elevated levels of depression, low levels of anxiety, and diminished quality of life. By 2 weeks posttreatment, depression decreased significantly and overall quality of life improved significantly, as well as quality of life in the specific FACT-B domains of Physical and Functional Well Being and the Breast Cancer Subscale. Following that time, the only significant change involved further improvement in breast-cancer-specific concerns.

Conclusions Results suggest that the primary psychological changes associated with ending breast cancer treatment occur quickly following the conclusion of treatment. Thereafter, psychological status appears to stabilize. The implications of these findings for treatment and directions for future research are discussed.
Keywords Breast cancer - Depression - Quality of life - End of treatment - Psychological adjustment

Souce: Supportive Care in Cancer. Volume 13, Number 12 / December, 2005

The Relationship of Religiosity and Spirituality to Quality of Life Among Cancer Patients

A. Elizabeth Rippentrop1, Elizabeth M. Altmaier2, 3, 5 and C. Patrick Burns4

Most quality of life (QOL) assessments measure patients’ emotional well-being, functional well-being, interpersonal/social well-being, and satisfaction with treatment. Little attention has been given to patients’ spirituality or religiosity. Further, studies that have examined the impact of spirituality or religiosity on QOL have not differentiated between the constructs. The purpose of this study was to examine religiosity and spirituality as separate variables, and to define their relationship to QOL for 61 persons with cancer. Regression analyses indicated that, while spirituality and religiosity are moderately intercorrelated, spirituality has a stronger relationship with QOL than religiosity. When attempting to understand a person's spiritual life and its impact on QOL, there is a need for clear distinction between and separate assessment of spirituality and religiosity.

KEY WORDS: spirituality - religiosity - quality of life - oncology - assessment

Source: Journal of Clinical Psychology in Medical Settings. Volume 13, Number 1 / March, 2006.

Cancer as Part of the Journey: The Role of Spirituality in the Decision to Decline Conventional Prostate Cancer Treatment and to Use Complementary and Alternative Medicine

Margaret White, MIR
Vancouver, British Columbia, Canada.

Marja Verhoef, PhD
Department of Community Health Sciences, University of Calgary

Background: The role of spirituality in patients' use of complementar y and alternative medicine (CAM) approaches to cancer management has hardly been explored. Objective: To explore the role of spirituality in cancer management by men with prostate cancer who have declined conventional treatment and are using CAM. Methods: This qualitative analysis is part of a longitudinal study to assess decision making by men with prostate cancer who decline conventional treatment and use CAM. In-depth interviews were conducted at study entry (n = 29). Themes were presented to participants in focus groups to further explore and validate the interview results. For a subset of participants (n = 10), spirituality emerged as an important theme; therefore, we conducted a secondary analysis of the interview data of these men to explore the role of spirituality in cancer management and decision making. Results: Spirituality appeared to influence all aspects of the cancer experience. Most participants intensified their use of spiritual practice after a diagnosis of prostate cancer. These practices included spiritual ceremonies, indigenous healing, prayer, meditation, and use of spiritual imagery. Themes related to the role of spirituality in cancer management include beliefs about Western medicine, the role of spiritual beliefs in treatment decision making, the use of spiritual imager y and metaphor in healing, and the impact of cancer on spirituality. The discussion of these themes draws on quotes and case examples, illustrating how spirituality influenced study participants' response to diagnosis, treatment decision making, and cancer care. Two case examples provide a more in-depth understanding of how some participants incorporated spiritual imagery and metaphor into treatment decision making and cancer care. Ways in which cancer influenced spirituality are also discussed. Having prostate cancer appeared to influence their spirituality by strengthening their links with a spiritual community, increasing feelings of gratitude toward life, and improving personal relationships. Relevance: These findings indicate that spiritual beliefs and practices may play an important role in the formation of treatment choices for some patients. Health care providers need to be aware of and address patient concerns about how conventional treatment may conflict with their spiritual beliefs and practices. Further research and medical education is needed on spirituality and prostate cancer.

Key Words: spirituality • prostate cancer • treatment decision making • complementary and alternative medicine

Source: Integrative Cancer Therapies, Vol. 5, No. 2, 117-122 (2006)

End-of-Life Content in Treatment Guidelines for Life-Limiting Diseases

Kimberly R. Mast, M.D. Marybeth Salama, M.D. Gabriel K. Silverman, B.A. Robert M. Arnold, M.D.
McAuley Medical Associates, Mercy Hospital, Pittsburgh, Pennsylvania. University of Pittsburgh, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. The Western Pennsylvania Hospital, Family Practice Residency Program, Department of Family and Community Medicine, Temple University School of Medicine, Pittsburgh, Pennsylvania. University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Background: Clinical guidelines are systematically developed statements that influence medical practice, education, and funding. Guidelines represent the consensus of leaders, often based on systematic reviews of the literature, regarding the "state of the art."

Objective: To assess the degree to which end-of-life care is integrated into nationally developed guidelines for chronic, noncurable, life-limiting diseases.

