Spirituality, Religion, and Health Interest Group
Hospital of the University of Pennsylvania
February 5, 2014
Spirituality & Oncology:
Views from Research
Chaplain John W. Ehman
University of Pennsylvania Medical Center – Penn Presbyterian
Philadelphia, PA
2/5/14
Research is a
“way of knowing”
Health care research has favored an approach
that focuses on spirituality/religion as…
… a value basis for personal meaning-making
(e.g., understanding illness), coping with
stress/crises, and decision-making
[ However, there is growing interest in how spiritual
practice may have functional, physiological effects.]
Patients’ Spiritual/Religious Beliefs
and Health Care Decision-Making
In a University of Pennsylvania study of pulmonary
outpatients (n=177), including lung cancer patients
nearly half said that they had spiritual/religious beliefs
that would influence their health care decision-making
whenever they may became “gravely” ill.
-- Ehman, J. W., et al., “Do patients want physicians to inquire…,”
Archives of Internal Medicine 159, no. 15 (1999): 1803-1806
Treatment Decision Factors
Ranking of the importance of treatment
decision factors by oncology patients:
1) Cancer doctor’s recommendation
2) Faith in God
3) Ability to cure
4) Side effects
5) Family doctor’s recommendation
6) Spouse’s input
7) Children’s input
--Silvestri, et al., “Importance of faith on medical decisions regarding cancer
care,” Journal of Clinical Oncology 21, no. 7 (April 1, 2003): 1379-1382
Brief RCOPE
1)
2)
3)
4)
5)
Looked for a stronger connection with God
Sought God’s love and care.
Sought help from God in letting go of my anger.
Tried to put my plans into action together with God.
Tried to see how God might be trying to strengthen me
in this situation.
6) Asked forgiveness of my sins.
7) Focused on religion to stop worrying about my problems.
---------------------------------------------------------------------------8)
9)
10)
11)
12)
13)
14)
Wondered whether God had abandoned me.
Felt punished by God for my lack of devotion.
Wondered what I did for God to punish me.
Questioned God’s love for me.
Wondered whether my church had abandoned me.
Decided the devil made this happen.
Questioned the power of God.
Religious Struggle & Mortality
2-year longitudinal study of 596 patients; 176 died
Brief RCOPE items significantly associated with an
increased risk of dying:
- Wondered whether God had abandoned me (28%)
- Questioned God’s love for me (22%)
- Decided the devil made this happen (19%)
The mortality risk appears to be focused those who engage
in negative religious coping on a chronic basis.
--Pargament, K. I., Koenig, H. G., et al., "Religious struggle as a predictor of mortality…,“
Archives of Internal Medicine 161, no. 15 (August 13-27, 2001): 1881-1885
--Pargament, K. I., Koenig, H. G., et al., "Religious coping methods as predictors,"
Journal of Health Psychology 9, no. 6 (November 2004): 713-730
Brief RCOPE
1)
2)
3)
4)
5)
Looked for a stronger connection with God
Sought God’s love and care.
Sought help from God in letting go of my anger.
Tried to put my plans into action together with God.
Tried to see how God might be trying to strengthen me
in this situation.
6) Asked forgiveness of my sins.
7) Focused on religion to stop worrying about my problems.
---------------------------------------------------------------------------8)
9)
10)
11)
12)
13)
14)
Wondered whether God had abandoned me.
Felt punished by God for my lack of devotion.
Wondered what I did for God to punish me.
Questioned God’s love for me.
Wondered whether my church had abandoned me.
Decided the devil made this happen.
Questioned the power of God.
Research increasingly indicates health-positive
effects of religion/spirituality.
For example:
• lower rates of coronary artery disease
-- in at least 12 of 19 studies (63%)
• lower cardiovascular reactivity and greater heart rate variability
-- in at least 11 of 16 studies (69%)
• lower blood pressure and generally less hypertension
-- in at least 36 of 63 studies (63%)
• better immune function
-- in at least 14 of 25 studies (56%)
• lower cancer rate and better outcomes
-- in at least 14 of 25 studies (56%)
--See: Koenig, H.G, et al., Handbook of Religion and Health, 2001/2011;
and Koenig, H.G., Testimony to the US House of Representatives
Subcommittee on Research and Science Education, 9/18/08
Theoretical Model of How Religion Affects Physical Health
--adapted from Koenig, et al., Handbook of Religion and Health, 2001
Stress
Hormones
R
E
L
I
G
I
O
N
Mental
Health
Social
Support
Health
Behaviors
Religion also affects Childhood Training,
Adult Decisions, and Values & Character;
which then in turn affect mental health,
social support, and health behaviors.
