REVIEW ARTICLE

Spirituality in Cancer Care at the End of Life

Betty Ferrell, PhD, MA, FAAN, FPCN, CHPN, Shirley Otis-Green, MSW, ACSW, LCSW, OSW-C,
and Denice Economou, MN, RN, CHPN

Abstract: There is a compelling need to integrate spirituality into the

provision of quality palliative care by oncology professionals. Patients
and families report the importance of spiritual, existential, and religious
concerns throughout the cancer trajectory. Leading palliative care organizations have developed guidelines that dene spiritual care and
offer recommendations to guide the delivery of spiritual services. There
is growing recognition that all team members require the skills to provide generalist spiritual support. Attention to person-centered, familyfocused oncology care requires the development of a health care
environment that is prepared to support the religious, spiritual, and
cultural practices preferred by patients and their families. These existential concerns become especially critical at end of life and following
the death for family survivors. Oncology professionals require education to prepare them to appropriately screen, assess, refer, and/or intervene for spiritual distress.
Key Words: Spiritual care, spirituality, suffering, palliative care,
National Consensus Project Guidelines, existential care,
cultural inuence on spirituality

team as an important aspect of their care. Only 6% of patients

report receiving spiritual care from their physicians and 13%
from their nurses. Physicians may consider the dimension of
spiritual care to be out of their realm of expertise and impractical for their day-to-day practice.9 Physicians tend to focus
primarily on the physical needs of patients, but patients and
families near end of life also struggle with the overall meaning
of their illness from a psychosocial-spiritual perspective.2,10
However, the best predictor for the exclusion of spiritual
care by all professionals is related to the lack of education and
skills to integrate that care into practice. Patients cannot receive
spiritual care from health care providers who have not been
provided with education and clinical skills to assess or respond to their needs. Given the high priority of spirituality to
patients, oncology professionals should strive to enhance this
area of clinical practice. Fortunately, there is an evolving body
of research and available resources to support the integration
of spirituality into formal training and continuing education
programs.

(Cancer J 2013;19: 431Y437)

piritual needs of patients and families facing cancer have

been increasingly recognized as an important aspect of
providing whole person care.1Y3 Although palliative care is
appropriate throughout the cancer trajectory, it is most urgently
needed when patients are facing the end of life. Patients near
the end of life may struggle to nd a purpose or meaning in
their life, and spirituality provides a foundation that helps patients transcend suffering and despair.4,5 The need for transcendence or the existential ability to nd meaning and purpose
within their illness experience is an essential part of providing
care from a biopsychosocial-spiritual perspective. Research has
shown that religion and spirituality are important aspects of
care that improve coping with the disease and symptoms as
well as improve quality of life (QoL), aid in decision making for
end-of-life care, and decrease suffering.6,7 Oncology professionals are often poorly prepared to address these critical concerns and may miss opportunities to integrate spiritual care as
an essential aspect of their palliative care interventions.
In a recent study done by Balboni et al.,8 a survey was
completed from multiple clinical sites where patients with advanced cancer were receiving radiation therapy for palliation.
This study described the factors that prevented spiritual care
from being provided by physicians and nurses at the end of
life. Patients considered spiritual care from their health care
From the City of Hope National Medical Center, Duarte, CA.
The authors have disclosed that they have no signicant relationships
with, or nancial interest in, any commercial companies pertaining
to this article.
Reprints: Betty Ferrell, PhD, MA, FAAN, FPCN, CHPN, City of Hope
National Medical Center, Division of Nursing Research and Education,
1500 E Duarte Rd, Duarte, CA 91010. E-mail: bferrell@coh.org.
Copyright * 2013 by Lippincott Williams & Wilkins
ISSN: 1528-9117

The Cancer Journal

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SPIRITUALITY, RELIGION, AND SUFFERING

