National surveys consistently support the idea that religion and spirituality are important to most individuals in the general population. More than 90% of adults express a belief in God, and slightly more than 70% of individuals surveyed identified religion as one of the most important influences in their lives.[
Research indicates that both patients and family caregivers [
A survey of hospital inpatients found that 77% of them reported that physicians should take patients' spiritual needs into consideration, and 37% wanted physicians to address religious beliefs more frequently.[
In addition, 61% of 57 inpatients with advanced cancer receiving end-of-life care in a hospital supported by the Catholic archdiocese reported spiritual distress when interviewed by hospital chaplains. The intensity of spiritual distress correlated with self-reports of depression but not with physical pain or perceived severity of illness.[
This summary will review the following topics:
Paying attention to the religious or spiritual beliefs of seriously ill patients has a long tradition within inpatient medical environments. Addressing such issues has been viewed as the domain of hospital chaplains or a patient's own religious leader. In this context, systematic assessment has usually been limited to identifying a patient's religious preference, while responsibility for management of apparent spiritual distress has fallen to the chaplain service.[
Interest in and recognition of the function of religious and spiritual coping in adjustment to serious illness, including cancer, has been growing.[
Of equal importance is the consideration of how and when to address religion and spirituality with patients and the best ways to do so in different medical environments.[
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.
Specific religious beliefs and practices should be distinguished from the idea of a universal capacity for spiritual and religious experiences. Although this distinction may not be salient or important on a personal basis, it is important conceptually for understanding various aspects of evaluation and the role of different beliefs, practices, and experiences in coping with cancer.
The most useful general distinction in this context is between religion and spirituality. There is no general agreement on definitions of either term, but there is general agreement on the usefulness of this distinction.[
In health care, concerns about spiritual or religious well-being have sometimes been viewed as an aspect of complementary and alternative medicine (CAM), but this perception may be more characteristic of providers than of patients. In one study,[
Religion is highly culturally determined. Spirituality is considered a universal human capacity, usually—but not necessarily—associated with and expressed in religious practice. Most individuals consider themselves both spiritual and religious. Some may consider themselves religious but not spiritual; others, including some atheists (people who do not believe in the existence of God) or agnostics (people who believe that God cannot be shown to exist), may consider themselves spiritual but not religious. In a sample of 369 representative cancer outpatients in New York City (33% minority groups), 6% identified themselves as agnostic or atheist, 29% attended religious services weekly; and 66% represented themselves as spiritual but not religious.[
One effort to characterize individuals by types of spiritual and religious experience [
Individuals in the third group were far more distressed about their illness and experienced worse adjustment than the other two groups. There is not yet consensus on the number or types of underlying dimensions of spirituality or religious engagement.
From the perspective of both the research and clinical literature on the relationships among religion, spirituality, and health, it is important to consider how investigators and authors define and use these concepts. Much of the epidemiological literature that indicates a relationship between religion and health is based on definitions of religious involvement such as:
Assessing specific beliefs or religious practices such as belief in God, frequency of prayer, or reading religious material is somewhat more complex. Individuals may engage in such practices or believe in God without necessarily attending services. Terminology also carries certain connotations. The term religiosity, for example, has a history of implying fervor and perhaps undue investment in particular religious practices or beliefs. The term religiousness may be a more neutral way to refer to the dimension of religious practice.