Infection
Cancer
Immune
System
Autonomic
Nervous
System
Disease Detection
and Treatment
Compliance
High Risk
Behaviors
(smoking, drugs)
Heart
Disease
Hypertension
Stroke
Stomach
& Bowel
Liver
& Lung
Accidents
& STDs
Other theoretical models emphasize how spiritual
beliefs may help people keep stressors in
perspective and control or how spiritual practices
may be a means for relaxation.
Research suggests that some forms of meditation
may actually change the way the brain processes
threat analyses and can protect against rumination
--- to the point that meditative practice might be
seen to affect cell longevity via lowered stress.
Patients’ Spiritual Needs
in Oncology and Serious Illness
Variety in Patients’ Sense of “Spiritual Needs”
Hospice patients were first asked: “What does the word spiritual mean to you
personally?” and then “What needs can you identify related to your spirituality
as you described it?”
Need for Religion: to pray, go to services, read/use scripture, read/use
inspirational material, sing/listen to music
Need for Companionship: need to be with family and friends, talk with
others, care for others, be with children
Need to Experience Nature: to look outside, be outside, have flowers
Need for Positive Outlook: to see smiles of others, laugh, think happy
thoughts, take one day at a time
Need for Involvement and Control: to have input into own life, be as
independent as possible, be involved with family activities, have information
about own care, be helped by others, have things stay the same
Need to Finish Business: to do a life review, finish life tasks, come to
terms with the present situation, resolve bitter feelings
--Hermann, C. P., "Spiritual needs of dying patients: a qualitative
study," Oncology Nursing Forum 28, no. 1 (Jan-Feb 2001): 67-72
Study of Perceived/Met Spiritual Needs at EOL
Perceived (%)
Laugh
100
Think happy thoughts
98
See the smiles of others
97
Be with family
96
Be with friends
96
Pray
95
Talk about day-to-day things
95
Have information about family and friends
88
Be with people who share my spiritual beliefs
88
Go to religious services
85
Be around children
83
Sing or listen to music
80
Read a religious text
80
Talk with someone about spiritual issues
79
Read inspirational materials
68
Use phrases from religious text
65
Use inspirational materials
59
Met (%)
65
76
81
65
64
96
82
77
74
30
72
80
64
75
69
86
86
--from: Hermann, C. P., “The degree to which spiritual needs of patients near
the end of life are met,” Oncology Nursing Forum 34, no. 1 (Jan 2007): 70-78
Study of Perceived/Met Spiritual Needs at EOL
Perceived (%)
Laugh
100
Think happy thoughts
98
See the smiles of others
97
Be with family
96
Be with friends
96
Pray
95
Talk about day-to-day things
95
Have information about family and friends
88
Be with people who share my spiritual beliefs
88
Go to religious services
85
Be around children
83
Sing or listen to music
80
Read a religious text
80
Talk with someone about spiritual issues
79
Read inspirational materials
68
Use phrases from religious text
65
Use inspirational materials
59
Met (%)
65
76
81
65
64
96
82
77
74
30
72
80
64
75
69
86
86
--from: Hermann, C. P., “The degree to which spiritual needs of patients near
the end of life are met,” Oncology Nursing Forum 34, no. 1 (Jan 2007): 70-78
Study of Perceived/Met Spiritual Needs at EOL
Perceived (%)
Laugh
100
Think happy thoughts
98
See the smiles of others
97
Be with family
96
Be with friends
96
Pray
95
Talk about day-to-day things
95
Have information about family and friends
88
Be with people who share my spiritual beliefs
88
Go to religious services
85
Be around children
83
Sing or listen to music
80
Read a religious text
80
Talk with someone about spiritual issues
79
Read inspirational materials
68
Use phrases from religious text
65
Use inspirational materials
59
Met (%)
65
76
81
65
64
96
82
77
74
30
72
80
64
75
69
86
86
--from: Hermann, C. P., “The degree to which spiritual needs of patients near
the end of life are met,” Oncology Nursing Forum 34, no. 1 (Jan 2007): 70-78
Unmet Spiritual Needs
A survey of 90 advanced cancer patients in Florida
revealed great variance in a sense of unmet spiritual
needs, but by far the most salient unmet spiritual need
was attendance at religious services. (It was identified
over 3.5 times more than the next most salient unmet
spiritual need: prayer.)
