This study demonstrates that religion is important to most advanced cancer patients, particularly to African Americans and Hispanics. Yet many patients become less able to participate in religious communities after becoming ill. Although private religious activities may address some spiritual needs, many advanced cancer patients do not have support from a religious community or from the medical system at a particularly vulnerable period of their illness trajectory. Our study showed that support of patients' spiritual needs was associated with an important clinical outcome—improved QOL. Furthermore, we uncovered a provocative association between religiousness and desires for aggressive treatment to extend life.
The finding that religion was important to most participants is consistent with prior studies of cancer patients6-10
and with the finding that 96% of US adults express a belief in God and 70% identify religion as one of the most important influences in their lives.25
Furthermore, as in other studies,26,27
African Americans and Hispanics rated religion as important more frequently than whites. Patients reported a decrease in religious service attendance after their cancer diagnosis consistent with prior studies,28,29
and they indicated a corresponding increase in private R/S activities. The finding that patients' private R/S activities increase may reflect patients' decreasing ability to attend religious services or that patients are seeking a deeper religiousness or spirituality at the end of life. Roberts et al,10
in a study of 108 women with gynecologic malignancies, found that 49% reported becoming more religious after their diagnosis, with none becoming less religious. As life-threatening illness confronts individuals with the reality and proximity of their mortality, R/S meaning may become increasingly important to patients at the end of life.
Spiritual needs were minimally supported by religious communities for approximately half of the participants, with support being greatest among African Americans. In addition, most patients reported that the medical system (including chaplains) provides little spiritual support. With pastoral visits usually representing only a sliver of the medical experience and physicians infrequently addressing R/S issues with patients,30-33
many patients might view their medical experience as devoid of spiritual support.
Numerous barriers prevent physicians from contributing to the provision of spiritual support at the end of life. These include the more recent historical development of a separation between R/S and medicine.5
Support for maintaining this separation is largely based on the concern that physicians might impose a specific set of R/S beliefs on patients, thereby compromising patient autonomy.34,35
Balancing this potential danger should be a recognition that R/S can contribute to coping with serious illness, and that in failing to address this domain of QOL, physicians may be neglecting an important force for healing and wholeness. There is considerable evidence that patients and individuals in the community support the integration of R/S into medical practice.32,33,36-38
This is not to suggest that the role of physicians is to be spiritual counselors; clearly physicians must respect their professional boundaries. However, physicians can participate appropriately in the spiritual care of patients by recognizing spiritual needs and advocating for attention to R/S concerns as routine features of clinical care.39
Furthermore, for physicians to facilitate the delivery of spiritual care, practical barriers should be addressed, including inadequate training in evaluating spiritual needs.40
Patients who reported greater spiritual support from outside and within the medical system had better QOL even after removing the support and existential QOL domains and controlling for other predictors of QOL. As physical health wanes, spiritual health may increasingly play a central role in determining patient well-being. This hypothesis is supported by the findings of Steinhauser et al41
in an investigation of factors important at the end of life among a random, national sample of 340 patients with advanced illness. Of nine attributes ranked by patients (eg, presence of pain, dying at home), being at peace with God was second in importance, with pain control only marginally ranking higher. Spiritual support may help patients find their peace with God and hence maintain QOL by providing them with opportunities to express spiritual concerns and receive spiritual counsel. Rummans et al,42
in a randomized, controlled trial of a multidisciplinary intervention in advanced cancer patients that included a spiritual component, found prospectively that patients receiving the intervention had improved QOL in comparison with controls. In addition, Kristeller et al43
alternately assigned cancer patients to a short, semistructured exploration of spiritual concerns by their oncologist and prospectively found a statistically significant improvement in depressive symptoms, QOL, and in a sense of interpersonal caring from their oncologist.
Higher levels of religiousness, in our study and those of others,6
were found to be associated with wanting all measures to extend life. Religious individuals may feel that because their illness is in divine hands, there is always hope for a miraculous intervention. In addition, religious individuals may place a value on life that supersedes potential harms of aggressive attempts to sustain life. Furthermore, Jenkins and Pargament9
have proposed, religiousness may assist in preserving meaning and connection to others in the face of illness, and this may uphold patients' desires to continue living. Although we, like others,6
found that religiousness was inversely associated with having an advance directive in our univariate analysis, we believe that this relationship was confounded by its association with race/ethnicity—a strong predictor in this sample for not having an advance directive. The additional finding that region (despite adjusting for factors such as race and religiousness) was associated with having a DNR order suggests that completion of these orders is partly a function of geographic differences in institutional practices.
The potential role that R/S plays in influencing patient QOL and in shaping treatment preferences suggests that the spiritual history44
should become a routine part of clinical care among patients with advanced illness, especially in caring for African American and Hispanic patients. Additional practices that have the potential to improve patient well-being include training of non-pastoral medical staff to identify spiritual needs and to improve awareness of R/S resources. The increasing presence of medical school courses on R/S is evidence of progress in this regard.45
Improved integration of pastoral staff into the medical team also has the potential to improve management of the spiritual aspects of illness. Finally, improving connections between the medical system and outside religious communities may facilitate incorporation of spiritual supporters into patient care. Some first steps toward this integration include inquiring about patients' spiritual supports and inviting their involvement in care. Direct communication between the medical team and spiritual supporters when desired by patients may also be beneficial at times.
Limitations of this study include the potential influence of selection bias, particularly the possibility of differences in R/S between participants and nonparticipants. Nonwhites were more likely to participate and were more religious. However, increasing reported distress at the time of recruitment was associated with nonparticipation and, among participants, greater religiousness. Although there were age differences in participation, age was not related to religiousness in the sample. Furthermore, the reasons for nonparticipation suggest another potential source for selection bias; for example, nonparticipants may have been not interested in participating because they were not religious or spiritual. However, the Coping With Cancer study assessed R/S as one of many coping factors, reducing the likelihood that nonparticipation was because of a specific disinterest in R/S. In addition, it is unclear in the questions regarding spiritual support how many patients did not have spiritual needs, although prior studies suggest that most cancer patients express spiritual needs.11-13
Finally, the cross-sectional nature of this study limits the interpretation of the relationship between spiritual support and QOL to a hypothesis-generating association.
Attention to R/S has been recognized as an important component of end-of-life care, as illustrated by the National Consensus Project for Quality Palliative Care guidelines.4
However, additional research is essential to their appropriate implementation. Methods for meeting patient spiritual needs should be explored, and the impact of such interventions should be assessed. In addition, the appropriate roles of various health care providers (eg, physicians, nurses) in managing spiritual needs should be clarified. Although incorporating R/S into care requires delicacy, attention to this dimension of health has the potential to enhance patient well-being at the end of life.