Spirituality and spiritual well-being are more challenging to define. Some definitions limit spirituality to mean profound mystical experiences. However, in effects on health and psychological well-being, the more helpful definitions focus on accessible feelings, such as:
This discussion assumes a continuum of meaningful spiritual experiences, from the common and accessible to the extraordinary and transformative. Both type and intensity of experience may vary. Other aspects of spirituality that have been identified by those working with patients include the following:
Low levels of these experiences may be associated with poorer coping.[
The definition of acute spiritual distress must be considered separately. Spiritual distress may result from the belief that cancer reflects punishment by God or may accompany a preoccupation with the question "Why me?" A cancer patient may also suffer a loss of faith.[
Religion and spirituality have been shown to be significantly associated with measures of adjustment to cancer and with management of cancer symptoms in patients. Religious and spiritual coping have been associated with lower levels of patient discomfort as well as reduced hostility, anxiety, and social isolation in patients with cancer [
Type of religious coping may influence quality of life. In a multi-institutional cross-sectional study of 170 patients with advanced cancer, more use of positive religious coping methods (such as benevolent religious appraisals) was associated with better overall quality of life and higher scores on the existential and support domains of the McGill Quality of Life Questionnaire. In contrast, more use of negative religious coping methods (such as anger at God) was related to poorer overall quality of life and lower scores on the existential and psychological domains.[
Spiritual well-being, particularly a sense of meaning and peace,[
This relationship has been specifically demonstrated in the cancer setting. In a cross-sectional survey of 85 hospice patients with cancer, there was a negative correlation between anxiety and depression (as measured by the Hospital Anxiety and Depression Scale) and overall spiritual well-being (as measured by the Spiritual Well-Being Scale) (P < .0001). There was also a negative correlation between the existential well-being scores and the anxiety and depression scores but not with the religious well-being score (P < .001).[
In a large (N = 418) study of breast cancer patients, a higher level of meaning and peace was associated with a decline in depression over 12 months, whereas higher religiousness predicted an increase in depression, particularly if the sense of meaning/peace was lower.[
A large national survey of 361 paired U.S. survivors (52% women) and caregivers (including spouses and adult children) found that for both survivors and caregivers, the peace factor of the FACIT-Sp was strongly related to mental health but negligibly or not at all related to physical well-being. The faith factor ("religiousness") was unrelated to physical or mental well-being.[
Another large national survey study of female family caregivers (N = 252; 89% White) found that higher levels of spirituality, as measured by the FACIT-Sp, were associated with much less psychological distress (measured by the Pearlin Stress Scale). Participants with higher levels of spirituality actually had improved well-being even as the stress caused by caregiving increased, while those with lower levels of spirituality showed the opposite pattern. This finding suggests a strong stress-buffering effect of spiritual well-being and reinforces the need to identify low spiritual well-being when assessing the coping capacity of family caregivers as well as patients.[
Data from the National Quality of Life Survey for Caregivers were used to examine the effects of spirituality on caregiving motivation and satisfaction. Caregivers received a baseline survey to measure motivation 2 years after a family member's cancer diagnosis and again at 5 years after diagnosis. Male caregivers were more likely to report internal/spiritual motives for caregiving, whereas the motives of female caregivers were not related to internal/spiritual reasons. However, both men and women who were able to identify a sense of spiritual peace in their caregiving efforts had better mental health after 5 years of caregiving. Evidence suggests that caregiver motivation affects long-term mental health and quality of life.[
One author [
Engaging in prayer is often cited as an adaptive tool,[
Ethnicity and spirituality were investigated in a qualitative study of 161 breast cancer survivors.[
One meta-analysis showed that positive religious involvement and spirituality appeared to be associated with better health and longer life expectancy, even after researchers controlled for other variables, such as health behaviors and social support.[
Another study [
Several randomized trials with cancer patients have suggested that group support interventions benefit survival.[
Raising spiritual concerns with patients can be accomplished by the following approaches:[
These approaches have different potential value and limitations. Patients may be reluctant to bring up spiritual issues and prefer to wait for the provider to broach the subject. Standardized assessment tools vary, have generally been designed for research purposes, and need to be reviewed and utilized appropriately by the provider. Physicians, unless trained specifically to address such issues, may feel uncomfortable raising spiritual concerns with patients.[
Table 1 summarizes a selection of tools to assess religion and spirituality. Several factors should be considered before choosing an assessment tool:
The line between assessment and intervention is blurred, and simply inquiring about an area such as religious or spiritual coping may prompt the patient's desire to further explore and validate this experience. Evidence suggests that only a small proportion of patients view such an inquiry as intrusive and distressing. Key assessment approaches are briefly reviewed below; pertinent characteristics are summarized in Table 1.