-- Hampton, D. M., et al., "Spiritual needs of persons
with advanced cancer," American Journal of Hospice
and Palliative Care 24, no. 1 (Feb-Mar 2007): 42-48
Correlates of Unmet Spiritual Needs
A study of 150 advanced cancer patients in North
Carolina found that 28% felt they received less
spiritual care overall than they needed, and these
individuals turned out to be at significantly greater
risk of depressive symptoms and poorer sense of
purpose in life, meaning and peace.
-- Pearce, M. J., et al., "Unmet spiritual care needs impact emotional
and spiritual well-being in advanced cancer patients," Supportive
Care in Cancer 20, no. 10 (Oct 2012): 2269-2276
Spiritual Distress Across the Cancer Trajectory
-- Murray, S. A., et al., "Patterns of social, psychological, and spiritual decline toward the
end of life...,” Journal of Pain and Symptom Management 34, no. 4 (Oct 2007): 393-402
Dynamics of a Deferring Religious Coping Style
A Wisconsin study using data from a sample of 192 breast cancer
patients shows how a deferring religious coping style can
simultaneously lead to positive and negative health outcomes.
Deferring control to God led to lower levels of breast cancer
concern (e.g., anxiety) but also lower levels of some problemfocused coping (e.g., taking action), which in turn led to lower
quality of life.
The significant indirect negative effect of deferring coping was
appeared to work through the lowering of action but not planning.
-- McLaughlin, B., et al., "It is out of my hands…,”
Psycho-Oncology 22, no. 12 (Dec 2013): 2747-2754
Dynamics of a Deferring Religious Coping Style
--adapted from McLaughlin, B., et al., "It is out of my hands…,”
Psycho-Oncology 22, no. 12 (Dec 2013): 2747-2754
Patients’ Use of Prayer for Pain Control
A cross-sectional sample of 157 inpatients were asked:
“Which of the following pain control methods (if any)
have you used since you were admitted?”
Pain Pills
Prayer
Pain Meds in IV
Pain Injections
Relaxation
Distraction
PCA Pump
Heat Application
Touch
Cold Application
67% said “yes”
62
54
51
27
top 10 answers
24
from 17 choices
21
18
16
13
--McNeill, et al., “Assessing Clinical Outcomes…,” Journal of
Pain and Symptom Management 16, no. 1 (July 1998): 29-40
Spiritual Practice & Physical Pain
A study of college-age students who were taught either a spiritual
meditation, secular meditation, or relaxation technique; which they
practiced for 20-minutes a day for 2 weeks.
The spiritual meditation group was able to tolerate an induced pain
experience* almost twice as long as did the other two groups, though
pain perception was reportedly not altered.
--Wachholtz & Pargament, "Is spirituality a critical ingredient…?“
Journal of Behavioral Medicine 28, no. 4 (August 2005): 369-384
* Holding one’s hand in a cold water bath of 2°C
Effect of Illness and Treatment
on Patients’ Spirituality
Mystical Experiences among Hospital Patients
A survey of 48 hospital patients found that 25% had experienced
some form of mystical spiritual experience while receiving treatment.
-- Witte, A. S., et al., "Mystical experience in the context of health
care." Journal of Holistic Nursing 26, no. 2 (June 2008): 84-92
An in-depth phenomenological study of seven survivors of prolonged
mechanical ventilation, all seven volunteered experiences of “angelic
encounters” (e.g., visits from deceased relatives) that had given them
encouragement.
-- Arslanian-Engoren, C. & Scott, L. D., "The lived experience of survivors of prolonged
mechanical ventilation…," Heart and Lung 32, no. 5 (Sep-Oct 2003): 328-334
Cancer Experiences and Spiritual Change
A 2010 study at the University of Pennsylvania of 614
cancer survivors who were 3-4.5 years postdiagnosis:
• 40.3% experienced highly positive spiritual
changes through the cancer experience
• 36.1% said they experienced a negative
spiritual change
-- Mao, J. J., et al., "Positive changes, increased spiritual importance, and
complementary and alternative medicine (CAM) use among cancer
survivors," Integrative Cancer Therapies 9, no. 4 (Dec 2010): 339-347
Spiritual Growth/Decline after Cancer Diagnosis
Piloting of a measure of spiritual transformation with 244 cancer patients at
medical clinics in Pittsburgh, PA, found that:
• Spiritual Growth tended to be higher when the patient's cancer was a
recurrence or advanced and was associated with positive spiritual coping.
