Spiritual Needs of Cancer Patients Important Part of Care

Roxanne Nelson

August 22, 2014

After asking a patient if she would like to be prayed for, Caroline Petrie, a community nurse working in the United Kingdom, was suspended from her job.

Petrie faced disciplinary action and the possible loss of her job. At the time of the incident, she was told that she had to "demonstrate a personal and professional commitment to equality and diversity" and that she could not use her "professional status to promote causes that are not related to health."

Petrie insisted that she never tried to force her religious beliefs on any of her patients, but simply asked if the patient wanted her to pray for her.

Although she was reinstated, the incident highlights the "line in the sand" that is often drawn when it comes to mixing religion and medicine. The intersection between faith, science, and healing is still hazy for many practitioners, and some are uncomfortable bringing spiritual practice into the care paradigm. But in this era of increasingly holistic care, it has become clear that religious and spiritual beliefs and practices are important to many patients. This can be particularly pronounced in people facing a potentially terminal disease, such as cancer, where one's own mortality suddenly becomes very real.

Polls and surveys show that more than 90% of Americans believe in God or a universal spirit, but the spiritual needs of patients and their families are not always obvious to healthcare professionals, said Stephen King, PhD, BCC, manager of chaplaincy at the Seattle Cancer Care Alliance.

Spirituality "is important to many cancer patients, even if it wasn't prior to their diagnosis," he said. "Patients often want providers to ask about it. They don't want a theological discussion, they just want to know that their providers are interested."

Unfortunately, the spiritual needs of patients might not be addressed until the disease reaches an advanced stage, or might not be addressed at all. "Spiritual care is often perceived to be the chaplain's job," Dr. King explained. "And while chaplains have an important role, everyone involved in the patient's care has a role to play in addressing the spiritual needs of cancer patients."

The first step is for providers to be aware of their own spiritual feelings and views, he explained. "They need to understand what makes them anxious and, if a person asks about faith, to acknowledge their own comfort level."

Awareness Needed

Spirituality and religion are different concepts, although they often overlap. Aligning with a specific religion indicates adherence to certain beliefs and dogma, whereas spirituality has been described as an awareness of something greater than the individual self. People can express their spirituality through religion and prayer or through other paths of spiritual pursuit and expression.

The spiritual component of care is one that patients are asking for, noted Robert Klitzman, MD, professor of clinical psychiatry and director of the masters of bioethics program at the College of Physicians and Surgeons at Columbia University in New York City. "It is extremely important to many patients with cancer and other chronic illnesses, and doctors need to be aware of that," he told Medscape Medical News.

In the late-19th century, medicine distanced itself from what is now considered holistic treatment, he commented. "American medicine wanted to become very scientific and distanced itself from what it saw as quackery," he said. "They rejected anything that wasn't scientific."

But the reality is very different for the patient, Dr. Klitzman continued. "Someone experiencing cancer and possibly facing the end of life doesn't think of science as one thing and spiritual issues as something else — they are seen as one and the same."

"We as doctors need to be aware of that; a patient's experience of illness involves the scientific medical aspect as well as the spiritual and existential aspect," he explained. "We need to educate doctors to be aware of that. That is not to say that doctors need to pray with patients or to believe anything themselves, but they need to be aware of it and ask patients about it."

"What's important is to show awareness that spirituality and religion are an important part of the experience that patients are going through," he added.

Helping Patients Cope

There has been a plethora of research addressing the role of religion and spirituality in medical care during the past decade or so. The growing body of literature has explored the impact of religion and spirituality on various mental and physical health outcomes, including quality and length of life. Not surprisingly, a great deal of research has focused on cancer care, and some studies suggest that spirituality, in particular, improves a patient's ability to cope with the illness and manage symptoms.

One large study of an ethnically diverse population of 1610 cancer patients showed that spiritual well-being is related to the ability to enjoy life, even while experiencing symptoms (Psychooncology. 1999;8:417-428).

An exploratory study that examined the relation between spirituality and immune function in 112 women with metastatic breast cancer revealed that the women who rated spiritual expression as important had more circulating white blood cells and higher total lymphocyte counts (Breast J. 2001;7:345-353).

A study of patients with advanced cancer demonstrated that the support of spiritual needs is associated with an improved quality of life, and that there is a "provocative" association between religiousness and the desire for aggressive treatment to extend life (J Clin Oncol. 2007;25:555-560).

A meta-analysis of 43 studies of patients with advanced cancer showed that those who had an enhanced sense of psychospiritual well-being were able to cope more effectively with the process of terminal illness and find meaning in the experience (J Adv Nurs. 2003;44:69-80).