Primary concerns when facing end of life are purpose
and meaning, love and relationship with others, and forgiveness. A denition of spirituality was provided by a Consensus Conference in February 2009, where national leaders in
spiritual care and palliative care from different disciplines together agreed on the following: Spirituality is the aspect of
humanity that refers to the way individuals seek and express
meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to
the signicant or sacred.11 This denition provides a framework that recognizes the signicance of integrating this care
into palliative practice.
Balducci12 discussed the suffering of cancer patients that
may be related to both physical and or spiritual distress. To ignore spiritual or religious needs and to focus only on the physical aspects of the disease risks providing inadequate care.
A review of evidence-based spiritual care literature done by
Kalish13 found that lack of clarity for the role of spiritual care
(from theoretical to practical implementation) was based on a
lack of education of both physicians and nurses as well as other
oncology professionals. There was a misconception regarding
what spiritual care is and how to provide this care. This review
acknowledged the lack of clarity around the multidisciplinary
approach to spiritual care and in particular the role of the chaplain. The most common barrier is the belief that spirituality is
limited to only religion. As described in the denition above,
spirituality encompasses many other aspects such as meaning
and purpose in life and relationships.
Pearce et al.14 found that failing to recognize the spiritual
concerns of patients can lead to depression and a lack of meaning and peace at the end of life. Research has shown a significant correlation between providing spiritual care and improved
QoL.14Y16 Spiritual or religious focused patients at the end of
life have been shown to have higher QoL when compared with
nonspiritual patients, even in the presence of pain.17

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There is also an emerging recognition that failure to address

the spiritual concerns of professionals is related to increased incidence of moral distress and has implications for maintaining
a sustainable workforce.18 Leading nurse researchers have identied the impact of existential suffering related to the provision

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of palliative and end-of-life care.19 In addition to supporting

spiritual care for patients and families, oncology settings need
to provide support for all staff members to address their own
spirituality and existential distress inherent in oncology care.
The average oncology professional will care for many seriously

TABLE 1. NCP Guidelines Regarding Spiritual Care

Domain 5: Spiritual, Religious, and Existential Aspects of Care
Guideline 5.1. The interdisciplinary team assesses and addresses spiritual, religious, and existential dimensions of care.
Criteria
Spirituality is recognized as a fundamental aspect of compassionate, patient- and family-centered care that honors the dignity
of all persons.
h Spirituality is dened as the aspect of humanity that refers to the way individuals seek and express meaning and purpose and
the way they experience their connectedness to the moment, to self, to others, to nature, and/or to the signicant or sacred.11
It is the responsibility of all interdisciplinary team members to recognize spiritual distress and attend to the patients and the familys
spiritual needs, within their scope of practice (NCCN Clinical Practice Guidelines in Oncology [NCCN Guidelines c], Distress
Management; Chaplaincy Services [DIS 21], version 3 2012. Fort Washington, Pa, 2013).
h The interdisciplinary palliative care team, in all settings, includes spiritual care professionals; ideally a board-certied
professional chaplain, with skill and expertise to assess and address spiritual and existential issues frequently confronted by
pediatric and adult patients with life-threatening or serious illnesses and their families.
h Communication with the patient and family is respectful of their religious and spiritual beliefs, rituals, and practices. Palliative
