BMJ  2004;329:123-124 (17 July), doi:10.1136/bmj.329.7458.123

Editorial

Spiritual needs in health care

May be distinct from religious ones and are integral to palliative care

Spiritual needs change with time and circumstances. The National Institute for Clinical Excellence guidance, Supportive and Palliative Care for Adults with Cancer, published in March 2004, acknowledges this and recommends that healthcare teams ensure accurate and timely evaluation of spiritual issues through regular assessment. This reflects the increasing emphasis on spirituality as a factor contributing to wellbeing and coping strategies.^1-4 A proliferation of textbooks and book chapters with titles containing the word "spirituality" seek to elucidate what spiritual care is, how it might be assessed, and how needs might be met.⁵ However, a lack of consensus remains as to what spirituality actually is.⁶

Some key words occur quite regularly in the various descriptions of spirituality in journals and textbooks (box). In health research we should differentiate between the terms spiritual and religious since, if they are used interchangeably, reports of spirituality may be describing religious practice and affiliation.^{7 8} These can be interrelated. Spiritual belief may or may not be religious, but most religious people will be spiritual. A non-religious person may still therefore have a deep spirituality and spiritual needs. Spiritual care is not just the facilitation of an appropriate ritual but engaging with an individual's search for existential meaning, as reflected in the existential domain of the McGill quality of life questionnaire.⁹

Variables such as religious practice often seem easier to measure. Where participants for research have drawn from communities where religious practice is at high levels, these studies have shown that participating actively in the life of the faith community seems to lead to better health profiles. Religion also strengthens people's ability to cope with life threatening disease,^{3 6 10} and its importance in predicting aspects of psychosocial need in patients with cancer has been reported.¹ These studies are examining religious affiliation and behaviour even though some of them talk about spirituality.

Recently researchers have begun to look at populations that may not be religious but claim to have a clear spiritual belief. King et al reported that 71% of people who entered their acute hospital study had an important spiritual belief, even though many did not express that in a religious way.⁸ Other studies confirm this proportion and are beginning to show the importance of spiritual belief in predicting clinical outcome,⁸ the management of death distress,¹¹ end of life despair,² and assessing quality of life in oncology patients.^{9 12}

Evidence is growing that spiritual belief and religious practice are important predictive factors for a larger proportion of people entering health care than previously thought. Many may benefit from support for this aspect of their life. A need exists for user friendly and brief measures to assess spiritual need in the absence of religious faith, so that it may be addressed properly rather than as some general panacea which is assumed to be good but is not individually tailored. Only in this way may we "ensure that the spiritual elements of disease are taken into account," as recommended in the guidance from NICE.

Key words and phrases in spirituality literature Meaning—making sense of life situations; deriving purpose from existence Existential—searching for personal meaning within one's life, death, and concerns about freedom and isolation Value—cherished beliefs and standards of, for example, truth, beauty, behaviour, or thoughts Transcendence—appreciation of dimension beyond self; creating ability to rise above "here and now" experience Connecting—relationships and communication with self, others, environment, higher power, the sacred Becoming—links to identity, personal growth, through reflection on life experience Coping—means of using or developing strategies in critical life events; achieving inner peace Spirituality—the search for existential or ultimate meaning within a life experience, such as illness. (This belief usually refers to a power other than the self, which people may or may not describe as God, higher power, or forces within nature, and with which they communicate. The power helps the person to transcend the here and now, re-establish hope and the ability to cope) Religion—is an expression of spiritual belief through a framework of rituals, codes, and practices; the sense of otherness or a power being a deity or supreme being Philosophical—relates to the same searching, but with a rejection of any influential power external to the self

Department of Palliative Care and Policy, King's College London, Weston Education Centre, London SE5 9RJ (pws7749{at}ntlworld.com)

School of Nursing and Midwifery, Southampton S017 1BJ

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Competing interests: None declared.

References

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2. McClain CS, Rosenfeld B, Breitbart W. Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients. Lancet 2003;361: 1603-7.[CrossRef][ISI][Medline]
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5. Aldridge D. Spirituality, healing and medicine: return to the silence. London: Jessica Kingsley, 2000.
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7. Speck P. Spiritual issues in palliative care. In: Doyle D, Hanks G, MacDonald M, eds. Oxford textbook of palliative medicine. Oxford: Oxford University Press, 1998: 805-16.
8. King M, Speck P, Thomas A. The Royal Free interview for spiritual and religious beliefs: development and validation of a self-report version. Psychol Med 2001;31: 1015-23.[CrossRef][ISI][Medline]
9. Cohen SR, Mount BM, Bruera E, Provost M, Rowe J, Tong K. Validity of McGill quality of life questionnaire in the palliative care setting: a multicentre Canadian study demonstrating the importance of the existential domain. Palliat Med 1997;11: 3-20.[ISI][Medline]
10. Feher S, Maly RC. Coping with breast cancer in later life: the role of religious faith. Psycho-Oncology 1999;8: 408-416.[CrossRef][Medline]
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12. Brady MJ, Peterman AH, Fitchett G, Mo M, Cella D. A case for including spirituality in quality of life measurement in oncology. Psycho-Oncology 1999;8: 417-28.[CrossRef][Medline]

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