This study demonstrated that patients with advanced cancer whose spiritual needs are met by the medical team have more than three-fold greater odds of receiving hospice care at the EoL in comparison with those not supported. High religious coping patients receiving full support of their spiritual needs had near five-fold greater odds of receiving hospice care and more than five-fold decreased odds of receiving aggressive care at EoL as compared with those not supported. These associations were over and above established predictors of EoL care, such as race29,30
and EoL care preferences.31,32
Additionally, spiritual care was found to be associated with better patient QoL at the EoL. Near-death QoL scores were increased 28% on average among patients receiving either pastoral care services or spiritual support from the medical team in comparison with those receiving no spiritual care. The associations of spiritual care with patient QoL near death are notable given adjustment for multiple potential confounds, such as baseline QoL, the patient-physician relationship, and care received at EoL. To our knowledge, this is the first study demonstrating prospective associations of spiritual care with medical care and QoL near death, findings that highlight the relevance of existing national spiritual care guidelines.22,23
The significant associations of spiritual support from the medical team with receipt of hospice and, among high religious coping patients, with receipt of aggressive care are consistent with data supporting the role of spiritual matters in EoL decision making. Silvestri et al,20
in a study of factors important to the medical decision making of patients with advanced lung cancer, found that among seven factors ranked by patients (eg, chances of cure), patients' faith in God ranked second in importance only to their oncologists' treatment recommendations. Additionally, religiousness and religious coping have been shown to be associated with greater preference for12,34
and receipt of21
aggressive EoL care, associations that may in part reflect unresolved spiritual issues in religious patients. Spiritual support may facilitate patients' facing spiritual issues and finding spiritual peace at EoL, thereby creating more receptivity to a transition away from aggressive care. Furthermore, discussion regarding the role of R/S beliefs in medical decision making may help patients more fully recognize EoL care options that are consistent with their R/S beliefs. Interestingly, the association of spiritual support with EoL care was present for spiritual support from the medical team, but not for receipt of pastoral care services. Caregivers such as doctors and nurses are generally the individuals providing counsel regarding medical decision making. Their acknowledgment of the R/S components of illness may be of particular importance in helping patients face the spiritual issues most directly impacting their care decisions.
The association of spiritual care with patient QoL at the EoL is supported by studies demonstrating the importance of R/S to patients confronting advanced illness5,10-13
and by studies revealing better QoL among patients with increased spiritual well-being13,18
and among those receiving spiritual support.12,24,35
Furthermore, advanced illness has been shown to raise spiritual concerns for most patients14,15
—a notable finding in light of the association of spiritual distress with QoL decrements.17,19
Finally, spiritual peace has been identified as a fundamental component of QoL near death.36
Steinhauser et al,36
in a random, national sample of 340 patients with advanced illness, found that of nine EoL attributes ranked in importance by patients, being at peace with God was, together with pain control, ranked highest. Spiritual care may allow patients to both express and explore the spiritual dimensions of approaching EoL, ultimately assisting them in attaining spiritual peace. The finding that spiritual care from chaplains and other members of the medical team were each associated with improved patient QoL near death reinforces their complementary roles in providing spiritual care.37
Chaplains play an essential role as professional providers of spiritual care; other medical providers also have a crucial role, including by performing spiritual assessments, recognizing spiritual needs, and making pastoral care referrals.
This study's limitations include the fact that, though models were adjusted for many potential confounds, there may be incomplete adjustment or unforeseen confounds not incorporated. Furthermore, the study's generalizability to those with noncancerous terminal illnesses and to those in other cultural contexts remains unclear. Studies on spiritual care in other populations are required. Patients assessed support of their spiritual needs without a stated definition of spiritual support, though the significant relationship of patient-rated spiritual support with receipt of pastoral care services suggests this measure is correlated with spiritual care provision. Finally, the study is limited by the undefined content and context of spiritual care performed by chaplains and other medical providers; further studies are required to more fully characterize its relationship to EoL outcomes.
In conclusion, spiritual care from the medical system seems to have important ramifications for patients at the EoL—helping them transition to hospice and improving their well-being near death. Furthermore, among high religious coping patients, spiritual support seems to reduce their risk of receiving aggressive interventions at EoL. However, despite national guidelines,22,23
spiritual care often remains absent for patients at the EoL.12
These findings underscore the need to educate medical caregivers in their appropriate roles in providing patient-centered spiritual care and the importance of integrating pastoral care into multidisciplinary medical teams.