care team members do not impose their individual spiritual, religious, existential beliefs or practices on patients, families,
or colleagues.
Guideline 5.2. A spiritual assessment process, including a spiritual screening, history questions, and a full spiritual assessment as
indicated, is performed. This assessment identies religious or spiritual/existential background, preferences, and related beliefs, rituals,
and practices of the patient and family, as well as symptoms, such as spiritual distress and/or pain, guilt, resentment, despair,
and hopelessness.
Criteria
h The IDT regularly explores spiritual and existential concerns and documents these spiritual themes in order to communicate them
to the team. This exploration includes, but is not limited to, life review, assessment of hopes, values, and fears, meaning, purpose,
beliefs about afterlife, spiritual or religious practices, cultural norms, beliefs that inuence understanding of illness, coping, guilt,
forgiveness, and life completion tasks. Whenever possible, a standardized instrument is used.
h The IDT periodically reevaluates the impact of spiritual/existential interventions and documents patient and family preferences.
h The patients spiritual resources of strength are supported and documented in the patient record.
h Spiritual/existential care needs, goals, and concerns identied by patients, family members, the palliative care team, or spiritual
care professionals are addressed according to established protocols and documented in the interdisciplinary care plan and
emphasized during transitions of care and/or in discharge plans. Support is offered for issues of life closure, as well as other
spiritual issues, in a manner consistent with the patients and the familys cultural, spiritual, and religious values.
h Referral to an appropriate community-based professional with specialized knowledge or skills in spiritual and existential issues
(e.g., to a pastoral counselor or spiritual director) is made when desired by the patient and/or family. Spiritual care professionals
are recognized as specialists who provide spiritual counseling.
Guideline 5.3. The palliative care service facilitates religious, spiritual, and cultural rituals or practices as desired by patient and
family, especially at and after the time of death.
Criteria
h Professional and institutional uses of religious/spiritual symbols and language are sensitive to cultural and religious diversity.
h The patient and family are supported in their desires to display and use their own religious/spiritual and/or cultural symbols.
h Chaplaincy and other palliative care professionals facilitate contact with spiritual/religious communities, groups, or individuals,
as desired by the patient and/or family. Palliative care programs create procedures to facilitate patients access to clergy; religious,
spiritual, and culturally based leaders; and/or healers in their own religious, spiritual, or cultural traditions.
h Palliative professionals acknowledge their own spirituality as part of their professional role. Opportunities are provided to engage
staff in self-care and self-reection of their beliefs and values as they work with seriously ill and dying patients. Core expectations
of the team include respect of spirituality and beliefs of all colleagues and the creation of a healing environment in the workplace.
h Nonchaplain palliative care providers obtain training in basic spiritual screening and spiritual care skills.
h The palliative care team ensures postdeath follow-up after the patients death (e.g., phone calls, attendance at wake or funeral,
or scheduled visit) to offer support, identify any additional needs that require community referral, and help the family during
bereavement (see Domain 3: Psychological and Psychiatric Aspects of Care, Guideline 3.2).
Clinical Implications
Spiritual, religious, and existential issues are a fundamental aspect of QoL for patients with serious or life-threatening illness and
their families. All team members are accountable for attending to spiritual care in a respectful fashion. In order to provide an optimal
and inclusive healing environment, each palliative care team member needs to be aware of his/her own spirituality and how it may
differ from fellow team members and those of the patients and families they serve.