Design: Four compendia were reviewed: The Healthcare Standards Directory ECRI, 2001; the Clinical Practice Guidelines Directory, 2000 edition; the National Guidelines Clearinghouse, (; and the National Library of Medicine's MEDLINE database on the OVID platform for guidelines on nine chronic diseases (chronic obstructive pulmonary disease, end-stage liver disease, amyotrophic lateral sclerosis, congestive heart failure, dementia, cerebrovascular accident, end-stage renal disease, cancer [breast, colon, prostate, lung], and human immunodeficiency virus). They were assessed by two reviewers for end-of-life content in 15 domains (e.g., epidemiology of death, symptom management, spiritual, family roles, and settings of care), the presence of eight specific terms dealing with palliative care, integration of palliative care information into the guideline, and descriptive variables.

Setting/Subjects: Not available.

Measurements: Each guideline was examined and rated on a 0–2 scale (0, absent content; 1, minimal content; 2, helpful content) using 15 end-of-life content domains. Scores from domains were summed and classified into 3 categories: 4 or less, minimal; 5–12, moderate; and more than 12, significant content.

Results: Ten percent of guidelines had significant palliative care content, 64% had minimal content, and 26% had moderate content. The least addressed domains dealt with spirituality, ethics, advocacy and family roles. When guidelines that dealt solely with prevention, acute exacerbations or complications of an illness, or specific treatment modalities were excluded 28% and 16% of these general guidelines (n = 58) had moderate and significant palliative care content, respectively, compared to 24% and 0% of all nongeneral guidelines. Similar results were found when analyzing the data by disease course or treatment focus. Only 14% of guidelines advised physicians to consider palliative care at a specific point in the disease course. Ninety-one percent of the guidelines mentioned death, dying, end of life, mortality, or terminal illness but only 36% mentioned palliation or hospice.

Conclusion: Current national guidelines on nine chronic, life-limiting illnesses offer little guidance in end-of-life care issues despite a recent increase in attention to this aspect of medical care.

Source: Journal of Palliative Medicine. Dec 2004, Vol. 7, No. 6 : 754 -773

Spiritual Struggle. Effect on Quality of Life and Life Satisfaction in Women With Breast Cancer

Juanita Manning-Walsh, Ph.D., R.N.
Western Michigan University Bronson School of Nursing

Background: Women with breast cancer experience stressors affecting quality of life (QOL) and life satisfaction. Little is known about effects of spiritual struggle as a coping strategy on QOL and life satisfaction.Purpose: Examine relationships between spiritual struggle, QOL, and life satisfaction.Method: Nonprobablility sample of 100 participants recruited from an Internet Web site with mailed questionnaires. Three instruments were used: breast cancer-specific version of Functional Assessment of Cancer Therapy Scale (FACT-B), Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT-Sp-12) combined for QOL, Negative Coping subscale of Religious Coping (RCOPE) for spiritual struggle, and a single-item measuring life satisfaction.Findings: Small inverse relationships between spiritual struggle, QOL (r = -.36, p < .001), and life satisfaction (r = -.31, p < .001) existed.Conclusions:Spiritual struggle gives voice to women’s questionings implying lower QOL and life satisfaction.Implications: Assessment of and assistance with managing spiritual struggle are necessary to promote QOL and life satisfaction among those facing difficult health problems.

Key Words: breast cancer • quality of life • life satisfaction • spiritual struggle • coping

Source: Journal of Holistic Nursing, Vol. 23, No. 2, 120-140 (2005)

Arts in Health Care. A New Paradigm for Holistic Nursing Practice

Mary Rockwood Lane, RN, PhD
University of Florida

Bringing creativity into health care has opened up a new dimension in nursing. Creative interventions have been shown to shorten hospital stays and reduce the patient's need for pain medication. In response to these benefits, many major medical centers around theworld have instituted arts in health care programs. Arts in Medicine is one such program that serves hundreds of patients. Itwas established by a nurse at the University of Florida and is directly tied to nursing care. Programs like this provide clinical models for nurses who want to integrate the arts into their health care practice. This article presents these models and discusses ways that nurses can easily implement creative interventions into their practice.

Key Words: creativity • art • spirit • dance • music • nursing interventions

Source: Journal of Holistic Nursing, Vol. 24, No. 1, 70-75 (2006)

Psychological Issues in End-of-Life Care

Susan D. Block, M.D.
Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital and Harvard Medical School Center for Palliative Care, Boston, Massachusetts.

This paper provides a systematic, evidence-based review of the psychological issues confronted by patients at the end of life, drawing on recent literature. The epidemiology, approach to clinical assessment, clinical presentation, and therapeutic options related to common psychological issues that arise in end-stage illness are described. The spectrum of normal and dysfunctional reactions are identified, and approaches to enhancing coping and quality of life are emphasized. The learner will be able to describe: (1) normal coping responses of patients at the end of life; (2) epidemiology of common psychiatric disorders at the end of life; (3) the approach to clinical assessment of psychological distress at the end of life; and (4) therapeutic approaches to common psychological problems at the end of life.

Source: Journal of Palliative Medicine. Jun 2006, Vol. 9, No. 3 : 751 -772