Tracy Balboni, MD, and Holly Prigerson, PhD 

People with advanced cancer felt they received little or no spiritual support from religious communities and the medical system, according to a new survey. However, those who did receive such support reported a better quality of life.

The study, led by researchers at Dana-Farber Cancer Institute and Harvard Medical School and published in the Feb. 10 issue of the Journal of Clinical Oncology, drew on data from the Coping with Cancer study, a multi-institutional investigation of advanced cancer patients and their main caregivers. Of 230 patients surveyed, the vast majority — 88 percent — considered religion to be at least somewhat important. But nearly half said their spiritual needs were largely or entirely unmet by a religious community, and 72 percent felt those needs were similarly unaddressed by the medical system.

The findings also indicated that greater spiritual support from religious organizations and medical service providers was strongly linked to better quality of life for patients, even after other factors were taken into account. Intriguingly, patients who considered themselves religious were more likely to want all possible measures taken to extend their lives.

"This study examined how much spiritual support advanced cancer patients received from religious organizations, as well as hospital-based doctors, nurses, and chaplains," said the study's lead author, Tracy Balboni, MD, a senior resident in the Harvard Radiation Oncology Program. "Our findings suggest that such support can help improve patients' quality of life at the end of life."

The infrequent recognition of the spiritual components of illness on the part of many hospitals may reflect a debate over the medical system's proper role in this area, the authors stated. Numerous barriers deter physicians from helping procure spiritual support services for patients at the end of life. Among these is a separation of the realms of medical science and religion that exists within many hospital cultures. Another is concern that physicians might try to impose a specific set of religious beliefs on patients.

Given religious faith's ability to help people cope with illness, physicians' reluctance to inquire about spiritual issues may deprive patients of an important force for healing and wholeness, the authors asserted. This does not mean that physicians should be spiritual counselors, "but they can participate appropriately in spiritual care by recognizing spiritual needs and advocating for attention to them," the authors wrote.

They advocate making a "spiritual history" — an account of a patient's religious upbringing and evolution — a routine part of patient care. "It's a way of saying to patients that we acknowledge their illness may have a spiritual dimension for them," Balboni stated. "It may make it easier for patients to bring up spiritual issues later in the course of their illness and may cue doctors and nurses into special concerns that may arise."

The study also tracked how patients' religious observances changed as a result of disease. In general, there was a shift from public to more private forms of spirituality, possibly because people with advanced illness are less able to attend services in a house of worship.

The finding that highly religious patients were the most likely to desire life-extending measures came as something of a surprise, said Balboni. Such individuals might be expected to submit to the natural unfolding of a divine plan, rather than want heroic measures. But, the authors suggested, "Religious individuals may feel that because their illness is in divine hands, there is always hope for a miraculous intervention. Religious individuals also may place a value on life that supersedes potential harms of aggressive attempts to sustain life."

In addition to recommending that spiritual histories be a routine part of care for patients with advanced illness, the authors offered other ways that caregivers can demonstrate concern for patients' spiritual well-being. These include training of non-pastoral medical staff to identify spiritual needs and improve patients' awareness of resources in this area. Integrating pastoral staff into the medical team is another suggestion, as is improving connections between the medical system and outside religious communities.

The research was funded in part by grants from the National Institutes of Health.

The study's senior author is Holly Prigerson, PhD, of Dana-Farber. Co-authors are Susan Block, MD, Christopher Lathan, MD, and John Peteet, MD, and Lauren Vanderwerker, PhD, of Dana-Farber, and Elizabeth Paulk of University of Texas Southwestern Medical Center.

Dana-Farber Cancer Institute (www.dana-farber.org) is a principal teaching affiliate of the Harvard Medical School and is among the leading cancer research and care centers in the United States. It is a founding member of the Dana-Farber/Harvard Cancer Center (DF/HCC), designated a comprehensive cancer center by the National Cancer Institute.