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Spirituality in Cancer Care at End of Life

TABLE 2. End-of-Life Spiritual Care Resources for Oncology Professionals

Internet Resources
Cancer.Net-End-of-Life Issues. http://www.cancer.net/publications-and-resources/oncologists-perspective/end-life-issues
& Steer CJ, Lee, C. Addressing spiritual care: calling for help. J Clin Oncol 2004;22(23):4856Y4858.
& Ramondetta LM, Sills D. Spirituality and religion in the art of dying. J Clin Oncol 2003;21(23):4460Y4462.
& Rousseau P. Spirituality and the dying patient. J Clin Oncol 200321(9 suppl):54sY56s.
City of Hope Pain & Palliative Care Resource Center (PRC). More than 1600 Resources and Links, with special section devoted
to spirituality resources: http://prc.coh.org; e-mail: prc@coh.org
Duke Center for Spirituality and Health. http://www.spiritualityandhealth.duke.edu/
George Washington University: Spirituality and Health Online Education and Resource Center Educational and Clinical
Resources in Spirituality, Religion, and Health. http://www.gwumc.edu/gwish/soerce/index.cfm; GWish at: 202-994-6220;
soerce@gwish.org
HealthcareChaplaincy.Org. http://www.healthcarechaplaincy.org/home.html
& Handbook of Patients Spiritual and Cultural Values for Health Care Professionals. http://www.healthcarechaplaincy.org/
userimages/Cultural%20Sensitivity%20handbook%20from%20HealthCare%20Chaplaincy%20%20%283-12%202013%29.pdf
& Cultural & Spiritual Sensitivity. A Learning Module for Health Care Professionals. http://www.healthcarechaplaincy.org/
userimages/Cultural_Spiritual_Sensitivity_Learning_%20Module%207-10-09.pdf
NCCN Distress Guidelines. http://www.nccn.org/clinical.asp
Oncology Nursing Society Spiritual Care SIG Toolkit. http://wwwnew.towson.edu/sct/resources.htm
Walking the Narrow Bridge: Religion, Spirituality and End-of-Life Decision-Making. (American Society on Aging, Aging Today
Newsletter) http://www.rrc.edu/sites/default/les/legacy/NARROWBRIDGE%20AGINGTODAY%20%282%29.PDF
Spiritual Care Instruments
Albers GE, de Vet HCW, Onwuteaka-Philipsen BD, et al. Content and spiritual items of quality-of-life instruments appropriate for use
in palliative care: a review. J Pain Symptom Manage, 2010;40(2):290Y300.
Ambuel B. Taking a spiritual history #19. J Palliat Med, 2003;6(6), 932Y933.
Anderson M. Sacred Dying: Creating Rituals for Embracing the End of Life. Roseville: Prima Publishing; 2001.
Ando M, Morita T, Akechi T. Factors in the short-term life review that affect spiritual well-being in terminally ill cancer patients.
J Hosp Palliat Nurs 2010;12(5):305Y311.
Baird P. Spiritual care interventions. In: Ferrell B, Coyle N, eds. Oxford Textbook of Palliative Nursing. New York: Oxford University
Press; 2010:663Y672.
Balboni MJ, Babar A, Dillinger J, et al. It depends: viewpoints of patients, physicians, and nurses on patient-practitioners prayer
in the setting of advanced cancer. J Pain Symptom Manage 2011;41(5):836Y847.
Belcher APRNAF, Grifths MMSNRNA. The spiritual care perspectives and practices of hospice nurses. J Hosp Palliat Nurs
2005;7(5):271Y279.
Borneman et al.30
Borneman T. Assessment of spirituality in older adults: FICA spiritual history tool. Try This: Best Practices in Nursing Care to
Older Adults, SP5, 2011. 2p 8 ref.
Breitbart W. Spirituality and meaning in supportive care: spirituality- and meaning-centered group psychotherapy interventions in
advanced cancer. Support Care Cancer 2002;10(4):272Y280.
Breitbart W. Reframing hope: meaning-centered care for patients near the end of life. Interview by Karen S. Heller. J Palliat Med
2003;6(6):979Y988.
Breitbart W, Gibson C, Poppito SR, et al. Psychotherapeutic interventions at the end of life: a focus on meaning and spirituality.
Can J Psychiatry 2004;49(6):366Y372.
Breitbart W, Rosenfeld B, Gibson C, et al. Meaning-centered group psychotherapy for cancer patients. Psychooncology 2006;19(1):21Y28.
Doka34
Ferrell B. Dignity therapy: advancing the science of spiritual care in terminal illness. J Clin Oncol 2005;23(24):5427Y5428.
Ferrell BF. Meeting spiritual needs: what is an oncologist to do? J Clin Oncol 2007;25(5):467Y468.
Holmes S, Rabow M, Dibble S. Screening the soul: communication regarding spiritual concerns among primary care physicians and
seriously ill patients approaching the end of life. Am J Hosp Palliat Med 2006;23(1):25Y33.
Koenig H, McCullough M, Larson D. Handbook of Religion and Health. New York: Oxford University Press; 2001.
Puchalski CM. Spirituality and medicine: curricula in medical education. J Cancer Educ 2006;21(1):14Y18.
Puchalski CM. Principles and practice of palliative care and supportive oncology. In: Berger A, Portenoy R, Weissman D, eds.
Spirituality. Philadelphia, PA: Lippincott, Williams & Wilkins; 2013.
Taylor EJ. Teamwork in palliative care: social work role with spiritual care professionals. Oncol Nurs Forum 2006;33(4):729Y735.
Van de Creek L. Spiritual assessment: six questions and an annotated bibliography of published interview and questionnaire formats.
Chaplaincy Today 2005;21(1):11Y22.
Widera EW, Rosenfeld KE, Fromme EK, et al. Approaching patients and family members who hope for a miracle. J Pain Symptom
Manage 2011;42(1):119Y125.
(Continued on next page)

