17-09-2016, 10:25 AM
Spirituality, quality of life, psychological adjustment in
terminal cancer patients in hospice
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The purpose of this study was to show the different components of spirituality in the last few weeks of life
for advanced cancer patients admitted to hospice and to evaluate quality of life (QoL), pain, anxiety,
depression and psychological adjustment to cancer. One hundred and fifteen patients were interviewed with
a series of rating scales: the Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being Scale,
the Hospital Anxiety and Depression Scale, the Visual Analogue Scale for pain, the Brief Coping
Orientation to Problem Experienced and the Functional Assessment of Cancer Therapy Scale – General
Measure. Workers and single patients with higher education level showed a worse QoL. Moreover, anxiety
and pain were negatively associated with QoL, while spirituality and ‘Instrumental Support’ coping style
were positively associated with QoL. In the Italian sample, it was observed that when patients are close to
death, faith is a more important component of spirituality than meaning/peace. This study confirms that
QoL could be related to physical and psychological symptoms, and this reiterates the importance of faith in
end-of-life care.
INTRODUCTION
In palliative care, quality of life (QoL) is a core concept
related to spirituality and physical, psychological and
social well-being (Sulmasy 2002).
Control of pain, along with psychological, social and
spiritual problems, is paramount. The goal of palliative care is to achieve the best QoL for patients and their
families.
The importance of spirituality in the care of dying
patients is appreciated by clinicians, researchers and educators
in end-of-life care. The Institute of Medicine lists
spiritual well-being as one of the six domains of quality
supportive care for the dying (Field & Cassel 1997). A
World Health Organization (1983) expert committee
asserted that spirituality ‘is an important element of cancer
pain management’.
In fact spiritual care is highlighted in hospices and
improves patients’ QoL. This plays a fundamental role in
maintaining patient well-being when coping with terminal
illness, and is well accepted at the end of life (Puchalski
et al. 2003; Visser et al. 2010).
When physical status declines, many patients with
advanced illness seek hope and struggle with questions
about their mortality and the meaning and purpose of life
in connection to the transcendent (McClain et al. 2003;
Balboni et al. 2010; Bovero et al. 2010).
Several researchers have demonstrated that higher
levels of spiritual well-being are associated with lower
levels of psychological distress variables such as depression,
hopelessness, desire for hastened death and suicidal
ideation among severely ill patients (Nelson et al. 2002;
McCoubrie & Davies 2006; Rodin et al. 2009; Balboni
et al. 2010).
When discussing spirituality, it is important to make a
distinction between religiosity and spirituality. Spirituality
can exist both within and outside of a religious framework,
and many individuals who consider themselves
spiritual may not adhere to any particular religion (Ellerhorst-Ryan
1988; Vaughan et al. 1988; Muldoon & King
1995). Religiosity is a related but distinct construct that
refers to organised behaviours, intended to put spirituality
into practice (Brady et al. 1999; Miller & Thoresen 2003).
Thus, religion refers to an organised system of beliefs,
practices and way of worship (Emblen 1992) that can serve
as a way to channel or direct the expression of spirituality
(Elkins et al. 1988). Although religion provides a structured
set of practices to help people become spiritual, religious
affiliation does not guarantee spirituality and many
individuals actively participate in religious rituals and
practices without seeking or finding the deeper meaning
that is a part of all organised religions (Donahue 1985).
Regarding distress many studies have analysed the most
distressing symptoms at the end of life (Kutner et al.
2007). Cancer pain is one of the most distressing symptoms
for cancer patients and it can have a major adverse
impact on QoL (Nekolaichuk et al. 2013).
Depression and anxiety are common in patients with
advanced illness and are associated with decreased functional
status, decreased QoL and greater difficulty managing
physical symptoms (Noorani & Montagnini 2007;
Wilson et al. 2007).
For instance, individuals with advanced cancer are
required to cope with the changes of terminal illness; consequently
the strategies that patients use to cope with
these changes can be important in predicting the QoL
(Gathchel & Oordt 2003).
While many of the studies have focused on the last
6 months of life, this study has focused a bit later, on the
last 4 months.
The purpose of this study was to investigate the
different components of spirituality (faith and meaning/
peace) and QoL of cancer patients admitted to hospice, evaluating pain, emotional distress and psychological
adjustment styles.
METHODS
Setting and sample
Patients were recruited from January 2009 to March 2010
at the ‘Vittorio Valletta’ hospice in Turin. All participants
were diagnosed with cancer, had a life expectancy of
4 months or less (one of the admission criteria for Italian
hospices) and a Karnofsky Performance Status (KPS) of 40
or lower. To be eligible for the study participation,
patients were asked to complete a brief cognitive assessment,
using the Mini-Mental State Examination (Folstein
et al. 1975). Those, who obtained a score of 19 or less,
were excluded from the study because of concerns they
might not be able to provide a valid informed consent or
give accurate responses to the study instruments. Patients
who were unable to speak Italian fluently or who had a
severe mental disorder were also excluded from the study.
During the baseline visit, a structured clinical interview
based on DSM-IV-TR criteria was conducted, to assess the
presence of mental disorder. The study was approved by
the ethics committee of the ‘San Giovanni Battista’ hospital
of Turin. The participants provided written informed
consent.
During the study period, 119 inpatients were admitted
to hospice. One study investigator (AB) interviewed participants
at their bedside with self-report and clinician-rated
tests in one or two sessions within 3 days of admission.
Clinical data were collected in a medical chart. Socio-demographic
and spirituality/religious data were gathered
through a semi-structured oral interview (AB).
Functional Assessment of Chronic Illness Therapy –
Spiritual Well-Being Scale
The Functional Assessment of Chronic Illness Therapy –
Spiritual Well-Being Scale (FACIT-Sp) contains 12 items
underlying two factors (Faith and Meaning/Peace) (Brady
et al. 1999). This scale is the most commonly used measure
of spirituality for cancer patients and has been validated
across languages and literacy levels (Peterman et al.
2002) including the Italian language. One characteristic of
this scale is that the wording of items does not assume a
belief in God. Therefore, it can be completed comfortably
by an atheist or an agnostic, yet touches on both traditional
religiousness dimensions (Faith factor) and spiritual
dimensions (Meaning/Peacefactor) on a 5-point Likert
scale ranging from 0 (not at all) to 4 (very much). The first
factor, Faith, contains four items and measures comfort and strength derived from one’s faith. The second factor,
Meaning/Peace, contains eight items and assesses a sense
of meaning, peace and purpose in one’s life. The summed
score ranges from 0 to 48, with higher scores representing
greater levels of spirituality