Study finds spiritual care still rare at end of life

NEW YORK (Reuters Health) - Physicians and nurses at four Boston medical centers cited a lack of training to explain why they rarely provide spiritual care for terminally ill cancer patients - although most considered it an important part of treatment at the end of life. 

"I was quite surprised that it was really just lack of training that dominated the reasons why," senior author Dr. Tracy Balboni, a radiation oncologist at the Dana-Farber Cancer Institute in Boston, told Reuters Health. 

Current U.S. palliative care guidelines encourage medical practitioners to pay close attention to religious and spiritual needs that may arise during a patient's end-of-life care. 

However, the 204 physicians who participated in the study reported providing spiritual care to just 24 percent of their patients.  Among 118 nurses, the figure was 31 percent. 

The 69 patients with advanced cancers who took the survey reported even lower rates, saying 14 percent of nurses and six percent of physicians had provided them some sort of spiritual care. 

Past research has shown that spiritual care for seriously ill patients improves their quality of life, increases their overall satisfaction with hospital care and decreases aggressive medical treatment, which may in turn result in lower overall health spending. 

"There was a time when nurses and physicians may have said, 'That's not my job,' but I think the tides are changing," said palliative care researcher Betty Ferrell of City of Hope, a cancer research and treatment hospital in Duarte, California. 

"I think we are realizing we can no longer ignore this aspect of care," said Ferrell, a professor of nursing who was not involved in the new study. 

Yet the reasons why spiritual care is rarely incorporated into patient treatment and dialogue have been poorly understood. 

To gain more insight, Balboni and her colleagues designed a survey - the first of its kind, to their knowledge - to compare attitudes toward spiritual care across randomly chosen patients, nurses and doctors in oncology departments at four hospitals. 

The questions were geared toward identifying barriers preventing healthcare professionals from delivering spiritual care, beginning with whether anyone felt it was inappropriate for them to be doing so. 

The participants' answers indicated that, on the contrary, a majority of providers and patients supported the appropriateness of eight specific examples of spiritual care, such as a doctor or nurse praying with a patient at his or her request or referring the patient to a hospital chaplain. 

Next, the researchers asked participants to rate previous spiritual care experiences.  Again, most ranked these as having a positive impact on care.  A fourth possibility offered to nurses and doctors was lack of time. 

"Indeed we found that on average 73 percent reported time to be a significant barrier to spiritual care provision to patients," Balboni told Reuters Health in an email. 

But those who noted insufficient time as a problem provided spiritual care just as often as those who reported having enough time.  That suggested time was not an issue after all, she added. 

In fact, a lack of training stood out as the biggest barrier to providing spiritual care in this small study. 

Only 13 percent of doctors and nurses reported having ever received spiritual care training. 

But those who had training were seven to 11 times more likely to provide spiritual care to their patients than those who hadn't been trained. 

A lack of "models" for training healthcare professionals to tend to patients' spiritual needs seems to be the underlying problem, Balboni told Reuters Health. 

"There are some basic models, but a rigorously developed spiritual care training model has not been established," she said. 

Ferrell, who leads End-of-Life Nursing Education Consortium workshops, said such small-scale organized training opportunities are drops in the bucket of a huge unmet training need. 

"We can't practice what we don't know," she said. " Physicians and nurses have never been taught to access and respond to spiritual need." 

In addition to training, the field of spiritual care needs a clear definition, said Dr. Christina Puchalski, director of the George Washington Institute for Spirituality and Health in Washington, D.C.

"There is quite a bit of controversy about asking only about religion," Puchalski said. " But previous studies have shown that it's not a patient's particular religious denomination that matters, but what gives meaning and purpose in peoples' lives -things such as family, arts, work, nature, yoga and other values." 

Puchalski, who invented a basic spiritual assessment questionnaire that is in wide use, added that the study could have benefitted by asking patients if nurses and doctors acted compassionately toward them, which is another example of spiritual care. 

In a country full of diverse cultures, spiritual care may be intimidating to medical workers, but training can help with that, Ferrell said. 

"For example, if we have a patient who says, 'I'm very devout in my faith and I never make decisions without consulting my rabbi,' then we immediately take that into account - perhaps by giving the patient extra time between procedures," she noted. 

"Patients are telling us spiritual care has to be done with greater intention," Ferrell said.