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TABLE 2. (Continued)
Internet Resources
Spirituality and Existential Care
Ersek M. The meaning of hope in dying. In: Ferrell BR, Coyle N, eds. Oxford Textbook of Palliative Nursing. New York: Oxford
University Press; 2006:513Y529.
Guenther MB. Healing: the power of presence. a reection. J Pain Symptom Manage 2011;41(3):650Y654.
Otis-Green S. The transitions program: existential care in action. J Cancer Educ 2006;21(1):23Y25.
Strang P, Strang S, Hultborn R, et al. Existential painVan entity, a provocation, or a challenge? J Pain Symptom Manage
2004;27(3):241Y250.
Spirituality in Palliative Care and Oncology Practice
Baird P. Spiritual care interventions. In: Ferrell B, Coyle N, eds. Oxford Textbook of Palliative Nursing. New York: Oxford University
Press; 2010:663Y672.
Balboni TAP, Balboni MJ, Phelps AC, et al. Provision of spiritual care to patients with advanced cancer: associations with medical care
and quality of life near death. J Clin Oncol 2010;28(3):445Y452.
Block SD. Perspectives on care at the close of life. Psychological considerations, growth, and transcendence at the end of life:
the art of the possible. JAMA 2001;285(22):2898Y2905.
Byock IR. To Life! Reections on spirituality, palliative practice, and politics. Am J Hosp Palliat Med 2007;23(6):436Y438.
Chochinov H, Hack T, Hassard T, et al. Dignity therapy: a novel psychotherapeutic intervention for patients near the end of life.
J Clin Oncol 2005;23(24):5520Y5525.
Ellis J, Lloyd-Williams M. Palliative care. In: Cobb M, Puchalski CM, Rumbold B, eds. Oxford Textbook of Spirituality in Healthcare.
New York: Oxford University Press; 2012.
Ferrell B, Borneman T, Otis-Green S, et al. Consensus project and pilot demonstration projects to improve the quality of spiritual care
in palliative care (abstract). J Support Oncol. 2010;8(5):A11.
Mattison D. The forgotten spirit: integrating spirituality in oncology health care. Hematol Oncol News Issues 2005:21Y23.
Otis-Green S, Ferrell B, Borneman T, et al. Integrating spiritual care into palliative care: an overview of nine demonstration projects.
J Palliat Med 2012;15(2):154Y162.
Puchalski C, Kilpatrick S, McCullough M, et al. A systematic review of spiritual and religious variables in Palliative Medicine,
American Journal of Hospice and Palliative Care, Hospice Journal. Journal of Palliative Care and Journal of Pain Symptom and
Management. Palliat Support Care 2003;1(1):7Y13.
Puchalski C. Time for listening and caring: Spirituality and the care of the chronically ill and dying. New York: Oxford University
Press; 2006.
Puchalski CM, Norris L, Walseman K. Communicating about spiritual issues with cancer patients. In: Surbone A, Zwitter M, Rajer M,
et al. New Challenges in Communication With Cancer Patients. New York: Springer; 2012:91Y104.
Puchalski CM, Ferrell B, ODonnell E. Spiritual issues in palliative care. In: Bruera E, Yennurajalingam S, eds. Oxford American
Handbook of Hospice and Palliative Medicine. New York: Oxford University Press; 2011:253Y268.
Reese DJ. Spirituality and social work practice in palliative care. In: Alitilio T, Otis-Green S, eds. Oxford Textbook of Palliative Social
Work. Oxford University Press; 2011:201Y213.
Selman L, Siegert R, Harding R, et al. A psychometric evaluation of measures of spirituality validated in culturally diverse palliative
care populations. J Pain Symptom Manage 2011;42(4):604Y622.
Soltura DL, Piotrowski LF. Teamwork in palliative care: social work role with spiritual care professionals. In: Alitilio T, Otis-Green S, eds.
Oxford Textbook of Palliative Social Work. Oxford University Press; 2011;495Y501.
Sulmasy DP. A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist 2002;42 spec(3):24Y33.
Sulmasy DP. The Rebirth of the Clinic: An Introduction to Spirituality in Health Care. Washington, DC: Georgetown University Press; 2006.

