Terminally Ill Religious Patients Cite Lack of Support from Medical System

BOSTON, Feb. 8 -- Many patients with advanced cancer aren't served well by the medical system when it comes to their spiritual or religious needs, according to a multicenter study.

Nearly 90% of patients with advanced cancer said in a study that religion and spirituality were important to them, and 72% of this group said their spiritual needs were met only minimally or not at all by the medical system, reported Tracy A. Balboni, M.D., M.P.H., of Harvard Medical School.

Also, nearly half of all spiritually inclined patients reported feeling bereft of support from their religious communities, the investigators wrote in the Feb. 10 issue of the Journal of Clinical Oncology.

They looked at religiousness and spiritual support in patients with advanced cancer as part of the Coping With Cancer study, a NIH-funded study of the factors associated with well-being and quality of life in patients with advanced cancer and their caregivers.

Patients could be included if they had a diagnosis of advanced cancer with expected prognosis of less than one year and failure of first-line therapy, had the diagnosis made at one of five participating sites, were ages 20 or older, had an identified unpaid caregiver, and were well enough to complete the interview.

Interviewers trained by research staff from Yale asked the patients to rate the importance to them of religion, the frequency of their religious service attendance, and how often they engaged in private spiritual activities such as prayer before and after their cancer diagnosis.

"Spiritual needs were minimally supported by religious communities for approximately half of the participants, with support being greatest among African Americans," the authors wrote.

"In addition, most patients reported that the medical system (including chaplains) provides little spiritual support. With pastoral visits usually representing only a sliver of the medical experience and physicians infrequently addressing religion and spirituality issues with patients, many patients might view their medical experience as devoid of spiritual support."

The patients were also asked to rate on a scale of 1 to 5 the level of religious support they felt from their religious communities and from the medical system, including doctors, nurses, and chaplains.

They found that 88% of the 230 participants who completed the study said that religion was "very" or "somewhat" important to them. A large majority of African Americans (89%) and Hispanics (79%) said that religion/spirituality was very important to them. This was significantly higher than among whites (59%).

"Increasing patient-reported distress at the time of study recruitment was significantly associated with increasing religiousness (P=0.01), whereas age was not associated with religiousness (P=0.53)," the authors wrote.

Slightly more than half of the patients (56%) attended religious services once a month or more before their cancer diagnosis, which decreased to 44% after the diagnosis. Patients prayed regularly significantly more after receiving a diagnosis (61%) than before (44%).

"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," the authors wrote. "Spiritual support by religious communities or the medical 0system was significantly associated with patient quality of life (P=0.0003)."

They also found that religious patients were nearly twice as likely to want all possible measures to extend life than non-religious terminal patients (odds ratio, 1.96; 95% CI, 1.08 to 3.57).

The authors noted that guidelines issued by the National Consensus Project for Quality Palliative Care recognized religion and spirituality as important components of end-of-life care.

"Methods for meeting patient spiritual needs should be explored, and the impact of such interventions should be assessed," they wrote. "In addition, the appropriate roles of various health care providers (e.g., physicians, nurses) in managing spiritual needs should be clarified. Although incorporating religion/spirituality into care requires delicacy, attention to this dimension of health has the potential to enhance patient well-being at the end of life."

In an accompanying editorial. Betty Ferrell, Ph.D., of the City of Hope National Medical Center in Duarte, Calif., noted that oncologists in particular can play an important role in spiritual support.

"Involvement of oncologists in spiritual assessment and advocacy for spiritual care is symbolic of a larger goal," she wrote. "The oncologist who dares to ask about spirituality imparts a vital message to the patient that they are being care for by someone who has not forgotten that a broken patient remains a whole person and that healing transcends survival."

Dr. Balboni and colleagues noted that the study may have been subject to selection bias, because of possible differences in religiousness or spirituality between participants and non-participants.