• Spiritual Decline was associated with negative spiritual coping, depressive
symptoms, and negative affect.
• Both Spiritual Growth and Spiritual Decline were less dynamic in older
patients than in younger patients.
“...[W]hen a trauma occurs, the spiritual aspects of the individual’s world view
and related resources (e.g., practices and relationships) may be threatened.
This threat initiates a spiritual struggle (i.e., spiritual coping) in order to either
'conserve or transform' one’s sense of the spiritual or sacred aspects of life.”
-- Cole, B. S., et al., "Assessing spiritual growth and spiritual decline following
a diagnosis of cancer: reliability and validity of the Spiritual Transformation
Scale," Psycho-Oncology 17, no. 2 (February 2008): 112-121.
Posttraumatic Growth in Leukemia Patients
Patients were surveyed after being newly diagnosed with leukemia, and again
roughly a month afterward and a third time roughly three months afterward.
• Greater posttraumatic growth was associated with younger age,
increased deliberate rumination, and degree of challenge to core
beliefs. Regarding the latter, the researchers note the theory that
growth does not occur due to the stressor itself, but from the
struggle and re-calibration of the individual’s assumptive world
following the stressor.
• Distress was associated with greater perceived threat, lower
deliberate rumination, higher intrusive rumination, and lower
spiritual well-being.
-- Danhauer, S. C., et al., "A longitudinal investigation of posttraumatic growth
in adult patients undergoing treatment for acute leukemia," Journal of Clinical
Psychology in Medical Settings 20, no. 1 (March 2013): 13-24
Study of Experience/Change in Breast Cancer Patients
At Time of Diagnosis
• Shock and fear of dying
• Sense of aloneness
• Trying to maintain self-identity
• Compelled to reach out for support from others and God
• Desiring to help others or feel needed by others (including congregations)
Four to Seven Months After Diagnosis
• Feeling more like their former self
• Importance of supportive relationships (including congregations)
• Changes in insight facilitated behavioral changes
• Fears about recurrence
Fourteen–Eighteen Months After Diagnosis
• Finding ways to prevent recurrence
• Defining a new normal self
• Change in priorities and relationships (to others, God, and congregations)
--Coward, D. D., et al., "Resolution of spiritual disequilibrium by women newly diagnosed
with breast cancer," Oncology Nursing Forum 31, no. 2 (March-April 2004): E24-31
Study of Experience/Change in Breast Cancer Patients
At Time of Diagnosis
• Shock and fear of dying
• Sense of aloneness
• Trying to maintain self-identity
• Compelled to reach out for support from others and God
• Desiring to help others or feel needed by others (including congregations)
Four to Seven Months After Diagnosis
• Feeling more like their former self
• Importance of supportive relationships (including congregations)
• Changes in insight facilitated behavioral changes
• Fears about recurrence
Fourteen–Eighteen Months After Diagnosis
• Finding ways to prevent recurrence
• Defining a new normal self
• Change in priorities and relationships (to others, God, and congregations)
--Coward, D. D., et al., "Resolution of spiritual disequilibrium by women newly diagnosed
with breast cancer," Oncology Nursing Forum 31, no. 2 (March-April 2004): E24-31
Spiritual Struggle and Coping
Studies of oncology and other patients,
using the Brief RCOPE
• Roughly 15% of patients may experience a level of spiritual
struggle that could risk hurting medical outcomes.
• Negative religious coping can co-exist with positive religious
coping, even at high levels.
• Younger patients indicate greater levels of spiritual struggle.
-- Fitchett, et al., "Religious struggle: prevalence…," International
Journal of Psychiatry in Medicine 34, no. 2 (2004): 179-196
Spiritual Distress from a Chaplain’s Assessment
A study of 165 advanced cancer patients in an acute palliative
care unit in Houston, TX, found that 44% indicated spiritual
distress (by a chaplain’s assessment).
Younger age was significantly and independently associated with
spiritual distress. Younger patients were more likely to report
despair, brokenness, helplessness, and meaninglessness.
--Hui, D., et al., “Frequency & correlates of spiritual distress…,” American
Journal of Hospice & Palliative Medicine 28, no. 4 (June 2011): 264-270
john.ehman@uphs.upenn.edu
www.uphs.upenn.edu/pastoral
www.ACPEresearch.net
Dynamics of a Deferring Religious Coping Style
--McLaughlin, B., et al., "It is out of my hands…,”
Psycho-Oncology 22, no. 12 (Dec 2013): 2747-54