Spirituality, Religion, and Health Interest Group

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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
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Research is a way of knowing
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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.

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Patients Spiritual/Religious Beliefs and Health
Care Decision-Making In a
University of Pennsylvania study of pulmonary
outpatients (n177), 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
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Treatment Decision Factors Ranking of the
importance of treatment decision factors by
oncology patients 1)
Cancer doctors recommendation
2) Faith in God
3) Ability to cure
4) Side effects
5) Family doctors
recommendation 6)
Spouses input 7)
Childrens 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
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Brief RCOPE   1) Looked for a stronger
connection with God 2) Sought Gods love and
care. 3) Sought help from God in letting go of
my anger. 4) Tried to put my plans into action
together with God. 5) 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) Wondered whether God had abandoned
me. 9) Felt punished by God for my lack of
devotion. 10) Wondered what I did for God to
punish me. 11) Questioned Gods love for me. 12)
Wondered whether my church had abandoned me. 13)
Decided the devil made this happen. 14)
Questioned the power of God.
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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
Gods 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
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Brief RCOPE   1) Looked for a stronger
connection with God 2) Sought Gods love and
care. 3) Sought help from God in letting go of
my anger. 4) Tried to put my plans into action
together with God. 5) 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) Wondered whether God had abandoned
me. 9) Felt punished by God for my lack of
devotion. 10) Wondered what I did for God to
punish me. 11) Questioned Gods love for me. 12)
Wondered whether my church had abandoned me. 13)
Decided the devil made this happen. 14)
Questioned the power of God.
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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
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Theoretical Model of How Religion Affects
Physical Health --adapted from Koenig, et
al., Hand- book of Religion and Health,
2001 Religion also
affects Childhood Training, Adult Decisions, and
Values Character which then in turn affect
mental health, social support, and health
behaviors.
Stress Hormones
Infection
Mental Health
Cancer
Immune System
R E L I G I O N
Heart Disease
Hyper- tension
Social Support
Autonomic Nervous System
Stroke
Stomach Bowel
Disease Detection and Treatment Compliance
Health Behaviors
Liver Lung
Accidents STDs
High Risk Behaviors (smoking, drugs)
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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.
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Patients Spiritual Needs in Oncology and
Serious Illness
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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
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Study of Perceived/Met Spiritual Needs at EOL
Perceived () Met
() Laugh 100 65 Think happy
thoughts 98 76 See the smiles of
others 97 81 Be with family
96 65 Be with friends 96
64 Pray 95 96 Talk about
day-to-day things 95 82 Have
information about family and friends 88
77 Be with people who share my spiritual
beliefs 88 74 Go to religious
services 85 30 Be around
children 83 72 Sing or listen to
music 80 80 Read a religious
text 80 64 Talk with someone about
spiritual issues 79 75 Read
inspirational materials 68 69 Use
phrases from religious text 65
86 Use inspirational materials 59 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
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Study of Perceived/Met Spiritual Needs at EOL
Perceived () Met
() Laugh 100 65 Think happy
thoughts 98 76 See the smiles of
others 97 81 Be with family
96 65 Be with friends 96
64 Pray 95 96 Talk about
day-to-day things 95 82 Have
information about family and friends 88
77 Be with people who share my spiritual
beliefs 88 74 Go to religious
services 85 30 Be around
children 83 72 Sing or listen to
music 80 80 Read a religious
text 80 64 Talk with someone about
spiritual issues 79 75 Read
inspirational materials 68 69 Use
phrases from religious text 65
86 Use inspirational materials 59 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
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Study of Perceived/Met Spiritual Needs at EOL
Perceived () Met
() Laugh 100 65 Think happy
thoughts 98 76 See the smiles of
others 97 81 Be with family
96 65 Be with friends 96
64 Pray 95 96 Talk about
day-to-day things 95 82 Have
information about family and friends 88
77 Be with people who share my spiritual
beliefs 88 74 Go to religious
services 85 30 Be around
children 83 72 Sing or listen to
music 80 80 Read a religious
text 80 64 Talk with someone about
spiritual issues 79 75 Read
inspirational materials 68 69 Use
phrases from religious text 65
86 Use inspirational materials 59 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
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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
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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
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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
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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 problem-focused 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
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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
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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 67 said yes Prayer
62 Pain Meds in
IV 54 Pain Injections
51 Relaxation 27 top 10 answers Distraction
24 from 17 choices PCA Pump 21 Heat
Application 18 Touch 16 Cold
Application 13 --McNeill, et
al., Assessing Clinical Outcomes, Journal
of Pain and Symptom
Management 16, no. 1 (July 1998) 29-40
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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 ones hand in a cold water
bath of 2C
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Effect of Illness and Treatment on Patients
Spirituality
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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
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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
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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. ...When a trauma occurs,
the spiritual aspects of the individuals 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' ones 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.
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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
individuals 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
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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 FourteenEig
hteen 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
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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 FourteenEig
hteen 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
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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
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Spiritual Distress from a Chaplains 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
chaplains 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
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john.ehman_at_uphs.upenn.edu www.uphs.upenn.edu/pas
toral www.ACPEresearch.net
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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