Spirituality in palliative care

The last issue of Annals of Palliative Medicine in 2022, the December issue, featured 16 Original Articles, 7 Editorials, 1 Study Protocol, 1 Editorial Commentary, and several Case Reports. It also featured a News article on the top reviewers for Annals of Palliative Medicine and a Meeting Report from the Ninth Annual Meeting of the Society for Palliative Radiation Oncology (SPRO), for which Annals of Palliative Medicine is the official journal (1). One of the Original Articles pertaining to spiritual wellbeing will be highlighted here.

Spirituality—defined in the medical literature as that which allows a person to experience transcendent meaning in life and as whatever beliefs and values give a person a sense of meaning and purpose in life (2)—remains a critical consideration in palliative medicine. Spiritual, religious and existential aspects of care collectively are a primary domain of palliative care, as recommended by the National Consensus Project for Quality Palliative Care intended to shape clinical practice in palliative care (3). Palliative care interventions, therefore, should ideally address physical symptoms, illness understanding, coping, and psychosocial and spiritual distress (4).

The association between spirituality and palliative care was an original focus of this journal (5), and it has been the focus on numerous manuscripts and even a comprehensive focused issue in Annals of Palliative Medicine (6). Spiritual wellbeing is associated with quality of life across a range of health conditions and can impact an individual’s interpersonal, religious, and spiritual relationships (7). Furthermore, spirituality can enhance coping in the face of critical illness (8). As such, assessing and supporting spirituality is increasingly being recognized across medical disciplines as a critical component of palliative care (9).

The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp) is one such tool that is commonly used to measure spirituality, either alone or as part of the larger Functional Assessment of Cancer Therapy-General (FACT-G) scale (10). The FACIT-Sp—a 12-item questionnaire scored on a 5-point Likert scale—is a reliable tool that can be employed across a variety of religions, cultures, and patient populations with differing medical conditions. The FACIT-Sp is further generalizable by providing a measure of spirituality without referring to the existence of God or a particular religious belief system (11).

Although the FACIT-Sp has become such a widely used measure of spiritual wellbeing, there has not been consensus on the best factor structure for this measure. Since its inception, analysis of the FACIT-Sp supported two factors, namely Meaning/Peace (8 items in the questionnaire assessing meaning, peace, and purpose in life) and Faith (4 items in the questionnaire assessing the effectiveness of spiritual beliefs in the context of serious illness). However, some investigators have more recently suggested that a 3-factor structure can allow for a more in-depth understanding of the impact of spiritual wellbeing in patients (12).

With current practice varied using a 2-factor (Meaning/Peace, Faith) or a 3-factor (Meaning, Peace, Faith) structure, in the December 2022 issue of Annals of Palliative Medicine, Ahmad and colleagues performed a factor analysis pertaining to spiritual wellbeing, examining the factorial structure of the FACIT-Sp. These National Institutes of Health investigators assessed 200 patients with severe and/or life limiting illnesses across a spectrum of diseases, including cancer, severe and/or rare genetic and non-genetic conditions, and blood dyscrasias.

After critically assessing no factor, 2-factor, 3-factor, and 4-factor requirements, the investigators found that a 3-factor model consisting of Meaning, Peace, and Faith accounted for the most variability and internal consistency, outperforming a 2-factor solution, whereas the 4-factor solution was determined not to be a valid model. The 3-factor solution allows for the delineation of Meaning and Peace as distinct dimensions in spirituality, which can influence potential clinical interventions that are aimed at increasing meaning in life or finding a sense of peace for patients afflicted with severe and/or life-limiting illnesses (13).

The findings by Ahmad et al. are critical to enhancing the care of patients with advanced and terminal conditions. It has been demonstrated that being diagnoses with terminal conditions, such as cancer, is associated with an increased desire for religious and spiritual consolation (14). Using the FACIT-Sp, therefore, can help to identify which dimension(s) of spiritual and/or religious consolation patients employ when suffering from distress due to medical illness. As such, by allowing for better understanding of the results from the FACT-Sp, the findings of this important analysis by Ahmad and colleagues can allow for a more effective assessment of spirituality and better inform interventions aimed at improving quality of life and spiritual wellbeing in palliative care settings.

While additional research should examine this scale and these findings in a more generalizable patient population across additional medical conditions and also among family members and/or caregivers of patients with advanced diseases, the findings by Ahmad and colleagues are a major step forward in this important and growing field of spiritual assessment in palliative medicine.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-23-60/coif). The author serves as the Editor-in-Chief of Annals of Palliative Medicine. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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