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September 2011 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Hui, D., de la Cruz, M., Thorney, S., Parsons, H. A., Delgado-Guay, M. and Bruera, E. "The frequency and correlates of spiritual distress among patients with advanced cancer admitted to an acute palliative care unit." American Journal of Hospice & Palliative Medicine 28, no. 4 (June 2011): 264-270.


SUMMARY and COMMENT: This month's featured study is of interest not only for its findings but for its methodology: namely, the incorporation of a chaplain's expert albeit subjective assessment of patients' spiritual distress in order to "determine the frequency and factors associated with spiritual distress in patients with advanced cancer admitted to the acute palliative care unit (APCU)" [p. 264] at the MD Anderson Cancer Center in Houston, TX. The palliative care chaplain involved, Steve Thorney, is a co-author.

The electronic charts of 165 consecutive APCU patients treated during the period of July 1 - October 31, 2007 were reviewed for demographic data, symptoms (according to the Edmonton Symptom Assessment System scale, which was developed by co-author Eduardo Bruera, et al.), and spiritual distress as indicated by the chaplain's standard assessment used at the facility [--see more, below]. After exclusions, data were analyzed regarding 113 patients. Among the findings: Spiritual distress was assessed to be present in 44% of the population.

In univariate analysis, younger age, pain, and depression were significantly associated with spiritual distress…. …Multivariate logistic regression analysis showed younger age and depression to be independently associated with spiritual distress…. Younger age (P = .009), pain (P = .027), and depression (P = .021) were also found to be associated with a greater number of spiritual distress domains in multivariate nonparametric linear regression analysis. …On the initial chaplain visit, despair was the most common spiritual distress domain expressed by patients in the APCU, followed by dread and brokenness. …Younger patients were more likely to report despair, brokenness, helplessness, and meaninglessness. Male patients were more likely to report despair. Patients with pain were more likely to feel alienation. [p. 266]

The "MD Anderson spiritual assessment tool" [p. 265] was developed by Steve Thorney and David Jenkins (former director of the Department of Chaplaincy) because of a "lack of validated assessment tools to specifically assess spiritual distress" [p. 265]. It is based upon the work of pastoral psychotherapist Roy Nash, who in 1990 wrote "Life’s Major Spiritual Issues..." [--see Related Items of Interest, below], describing "22 spiritual polarities or domains that people experience throughout the course of their life journey" [p. 265]. From this, Thorney and Jenkins identified "7 spiritual distress domains that were felt most relevant to supportive cancer care: hope versus despair, wholeness versus brokenness, courage versus anxiety/dread, connected versus alienated, meaningful versus meaningless, grace/forgiveness versus guilt, and empowered versus helpless" [p. 265]. The tool is used by MD Anderson chaplains and is also available as a Spiritual Self-Assessment on the hospital website. The article gives operational definitions for each of the component concepts in this set of spiritual distress domains [--see p. 265]. For the purpose of the study, spiritual distress was indicated by a finding in the chaplain's progress notes that "patients had 2 or more of the following distress domains: despair, dread, brokenness, helplessness, alienation, meaningless, and guilt/shame" [p. 265].

The authors acknowledge that there is a "need to develop validated spiritual assessment tools" and state that though their own tool may have "content and face validity, further studies are required to examine its reliability, validity, and responsiveness to change" [p. 267]. For this reader, the incorporation of such an instrument in data collection underscores an important point about methodology in spirituality & health research at this stage in the development of the field: Measures generally remain divided between clinical instruments that might have research applications and research-oriented instruments that might have clinical applications. An advantage of the use of clinically-oriented instruments is that they tend to be designed to preserve the dynamic pastoral interaction between the patient and the chaplain (or between the patient and a clinician, as in the case of the popular FICA assessment, which was recently studied for clinical validity --see the August 2010 Article-of-the-Month). Significantly, while the MD Anderson spiritual assessment tool is publicly available to patients as a self-assessment, it is not put to patients by the chaplains in any direct way but rather is used merely as a means for chaplains to organize, report, and track their sense of spiritual issues that come up in pastoral interactions. Of course, an obvious disadvantage of such clinically-oriented instruments or guides is that they are not designed with scientific rigor in mind. Some research instruments have shown potential for clinical as well as research applications (--see, for example, the June 2005 Article-of-the-Month), yet they tend to have a research feel that can make them awkward to integrate into clinical encounters. The present study's use of a chaplain's subjective spiritual assessment may be a fruitful subject for discussion among chaplain researchers, as we explore methods for spiritual assessment and data collection that attend to both a need for scientific rigor and a respect for pastoral process.