Finally, a study of colorectal cancer patients reported that spiritual well-being is linked to lower distress levels. The factors most strongly associated with a reduction in emotional distress were finding peace and finding meaning to life (Support Care Cancer. 2011;19:757-764).

Should I Pray With My Patients?

David Levy, MD, a neurovascular surgeon at the UC San Diego Health System, has added a component to his practice; when it is appropriate, prayer has become part of his regular interaction with patients.

"My focus is on the patient's spirituality," Dr. Levy told Medscape Medical News. He pointed out that guidelines from the Joint Commission on Accreditation of Healthcare Organizations say that patients' spirituality should be attended to in ways that are important to them.

"I find it important enough for patients' health to take a spiritual history and to find out if they have a faith, if prayer is part of that, and so on. I ask anywhere from 2 to 5 questions about it, depending on how they respond. If they say 'no, it's not important to me,' I'm not going to belabor the point," he explained.

Dr. Levy emphasized that the purpose of taking a spiritual history is not to assess or change patients' spiritual outlook, but to assist in their care.

"I want to use everything in my armamentarium to get the best outcome," Dr. Levy said. That includes spiritual and psychologic outcomes, he noted, because when people get sick and they need help, they often revert to the spiritual. They may ask if God is punishing them or what did they did to deserve their disease. "When we are out of control, we look for someone who is in control or who can help."

"I love to use this in a positive way, and I find that if I tell certain patients that God is not angry with them, it comforts them," Dr. Levy explained. "I find that I can help patients better if I know where they are on their journey of faith," he said.

I think you do a great disservice to people if you don't at least ask them.

All patients should be asked about faith and spirituality, especially those dealing with cancer or another life-threatening illness, Dr. Levy commented. "You do a great disservice to people if you don't at least ask them," he said. "We shouldn't be afraid of offending someone. If the patient seems to be offended, we should just apologize and move on."

He pointed out that most of his patients believe in some type of higher power, but the rate is lower in the scientific community. Thus, when treading into the spiritual realm, the patient often knows more than the physician. "That makes some doctors uncomfortable," Dr. Levy noted. "It can be unnerving to blunder into something, and even taking a spiritual history can make some people uncomfortable."

Dr. Levy prays for every patient privately prior to surgery, but not only for the patient, but for himself, the staff, and everyone else involved. "That is my custom, and no one has shown praying blessings on people has ever hurt anyone, and many believe it helps."

Listen and Refer

However, some experts believe that the spiritual needs of the patient should be only addressed by those who are trained and qualified in that field.

The line between assessment and intervention can sometimes be blurred, and patients can perceive questions about their spiritual or religious concerns as an opening for further exploration. That should not be in the realm of the provider, according to Richard Sloan, PhD, chief of the division of behavioral medicine at Columbia University.

"Physicians need to know the things that are important to the patient," he told Medscape Medical News. "But knowing what is important and acting on it are 2 different things."

Cancer patients who express a desire to explore spiritual and religious issues should be referred to appropriate professionals, Dr. Sloan explained. "It is not okay for physicians to take it upon themselves to meet the spiritual needs of the patient when they are poorly trained in that realm."

It is also inappropriate for providers to push any particular religious or spiritual views on patients, he noted.

"It is perfectly appropriate to ask the patient about spiritual or religious needs; the most appropriate response is then to refer the patient to a chaplain or counselor," Dr. Sloan reiterated. "It is not something for physicians to address themselves, as they are not trained in that capacity and do not have the time. In fact, they can end up doing harm."

Dr. Sloan said he believes that physicians should not pray with patients, even if they are of the same faith. "Instead, the physician can say something like 'I am happy to sit with you while you pray,' or something along those lines," he explained. "It's not a good idea to pray with a patient because of the asymmetric power of the relationship between physicians and patients."

The Doctor as Patient

Physicians often do not realize the importance of spirituality to their patients until they find themselves in the same boat. Several years ago, Dr. Klitzman interviewed more than 70 people who have experienced medicine as doctors and as patients, and compiled his research in the book entitled When Doctors Become Patients.

"Many of them had cancer, and one of the things that struck me most of all was how often spiritual issues came up," he said. "This was not what I was expecting, but over and over I heard the same thing. Doctors told me that their patients used to say 'Doc, will you pray with me, and I just pooh-poohed it. Then I became a patient and realized how important those issues are'."

Some of the physicians interviewed told him that they wished they could believe in something but they were too much of a scientist, others said they could see how it could help patients, and some felt the need to reconsider their beliefs.

"The more we are aware of what it's like to be a patient, the better doctors we can be," Dr. Klitzman said.

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