ill patients and will experience numerous patient deaths each

month. The cumulative effect of this loss can be extreme and result in personal stress with impact on professional practice.
The National Comprehensive Cancer Networks (NCCNs)20
clinical practice guidelines in Oncology Distress Management
dene palliative psychosocial care to include spiritual care and
chaplaincy needs of patients. The guidelines recommend that
spiritually distressed patients be referred to chaplaincy services
for evaluation related to grief, concerns about death and afterlife issues, conicted or challenged belief systems, loss of faith,
concerns with nding meaning and purpose in their life, and
other spiritual concerns. The algorithm for spiritual assessment
includes spiritual, philosophical, prayer, and ritual interventions.

CULTURAL AND RELIGIOUS IMPACT

Culture and faith traditions dramatically affect a patients
and familys response to illness and plan for care. Religion and

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religious coping relate to spiritual pain and nding meaning for

the disease and how it relates to their life purpose.21 Culture
is the overriding inuence for ones values and behaviors and
provides the basis for a patients views of illness, suffering, and
death.7 Ethnic groups, for example, Hispanic and African
American communities, have shown a greater interest for
spiritual interventions in their health care.22 A convenience
sample of 248 patients found that three fourths of the patients
had at least 1 spiritual need that related to fear, seeking hope,
or nding meaning in their lives.22 Many patients at the end of
life experience spiritual needs even when they consider themselves nonreligious.6 Interestingly, in another survey, 22% of the
patients stated they were not religious or spiritual, yet 40% of
those stated they had 4 or more spiritual issues.23 Patients
may question if their lives have meaning, if they are leaving a
legacy, and if they have had meaningful relationships. Patients
also may struggle with fears about life beyond death and have
great distress in living with uncertainty.
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Cultural inuence manifests in patients differently and is

impacted by race or ethnicity as well as other inuences including education level, community where they live, and economic standing.7 The signicance of cultural inuence on how
patients and families respond to palliative care is incorporated
into spiritual care and is seen as an important part of providing sensitive and appropriate palliative care. The National Consensus Project (NCP) guidelines include recommended aspects
for meeting the spiritual, religious, and existential aspects of
care when providing quality palliative care.24 Attention to these
concerns is of increased importance in the care of the imminently dying with implications for bereavement. The risk for
complicated bereavement by family members is associated with
unmet spiritual, religious, and ritual requests and practices.25

NCP GUIDELINES
One of the major advances in the eld of palliative care
has been the development of clinical practice guidelines to ensure the quality of care. The NCP Clinical Practice Guidelines
for Quality Palliative Care is a collaborative project of the key
organizations in the eld of palliative care. This includes the

Spirituality in Cancer Care at End of Life

American Academy of Hospice and Palliative Medicine, Hospice

and Palliative Nurses Association, Center to Advance Palliative
Care, National Association of Social Workers, and the National
Hospice and Palliative Care Organization. The NCP guidelines
include 8 essential domains of care, and domain 5 is focused
on spiritual, religious, and existential aspects of care (Table 1).
The third edition of these guidelines was released in 2013
(www.nationalconsensusproject.org).
These guidelines stress the role of organizations in building spiritual care within palliative care. Although this may seem
like a fundamental idea, in reality, spiritual care is often ignored
as clinicians primarily focus on the physical aspects of care.
Another common barrier is a belief that only chaplains should
be involved in spiritual care rather than recognizing the role of
all clinicians in addressing this important domain.
The 3 key aspects of the spiritual care domain of the NCP
guidelines address assessment of spiritual, religious, and existential dimensions of care; the process of spiritual assessment;
and cultural rituals or practices (Table 1).
The NCP guidelines have been the foundation of subsequent work in addressing the quality of palliative care by the

