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Terminally ill patients who are supported by religious communities are more likely to receive aggressive end-of-life care rather than hospice care; spiritual support from medical teams may reverse this
  1. Ingela C V Thuné-Boyle
  1. Department of Epidemiology and Public Health, University College London, London, UK
  1. Correspondence to : Dr Ingela C V Thuné-Boyle, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK; i.thune-boyle{at}

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Implications for practice and research

  • Patients with cancer in the USA who receive spiritual support from religious communities alone may receive more aggressive end-of-life (EOL) medical interventions and are less likely to access hospice care.

  • Additional spiritual care and EOL discussions by the medical team may reduce aggressive treatments.

  • Research is needed outside the USA to validate these findings in more secular cultures and establish the efficacy of spiritual needs interventions.

  • Evidence-based training is essential to allow healthcare professionals (HCPs) to implement guidelines to ensure appropriate EOL care.


The provision of spiritual care by HCPs during the palliative phase of cancer is linked to improved quality of life (QOL), a higher level of hospice admission and less aggressive EOL medical care.1 The purpose of this study was to examine how provision of spiritual care by religious communities influences QOL and medical care during EOL, particularly among ethnic minorities and people with high levels of positive religious coping.


The study assessed 343 patients with advanced cancer at baseline and 2–3 weeks after death (through medical notes). Single items assessed spiritual support from religious communities and the medical system. Questions about the use of chaplaincy services, the importance placed on religion and positive religious coping were asked. Information about patient's QOL, the patient–physician relationship, EOL care discussions, advanced directives, hospice care, aggressive EOL care and location of death were collected.


Patients with higher perceived spiritual support from religious communities were less likely to receive hospice care, more likely to receive aggressive EOL interventions and were more likely to die in intensive care units (ICUs). For ethnic minorities and those with high levels of religious coping, this effect was more pronounced. Those receiving additional spiritual support from the medical team had higher rates of hospice use, fewer aggressive interventions and fewer admissions to ICU. EOL care discussions were associated with fewer aggressive treatments.


The study was prospective in design with adequate power. However, Balboni et al general assessments exploring spiritual support and religious coping have limitations. The maladaptive effect of negative religious coping was not examined, neither were its complexities taken into account.2 Single items examining spiritual support ignore the multidimensional nature of support, and there may be denominational differences in how religious communities foster support in their members. Furthermore, the relevance of these results in more secular but multicultural societies such as the UK is unclear. Additional research outside the USA is therefore needed. Research is also needed to establish the efficacy of interventions assessing and addressing patient's spiritual needs.

Patients’ psychosocial needs are routinely addressed within cancer care. However, the spiritual domain is often ignored despite guidelines and growing evidence of its significance.3 Balboni et al show the potential consequences of such needs being ignored but HCPs often lack the skills and confidence to address them. Evidence-based training is required to allow successful implementation of current guidelines and there is a need to understand who is best suited to carry out such assessments and address patients’ spiritual needs. In the USA, it is often suggested that the physician is best placed to carry out this task. However, in the UK, a specialist cancer nurse may be more appropriate, as they are already trained to assess and address patient's psychosocial needs and make appropriate referrals.

Balboni et al acknowledge a limited understanding of spiritual needs and support in their study. Indeed, there is a general lack of clarity to what we mean by spiritual needs.4 Common psychological constructs are often relabelled as spiritual and HCPs use definitions that may be incongruent with patient's beliefs. Constructs such as meaning and purpose are defined as spiritual but atheists/agnostics may find meaning and purpose in their illness experience through non-spiritual means. This may be particularly prevalent in Europe. Examining these constructs without labelling them initially may be preferable; if the patient deems them spiritual and there is distress, they have spiritual needs. Suitable care and support can then be provided and appropriate, agreed referrals can be made.

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  • Competing interests None.

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