Standardized Assessment Measures
One of several paper-and-pencil measures can be given to patients to assess religious and spiritual needs. These measures have the advantage of being self-administered; however, they were mostly designed as research tools, and their role for clinical assessment purposes is not as well understood. These measures may be helpful in opening up the topic for exploration and for ascertaining basic levels of religious engagement or spiritual well-being (or spiritual distress). Most tools assume a belief in God and may seem inappropriate for an atheist or agnostic patient, who may still be spiritually oriented. All of the measures have undergone varying degrees of psychometric development, and most are being used in investigations of the relationship between religion or spirituality, health indices, and adjustment to illness.
The questions are worded well and may provide a good initiation for further discussion and exploration.
The meaning and peace factor has been shown to have particularly strong associations with psychological adjustment, in that individuals who score high on this scale are much more likely to report enjoying life despite fatigue or pain, are less likely to desire a hastened death at the end of life,[
Analyses show that the STS accounts for additional variance on depression, other measures of adjustment (Positive and Negative Affect Schedule), and the Daily Spiritual Experience Scale.[
The following semistructured interviewing tools are designed to facilitate an exploration of religious beliefs and spiritual experiences or issues by the physician or other health care provider. The tools take the spiritual history approach and have the advantage of engaging the patient in dialogue, identifying possible areas of concern, and indicating the need to provide for further resources such as referral to a chaplain or support group. These approaches, however, have not been systematically investigated as empirical measures or indices of religiousness or of spiritual well-being or distress.
The six domains cover 22 items, which may be explored in as little as 10 or 15 minutes or integrated into general interviewing over several appointments. A strength of this tool is the number of questions pertinent to managing serious illness and understanding how patient religious beliefs may affect patient care decisions.
|Tool||Developer||Purpose/ Focus/ Subscale (No.)||Specific to Cancer Patients?||Level of Psychometric Development||Length/ Other Characteristics/ Comments|
|DRI/DUREL = Duke Religious Index; FACIT-Sp = Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being; FACT-G = Functional Assessment of Cancer Therapy–General; FICA = Faith, Importance/Influence, Community, and Address Spiritual History; RCOPE = Brief Measure of Religious Coping; SPIRIT = The SPIRITual History.|
|Systems of Belief Inventory (SBI-15R)[
||Holland et al.||Two factors: Beliefs/experience (10); religious social support (5)||Yes||High||Four items assume belief in God|
||Sherman et al.||Religious involvement (5)||Yes||Moderate|
||Brady et al.; Peterman||Two factors: Meaning & peace (8), faith (4)||Yes||High. Limited cross-validation data.||Part of FACT-G quality-of-life battery[
||Pargament et al.||Two factors: Positive coping; negative coping/distress||No||Very High|
|Fetzer Multidimensional Scale[
||Fetzer||Multiple subscales||No||High. Under development.|
|FICA: Spiritual history[
||Puchalski et al.||Brief spiritual history||No||Low||MD interview assessment|
||Maugans||In-depth interview with guided questions||No||Low||MD interview assessment|
|Spiritual Transformation Scale (STS)[
||Cole et al.||Two factors: Spiritual Growth and Spiritual Decline||Yes||Moderate||Forty items. Unique to assessing change in spiritual experience post–cancer diagnosis.|
Various modes of intervention or assistance might be considered to address the spiritual concerns of patients, including the following:
Two survey studies [
A task force [
Inquiring about religious or spiritual concerns may provide valuable and appreciated support to patients. Most cancer patients appear to welcome a dialogue about such concerns, regardless of diagnosis or prognosis. In a large survey, 20% to 35% of outpatients with cancer expressed the following:[
It is appropriate to initiate such an inquiry once initial diagnosis and treatment issues have been discussed and considered by the patient (approximately a month after diagnosis or later). In a large, multisite, longitudinal study of patients with advanced cancer,[
Support from the medical team predicted the following:
The statements in Table 2 may be used to initiate a dialogue between health care provider and patient.
