Spirituality in Palliative Care (General)
Posted:Friday, January 13 2006 @ 09:49:58 AM
by Adam B. Cohen, Ph.D., and Harold G. Koenig, M.D.
Spirituality in Palliative Care
Interest in religion and spirituality as a source of resilience in coping with serious physical illness has seen a dramatic increase in recent years (Koenig et al., 2001a, 2001b; Plante and Sherman, 2001). Health care professionals providing medical care to patients with serious illnesses should consider the roles that they can play in meeting patients' religious and spiritual needs. Compassionately addressing these issues may increase the health of patients and/or increase the comfort and meaning in the process of illness and the process of dying.
From a research perspective, these issues are woefully underaddressed. Questions that need to be answered include the religious and spiritual needs of people of different religions, the positive and negative effects of religion and spirituality in palliative and end-of-life care, and the contributions that religious and spiritual institutions as well as health care professionals can make to such endeavors. One additional area is the concern on the part of religious or spiritual family members and health care professionals about whether the ill or dying patient has adequately prepared for death. It is unknown how commonly such issues impact patient-family interactions or patient care. Most of the extant research on religion and health has been performed using Christian participants (Koenig et al., 2001b). We will focus our discussion on the Jewish and Christian traditions because those are the traditions with which we are most familiar; but, research is sorely needed on issues related to spirituality and medical outcomes in non-Judeo-Christian populations.
Several studies have demonstrated high rates of depression and other mental disorders among people with chronic illness or disability (Koenig and Blazer, in press). In fact, nearly half of acutely hospitalized patients experience some degree of clinically significant depression, and the severity of depression is directly related to the extent of their medical illness and associated loss of function (Koenig et al., 1997). Issues related to depression in patients such as these may often involve a religious or spiritual dimension. At the end of life, in particular, palliative care patients might be especially likely to have spiritual concerns related to their conditions and their impending deaths.
Religious and spiritual needs are very common in elderly patients, and may be especially so in patients near the end of life and in those who are struggling daily with conditions that are incurable. Even among nonterminal but hospitalized patients, one study suggested that three-quarters of medical-surgical patients had three or more religious needs (Fitchett et al., 1997). These researchers found an even higher percentage -- 88% -- of psychiatric inpatients have such religious needs, highlighting the already mentioned link between psychiatric distress and religious or spiritual needs.
The same important link between illness and religious or spiritual needs was shown in another study that found that among 330 consecutively admitted medical patients over 60 years of age, 85% used religion to help them to cope to at least a moderate extent, and 40% cited religion as the single most important factor in their coping (Koenig, 1998). Another study showed that about two-thirds of older women and one-third of older men gave religious responses to open-ended questions about how they coped with the worst aspects of their lives (Koenig et al., 1988). A high prevalence of religious coping has been shown to be present in people with end-stage kidney disease (Tix and Frazier, 1998), AIDS (Kaldjian et al., 1998), heart disease (Saudia et al., 1991), cancer (Ginsburg et al., 1995; Halstead and Fernsler, 1994; Roberts et al., 1997) and other serious medical illnesses (Harris et al., 1995; Stern et al., 1992).
Religiosity and spirituality have various definitions (Koenig et al., 2001b). Patients' religious needs may include making peace in one's relationship with God and with others in one's life, readying oneself for the afterlife, and attending to the ritual requirements of one's religion. Patients' spiritual needs, often described as more general than religious needs, may include the problem of finding meaning and a sense of control in one's life, forgiving oneself and others, obtaining forgiveness, reflecting on the course of one's life and one's accomplishments, and saying goodbye to loved ones. In helping patients to address their spiritual needs, clearly the first priority must be relieving their physical symptoms and their psychiatric symptoms.
For people of many religions, religious and spiritual forms of coping may provide uniquely meaningful ways of dealing with chronic illness. In one study, religious coping was found to be the most powerful of 14 variables measured at baseline in predicting depression scores at a six-month follow-up after hospitalization (Koenig et al., 1992). Religious coping may be more effective at ameliorating affective and cognitive symptoms of depression, as opposed to somatic symptoms (Koenig et al., 1995).
Although there is a sizable literature showing beneficial effects of religion on health outcomes (Koenig et al., 2001b), religious and spiritual beliefs may create concerns in dying patients or patients undergoing palliative care and their families (Franks et al., 1990-1991; Fry, 1990). Such concerns could be related to fears of one's relationship with God and of going to hell, feelings of abandonment by one's religious community, and fears that the devil is involved in one's illness. In one study, these types of fears were associated with a significantly higher mortality rate two years following discharge from the hospital (Pargament et al., 2001), although it is also possible that such fears increase in patients as they prepare for death. Some recent research is suggestive of potential differences in certain types of religious coping among members of some religions (Cohen and Rozin, 2001). Hospice workers, nurses, chaplains and physicians need to be aware of the unique emphases of each religion -- and within each religion -- and adjust their spiritual care appropriately. Often, simply engaging patients in discussions about such issues -- and respecting and validating their feelings and religious beliefs -- can go a long way in helping them to achieve a "good" death.
When health care providers realize that their patient is struggling with religious or spiritual beliefs and concerns, then clergy with health care training in that patient's particular tradition should be enlisted.
Finally, a person's religious or spiritual beliefs may influence their medical decision-making toward the end of life, including decisions about withdrawing life support and foregoing curative treatments. These beliefs may be unique to the person's particular religion. Clinicians should discuss with patients, or their proxy decision-makers, how their religious or spiritual beliefs are affecting their decisions. Such dialogue will help to avoid much misunderstanding and conflict at the end of life.
Dr. Cohen is a postdoctoral fellow at the Center for the Study of Aging and Human Development and the Center for the Study of Religion/Spirituality and Health at Duke University Medical Center.
Dr. Koenig is associate professor of psychiatry and medicine and director of the Center for the Study of Religion/Spirituality and Health at Duke University Medical Center.
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