Suggestions for the Use of the Article for Discussion in CPE: 

This month's article should be of special value to students interested in spiritual assessment, and discussion could focus not only on the study's results but on the use the MD Anderson spiritual assessment tool. What do students think of the tool's domains or polarities? The authors' operational definitions of the domains [p. 265] provide a rich list of concepts for consideration, and any one of those could be explored and debated as to its nature and manifestation. Also, students could look specifically at the study's finding of associations between spiritual distress and younger age, pain, and depression, and think what might lie behind those associations, in light of the authors' own insights [--see p. 267]. What do students make of the finding that almost half of the patients in this population were assessed to have spiritual distress? See the graph on p. 268 regarding the distress domain incidence.


Related Items of Interest:

I. The MD Anderson spiritual assessment tool is upon the work of Roy B. Nash, specifically his article: "Life’s major spiritual issues: an emerging framework for spiritual assessment and pastoral diagnosis," Caregiver Journal 7, no. 1 (1990): 3-42.


II. The same basic research team that produced our featured article has also published:

Delgado-Guay, M. O., Hui, D., Parsons, H. A., Govan, K., De la Cruz, M., Thorney, S. and Bruera, E. "Spirituality, religiosity, and spiritual pain in advanced cancer patients." Journal of Pain & Symptom Management 41, no. 6 (June 2011): 986-994. [(Abstract:) CONTEXT: Spirituality, religiosity, and spiritual pain may affect advanced cancer patients' symptom expression, coping strategies, and quality of life. OBJECTIVES: To examine the prevalence and intensity of spirituality, religiosity, and spiritual pain, and how spiritual pain was associated with symptom expression, coping, and spiritual quality of life. METHODS: We interviewed 100 advanced cancer patients at the M.D. Anderson palliative care outpatient clinic in Houston, TX. Self-rated spirituality, religiosity, and spiritual pain were assessed using numeric rating scales (0=lowest, 10=highest). Patients also completed validated questionnaires assessing symptoms (Edmonton Symptom Assessment Scale [ESAS] and Hospital Anxiety and Depression Scale), coping (Brief COPE and Brief R-COPE), the value attributed by the patient to spirituality/religiosity in coping with cancer (Systems of Belief Inventory-15R), and spiritual quality of life (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being-Expanded [FACIT-Sp-Ex]). RESULTS: The median age was 53 years (range 21-85) and 88% were Christians. Almost all patients considered themselves spiritual (98%) and religious (98%), with a median intensity of 9 (interquartile range 7-10) of 10 and 9 (range 5-10) of 10, respectively. Spiritual pain was reported in 40 (44%) of 91 patients, with a median score of 3 (1-6) among those with spiritual pain. Spiritual pain was significantly associated with lower self-perceived religiosity (7 vs. 10, P=0.002) and spiritual quality of life (FACIT-Sp-Ex 68 vs. 81, P=0.001). Patients with spiritual pain reported that it contributed adversely to their physical/emotional symptoms (P<0.001). There was a trend toward increased depression, anxiety, anorexia, and drowsiness, as measured by the ESAS, among patients with spiritual pain (P<0.05), although this was not significant after Bonferroni correction. CONCLUSION: A vast majority of advanced cancer patients receiving palliative care considered themselves spiritual and religious. Spiritual pain was common and was associated with lower self-perceived religiosity and spiritual quality of life.]


III. An article not cited in the present study but which may nevertheless be a good companion piece is: Fitchett, G., Murphy, P. E., Kim, J., Gibbons, J. L., Cameron, J. R. and Davis, J. A., "Religious struggle: prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients," International Journal of Psychiatry in Medicine 34, no. 2 (2004): 179-196 --featured as our November 2004 Article-of-the-Month. Fitchett, et al. used the Negative Religious Coping subscale of the Brief RCOPE, setting as a threshold for "religious struggle" at least two of the subscale's seven items. (Note that Hui, et al. set as the threshold for "spiritual distress" at least to domains of their own seven-item assessment.) Both studies found indications that younger patients may be an at-risk population calling for special attention by chaplains.


IV. Our featured article focuses on the concept of "spiritual distress," though the authors eventually refer to the concept of spiritual pain and appear to use it synonymously with distress. For more on spiritual pain, see the June 2004 Articles-of-the-Month.


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