FIGURE 1. Completing a spiritual history using the FICA* Spiritual History Tool. FICA is an acronym to guide health care professionals
in completing a spiritual history. The questions were developed to guide an interview to obtain critical information so that a
patients spiritual, religious, and existential concerns could be integrated into a comprehensive plan of care. F = faith, belief, values:
What beliefs and values give your life meaning? I = importance, inuence: How do these belief or values help you to cope with stress or
inuence your health care decision making? C = community: Do you receive support from a community of people who share your beliefs and
values? A = address, actions: In what ways can we (your health care team) address any spiritual, religious, or existential concerns that you
may encounter as you cope with your illness? *Adapted from Puchalski CM with permission. Restorative medicine. In: Cobb M, Puchalski
CM, Rumbold B, eds). Oxford Textbook of Spirituality in Healthcare. Oxford, Great Britain: Oxford University Press; 2012:197Y210.
Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both
from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
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Ferrell et al

National Quality Forum, the Joint Commission, and other quality monitoring organizations. The NCP guidelines can also be
a valuable resource for cancer care settings as they seek to develop palliative care programs. There is signicant effort in the
oncology community including work by the American Society
of Clinical Oncology to integrate palliative care into routine
oncology care.25a

RESOURCES
Despite widespread organizational support for the inclusion
of spiritual care into palliative care, few professionals have been
adequately prepared for this role. Even health care chaplains
have only recently had access to a palliative care competencybased curriculum and specialty certication.26 In 2013, the
Health-Care Chaplaincy organization will launch the rst certication for chaplaincy in palliative care. In recognition that
oncology professionals may lack adequate preparation for their
role in addressing spiritual concerns of patients and families,
there has been increased effort to consolidate resources into
more centrally accessible sites. The George Washington Institute for Spirituality and Health (www.gwish.org) and the City of
Hope Pain and Palliative Care Resource Center (http://prc.coh.org)
house resources that are readily accessible, regardless of discipline or faith tradition. Table 2 highlights numerous resources
helpful for oncology professionals. Materials in Table 2 include
Web sites with information on screening, assessment and spiritual interventions, resources related to existential exploration,
and research that has been conducted in spirituality in the context
of oncology and palliative care. Although few validated clinical
instruments exist, instruments such as the Functional Assessment of Chronic Illness TherapyVSpiritual Well-being Scale,
(FACIT-Sp),27 FACT, (an acronym for Faith, Active, Coping,
Treatment),28 FICA (an acronym for Faith, Importance, Community and Address),29,30 HOPE (an acronym for Hope, Organized religion, Personal spirituality and practices, and Effects
of spirituality on medical care and end-of-life issues),31 SPIRIT
(an acronym for Spiritual belief system, Personal spirituality,
Integration with a spiritual community, Ritualized practices and
restrictions, Implications for medical care, and Terminal events
planning),32 and the Spiritual Well-Being Scale (SWBS)33 have
been developed for research and clinical use. Previous research
attention has focused primarily on measuring religiosity, and
only recently has the broader construct of spirituality been explored.34 These tools can be incorporated into clinical practice
so that patients spiritual, religious, and existential needs are
identied. Figure 1 offers an example of how the FICA Spiritual
History Tool can be used by health care professionals to guide
an interview that collects information that can be integrated into
a comprehensive plan of care.

SUMMARY
Facing a diagnosis of cancer raises spiritual and existential concerns for patients, families, and the professionals involved in their care. Beliefs regarding meaning and purpose
evolve over time and are culturally inuenced. Unattended
spiritual distress is an important source of suffering. Leading
organizations recognize the urgent need to prepare oncology
professionals for their responsibility to address these issues. The
NCP guidelines highlight the importance of integrating spiritual, religious, and existential care into the provision of quality
palliative care. Failure to address these issues leaves staff vulnerable to moral distress.
As illness progresses, these concerns become magnied.
Failure to address them can heighten the risk for complicated
bereavement. Spirituality is also of great concern for cancer

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survivors who often struggle to nd meaning in their cancer diagnosis and their survival. Cancer survivors face tremendous
existential impact of a cancer diagnosis and live with uncertainty and many long-lasting impacts of survivorship. Oncology
professionals can benet from a range of resources that provide guidance to address the spiritual, religious, and existential
concerns associated with cancer.
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3. Amoah CF. The central importance of spirituality in palliative care
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