Meeting Terminal Patients' Spiritual Needs Improves Quality of Life

Dec. 19, 2009— -- When medical teams acknowledge a patient's spiritual needs as death approaches, that patient is more likely to receive hospice care and have a better quality of life in his or her remaining days, researchers say.

Those with advanced cancer who felt their spiritual needs were met by their medical team had more than a three-fold greater chance of getting hospice care than those who felt their needs weren't supported, according to Dr. Tracy Balboni of Dana Farber Cancer Institute in Boston.

They also had a better quality of life near the end, and those most at peace with their prognosis were less likely to receive futile aggressive care, she and colleagues wrote in the Journal Of Clinical Oncology.

"Other studies have suggested that patients' religiousness and or spirituality play an important role in end-of-life decision making and how they think of their illness," Balboni told MedPage Today. "That might play a role as far as impacting care at the end of life."

"It's also an important component of quality of life," she added. "So by addressing a patient's spiritual needs, the medical team and pastoral care services are helping to uphold patient quality of life even as they're facing the end of life."

Previous studies have found that the majority of patients with an advanced illness view religion or spirituality as personally important and have spiritual needs. As Balboni noted, patient spirituality has important implications for medical decision making.

Even though spiritual care has been incorporated into national care guidelines, Balboni said, it remains notably absent for most patients at the end of life. The paucity of data examining prospective associations of spiritual care on patient well-being just before death may be partially responsible.

So the researchers conducted the Coping with Cancer study, which investigates how psychosocial factors, including spiritual care, influence patients' end-of-life care and quality-of-life.

Patients' perception of spiritual care was assessed at baseline, with questions about satisfaction with spiritual care from both their medical team and pastoral services.

The researchers assessed whether the patients had hospice care in the last week of life, and whether they received resuscitation, ventilation, or an ICU stay as a measurement of aggressive care.

Caregivers were also asked to evaluate quality of life in the patient's last week.

Patients died a median of 116 days after the baseline interview, with 73 percent receiving hospice care and 17 percent having had some aggressive care.

The researchers found that the majority of patients -- 60 percent -- reported that their spiritual needs were minimally or not at all supported. About half -- 54 percent -- hadn't received pastoral care visits.

Patients whose spiritual needs were largely or completely supported by the medical team were three-and-a-half times more likely to receive hospice care at the end of life than those whose needs weren't met.

The researchers also found that patients who had high religious coping -- or those who were most at peace with their prognosis -- were one-fifth as likely to receive aggressive care at the end of life.

"When patients have their spiritual needs well supported, they become much less likely to receive aggressive end-of-life care," Balboni said.

This prompts the question of whether medical care that recognizes the spiritual components of facing a terminal illness may help to prevent futile, aggressive care at the end of life.

The researchers wrote that greater spiritual support from the medical team was associated with better patient quality of life near death, both in unadjusted and adjusted models, as was the receipt of pastoral care services.

"This study shows both how important spiritual care is to patients at the end of their lives and how often they do not receive that care," said Wendy Cadge of Brandeis University, who recently published results of a study on how physicians respond to patients' personal requests for prayer in Southern Medical Journal.

Cadge and colleagues found that most physicians either reframe the patient's request or they try to accommodate it in some other way; only a small number prayed with patients exactly as they had asked, Cadge told MedPage Today.

"It certainly would be helpful for physicians to have some prior training in understanding the range of ways they can respond," Cadge said. "And if hospitals expanded their chaplaincy services, more patients would likely receive [spiritual] care."

Balboni agreed that the findings underscore the need to educate medical caregivers in their appropriate roles in providing spiritual care, as well as the importance of integrating pastoral care into multidisciplinary medical teams.

"There needs to be more training of clinicians from medical school and beyond, and that includes physicians, nurses, social workers, and all those involved in caring for patients facing life-threatening illness," Balboni said.

"It also underscores the importance of pastoral care services and how valuable it can be -- not only to have [their support], but also to have them incorporated into interdisciplinary care teams. They can be part of ongoing education of clinicians regarding the spiritual needs of patients, as well as helping the [medical] team take a holistic view of the patient in caring for them."

The researchers noted that the study may have been limited by unforeseen confounders and may not be generalizable to to those with non-cancerous terminal illnesses.