Spiritual Interventions Improve QOL, Outcomes in HF

Batya Swift Yasgur MA, LSW

March 31, 2022

A new review suggests that spirituality can have a positive impact on quality of life (QOL) in patients with heart failure (HF), and that it should be considered a potential target for palliative care interventions.

In their review, researchers found 47 studies supporting the role of a spiritual intervention in improving QOL and patient outcomes, providing caregiver support, and reducing depression and anxiety in HF patients.

"Spirituality is an increasingly recognized domain for patients with HF, and studies have shown an association between improved quality of life and mood in patients with HF, as well as improvement in outcomes such as reduced hospitalizations and mortality," lead author Rachel Tobin, MD, resident in internal medicine, Duke University Hospital, Durham, North Carolina, told theheart.org | Medscape Cardiology.

"Studies suggest that as HF progresses, spirituality may become increasingly important to patients with HF and their caregivers. Further studies and uniform measures of spirituality are needed to better understand spirituality in patients with HF," she said.

The review was published in the April issue of JACC: Heart Failure.

Core Domain

Patients with HF have poor QOL; experience high levels of depression, anxiety, and spiritual distress; and are a population with "unique spiritual needs. given the unpredictable HF clinical course, characterized by hopelessness, isolation, and altered self-image," the authors write.

Palliative care focuses on QOL and relieving suffering and is recommended by several major cardiovascular societies, including the American College of Cardiology and the American Heart Association/American Stroke Association.

Spirituality is a "multidimensional construct, characterized by many domains," the authors explain. A key component is "finding meaning and purpose," which is applicable to people who do or do not espouse a specific organized religion. In fact, many people view themselves as "highly spiritual but deny ties to religion."

"Given advances in HF treatment, patients are living longer, which puts further emphasis on quality of life and palliative care,” Tobin commented.

"Spirituality is a core domain of palliative care, and compared to patients with cancer, there are limited data describing the role of spirituality in patients with HF," she said. "We believe spirituality serves as a potential target for palliative care interventions to improve patient-centered and clinical outcomes in patients with heart failure."

Unaddressed Spiritual Need

Of 592, citations the researchers selected 47 studies to explore the current knowledge of spirituality in HF patients, describe associations between spirituality and QOL and between spirituality and patient outcomes, and derive potential clinical applications and future directions.

In total, there were 10 different instruments used in the various studies to measure spirituality, which ranged from a simple question of "are you at peace?" to more complex questionnaires with multiple subscales.

Although these instruments have been validated in an array of other chronic illnesses, they have not been validated in patients with HF, the authors note.

The Functional Assessment of Chronic Illness Therapy-Spiritual Wellbeing Scale (FACIT-Sp) was the commonly used instrument. It consists of two subscales: one measuring faith and one measuring peace.

The researchers found "high levels of spirituality" reported in studies of patients with HF. However, they also found a large percentage of patients with "unaddressed spiritual needs," with up to one-fourth reporting only a "limited sense of peace." In one study, close to half of an outpatient sample of patients with HF reported "unmet spiritual needs."

Patients with HF often experience poor QOL, marked by high levels of anxiety and depression, they note. Although spirituality has been associated with better QOL and less depression and anxiety in other chronic illnesses, there is "little information" about the role of spirituality in patients with HF. One study found that patients with HF and patients with cancer had similar spiritual wellbeing scores, but the HF patients reported higher levels of depressive symptoms than those with advanced cancer.

Most studies of spirituality in HF looked at QOL or mood, and almost all of them showed a "significant association between improved QOL and mood in patients with HF with higher levels of spirituality."

Spirituality-based Interventions

Few studies investigated the impact of a spiritual intervention on patients with HF. However, those that did found generally positive effects.

For example, the PAL-HF (Palliative Care in Heart Failure) trial, which randomized patients to receive either a palliative care intervention or to usual care, showed improvement in spiritual wellbeing in patients in the intervention group, compared with those in the usual group, as measured by the FACIT-Sp. Other measurement tools also revealed increased QOL and lower levels of depression and anxiety in these patients. Another study of a 12-week mail-based psychosocial intervention showed that patients experienced improved QOL and less depression and searching for meaning.

International studies "demonstrated that, globally, spirituality is instrumental in QOL of patients with HF," the authors report.

The researchers also looked at the potential association between spirituality and patient outcomes, noting that spirituality has been found to be associated with lower mortality and rehospitalization in patients with other chronic illnesses.

Spirituality was found to be associated with a lower risk for mortality and better outcomes.

  • One study showed that religion and spirituality were both associated with better health behaviors at baseline, and spirituality was associated with a 20% reduction in mortality in a cohort of patients with HF.

  • A retrospective cohort study showed faith to be associated with significant reduction in 30-, 90-, and 180-day mortality.

  • Several studies showed associations between medication adherence and spirituality in patients with HF.

Spiritual interventions may be beneficial not only to patients, but also to caregivers, with preliminary findings suggesting "that caregivers exhibit spiritual needs and could benefit from targeted spiritual interventions," the authors state.

"We strongly advocate that further research and investigations are needed to better understand the role of spirituality in patients with heart failure," Tobin said.

She noted that members of her group "are working to validate a spirituality screening tool that could identify patients at risk for spiritual distress and most likely to benefit from spirituality-based interventions."

Spiritual History

Commenting on the study for theheart.org | Medscape Cardiology, Harold Koenig, MD, professor of psychiatry and behavioral sciences and associate professor of medicine, Duke University Medical Center, Durham, said he agrees with the authors that spirituality may be a potential target for palliative care interventions in patients with HF.

"Physicians should take a detailed spiritual history and listen to patients' beliefs and practices that are important to them and identify spiritual needs, referring to chaplains who are trained to address those needs," said Koenig, director of the Center for Spirituality, Theology and Health at Duke University, who was not involved with the study.

Prospective studies "that follow individuals over time, assessing their mental health, quality of life, and changes in their religious and spiritual beliefs, are the kinds of studies that are needed," he suggested. "Such studies could identify areas of intervention that would help individuals who are dying come to a sense of peace, both emotionally and spiritually, at the end of their lives."

No source of funding listed. Tobin reports no relevant financial relationships. The other authors' disclosures are listed on the original paper. Koenig reports no relevant financial relationships.

JACC Heart Fail. 2022;10:217-226. Abstract


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