|Health Care Provider Inquiry||Question for Patient|
| a Adapted from Kristeller et al.[
|Introduce issue in neutral inquiring manner.||"When dealing with a serious illness, many people draw on religious or spiritual beliefs to help cope. It would be helpful to me to know how you feel about this."|
|Inquire further, adjusting inquiry to patient's initial response.||Positive-Active Faith Response: "What have you found most helpful about your beliefs since your illness?"|
|Neutral-Receptive Response: "How might you draw on your faith or spiritual beliefs to help you?"|
|Spiritually Distressed Response (e.g., expression of anger or guilt): "Many people feel that way…what might help you come to terms with this?"|
|Defensive/Rejecting Response: "It sounds like you're uncomfortable I brought this up. What I'm really interested in is how you are coping…can you tell me about that?"|
|Continue to explore further as indicated.||"I see. Can you tell me more (about…)?"|
|Inquire about ways of finding meaning and a sense of peace.||"Is there some way in which you are able to find a sense of meaning or peace in the midst of this?"|
|Inquire about resources.||"Who can you talk to about these concerns?"|
|Offer assistance as appropriate and available.||"Perhaps we can arrange for you to talk to someone/There's a support group I can suggest/There are some reading materials in the waiting room."|
|Bring inquiry to a close.||"I appreciate you discussing these issues with me. May I ask about it again?"|
A common concern is whether to offer to pray with patients. Although one study [
In a study of 70 patients with advanced cancer, 206 oncology physicians, and 115 oncology nurses, all participants were interviewed about the appropriateness of patient-practitioner prayer in the advanced-cancer setting. Results showed that 71% of patients, 83% of nurses, and 65% of physicians reported that it is occasionally appropriate for a practitioner to pray with a patient when the patient initiates the request. Similarly, 64% of patients, 76% of nurses, and 59% of physicians reported that they consider it appropriate for a religious/spiritual health care practitioner to pray for a patient.[
The most important guideline is to remain sensitive to the patient's preference. Asking patients about their beliefs or spiritual concerns in the context of exploring how they are coping in general is the most viable approach in exploring these issues.
Traditionally, hospital chaplains deliver religious or spiritual assistance to patients.[
Another traditional approach in outpatient settings is having spiritual/religious resources available in waiting rooms. This activity is relatively easy to do, and many resources exist. A breadth of resources covering all faith backgrounds of patients is highly desirable (refer to the Additional Resources section).
Support groups may provide a setting where patients may explore spiritual concerns. The health care provider may need to identify whether an in-person or online group addresses these issues. The published data on the specific effects of support groups on assisting with spiritual concerns is relatively sparse, partly because this aspect of adjustment has not been systematically evaluated. A randomized trial [
A study of 97 lower-income women with breast cancer who were participating in an online support group examined the relationship between a variety of psychosocial outcomes and religious expression (as indicated by the use of religious words such as faith, God, pray, holy, or spirit). Results showed that women who communicated a deeper religiousness in their online writing to others had lower levels of negative emotions, higher levels of perceived health self-efficacy, and higher functional well-being.[
One author [
Other therapies may also support spiritual growth and post-traumatic benefit finding. For example, in a nonrandomized comparison of mindfulness-based stress reduction (n = 60) and a healing arts program (n = 44) in cancer outpatients with a variety of diagnoses, both programs significantly improved facilitation of positive growth in participants, although improvements in spirituality, stress, depression, and anger were significantly larger for the mindfulness-based stress reduction group.[
Many health care providers may regard spirituality, religion, death, and dying as a taboo subject. The meaning of illness and the possibility of death are often difficult to address. The assessment resources noted above may help introduce the topic of spiritual concerns, death, and dying to a patient in a supportive manner. In addition, reading clinical accounts by other health care providers can be helpful. For example, a qualitative study using an autoethnographic approach to explore spirituality in members of an interdisciplinary palliative care team. Findings from this work yielded a collective spirituality that emerged from the common goals, values, and belonging shared by team members. Participants' reflections offer insights into patient care for other health care professionals.[
Although a considerable number of anecdotal accounts suggest that prayer, meditation, imagery, or other religious activity can have healing power, the empirical evidence is extremely limited and inconsistent.[
These reference citations are included for informational purposes only. Their inclusion should not be viewed as an endorsement by the PDQ Supportive and Palliative Care Editorial Board or the National Cancer Institute.
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
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Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about religious and spiritual coping in cancer care. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
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Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
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PDQ® Supportive and Palliative Care Editorial Board. PDQ Spirituality in Cancer Care. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/coping/day-to-day/faith-and-spirituality/spirituality-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389436]
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Last Revised: 2022-03-01
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