Toward a socio-spiritual approach? A mixed-methods systematic review on the social and spiritual needs of patients in the palliative phase of their illness

Spiritual Care Expectations Among Cancer and Noncancer Patients With Life-Threatening Illnesses

BACKGROUND

Spirituality is a core element in holistic nursing care. Therefore, it is necessary to understand the spiritual care expectations of cancer and noncancer patients with life-threatening illnesses.

OBJECTIVE

The aim of this study was to identify the spiritual care expectations of vulnerable patients with life-threatening illnesses.

INTERVENTIONS/METHODS

This study uses both quantitative and qualitative approaches, and data were collected from 232 patients. For quantitative data, we used the Nurse Spiritual Therapeutics Scale (NSTS), which comprises 20 items. Qualitative data were collected using an open-ended question. Quantitative data were analyzed using descriptive statistics, independent t tests, 1-way analysis of variance, and item and factor analysis. Qualitative data were analyzed using content analysis.

RESULTS

The mean score of spiritual care expectations ranged from 2.27 to 3.07. There was a significant difference in NSTS mean score between cancer and noncancer patients. In exploratory factor analysis, NSTS was extracted into 3 factors and items belonging to the 3 factors showed similarity between cancer and noncancer patients. Qualitative data using content analysis revealed the following 3 themes: "treat with respect," "religious support," and "comfort with presence." The 3 factors corresponded with 3 themes: factor I versus "treat with respect," factor II versus "religious ritual," and factor III versus "comfort with presence."

CONCLUSIONS

Spiritual care expectations of cancer and non-cancer patients with life-threatening illnesses were identified and the findings provide valuable data regarding the expectations of patients' spiritual care.

IMPLICATIONS FOR PRACTICE

Our findings emphasize integrating patient-reported outcomes with spiritual care to stimulate patient-centered care, thus promoting holistic palliative or end-of-life care.

'It is important to feel invited': what patients require when using the Utrecht Symptom Diary - 4 Dimensional, a qualitative exploration

Background

In palliative care, the Utrecht Symptom Diary - 4 Dimensional (USD-4D), a Dutch-adapted and validated patient-reported outcome measure, supports multidimensional symptom management through identification and monitoring of, as well as dialogue on symptoms and needs. For the USD-4D to optimally support patients' autonomy, it is essential to know what patients need to use it.

Objective

This study aims to identify what patients need when using the USD-4D in clinical palliative care.

Design

A generic qualitative design with primary and secondary analyses of semistructured interviews.

Methods

Patients ⩾18 years with a life-limiting illness were purposefully recruited within hospice and home care settings if they were in their last year of life as identified by the surprise question. Patients had to be aware of their life-threatening condition. Patients were selected in two tranches. In the first tranche, patients had to have completed the USD-4D at least once. The second tranche consisted of patients who were not familiar with the USD-4D in clinical practice and were interviewed in a previous study on the content validity of the USD-4D. The interviews were transcribed verbatim and were subjected to thematic analysis.

Results

Twenty-five patients were included (14 men, ages 44-87). Patients' needs when using the USD-4D were summarized in three themes: (1) feeling invited, (2) being aware of the purpose and function of the USD-4D, and (3) experiencing a personal and nonjudgmental approach.

Conclusion

For patients to optimally benefit from the USD-4D as a supportive measure of their autonomy in clinical palliative care, it is essential that they feel invited to use it. Healthcare providers are tasked with setting the right preconditions for patients to want and to be able to use the USD-4D. For patients, this means healthcare providers should always be attuned to their personal preferences when communicating the purpose and function of the USD-4D and when they enter into dialogue with them.

Exploring spirituality, religion and life philosophy among parents of children receiving palliative care: a qualitative study

BACKGROUND

Few studies have examined the spiritual environment of parents of children receiving palliative care in Southern European countries, which are mostly characterized by secularization (or the abandonment of traditional religiosity) and an increase of cultural and religious diversities resulting in a much broader spectrum of spiritual and religious beliefs. This study aimed to explore the parents' own spirituality, religiosity, and philosophy of life in coping with the care of their child with palliative needs.

METHODS

Qualitative interviews of 14 parents of children included in a palliative care program in a pediatric hospital in Barcelona, Spain. Inclusion criteria were parents of children who have been cared for the palliative care program for a minimum of 3 months and who displayed a willingness to talk about their personal experiences and gave written consent. Interviews were audio-recorded, transcribed by an independent service, and analyzed on a case-by-case basis using Interpretative Phenomenological Analysis.

RESULTS

The three domains identified were life philosophy, relational, and transcendent. Life philosophy included principles that guided parents' decision-making, and how the onset of their child's serious illness had promoted a change in their values. Relational was focused on how they perceived themselves (e.g. motherhood), others (e.g. one's own child exceptionality), and the way they believed others perceived and supported them (e.g. relatives, friends, and healthcare providers). The transcendent domain involved God-related concepts, divinity and divine intervention (e.g. a miracle as an interpretive framework for that which cannot be explained within scientific knowledge limitations).

CONCLUSIONS

Inflexible categories identifying parents as having a particular religious faith tradition are not sufficient to capture the interrelation of knowledges (ethical, religious, scientific) that each parent generates when faced with their child receiving palliative care. Clinicians should explore parents' spirituality in an individualized way that responds to the uniqueness of their experiential process.

How to Manage the Suffering of the Patient and the Family in the Final Stage of Life: A Qualitative Study

BACKGROUND

The end of life and death have changed from being issues managed within the family, assumed as part of life, to occur within health institutions for the majority of patients. The amount of patients dying at home has decreased, and the roles of families and communities in death and dying have become involuted, threatening related traditions and knowledge. As a result, a need to promote the end of life at home in this new self-serving society has arisen. In that context, the main objective of this study was to find out what patients and their families need during the end-of-life process in order to feel effectively accompanied at this time.

METHODS

With that objective, a descriptive qualitative study was conducted via the content analysis of data from semi-structured interviews and focus groups. This research adhered to the COREQ guidelines. The sample consisted of 36 informants selected via intentional sampling of family members and patients integrated into the Comprehensive Palliative Care Process (PAI Paliativos).

RESULTS

The results suggest the existence of several common needs such as communication and presence, including the conspiracy of silence as an important factor generating suffering for both. However, there are specific needs such as autonomy, dignity, and respect for patients, which must be taken into account.

CONCLUSIONS

The results of this study will allow us to establish intervention strategies for effective accompaniment of patients' family members at the end of life and the avoidance of ethnocentrism in this process. This study was retrospectively registered with the (nursrep-1194226) on the (21 April 2023).

Barriers and facilitators that hospital clinicians perceive to discuss the personal values, wishes, and needs of patients in palliative care: a mixed-methods systematic review

Background

The exploration and monitoring of the personal values, wishes, and needs (VWN) of patients in the palliative phase by hospital clinicians is essential for guiding appropriate palliative care.

Objective

To explore the barriers and facilitators concerning communication with patients in the palliative phase about their VWN as perceived by hospital clinicians.

Design

A mixed-methods systematic review following the Joanna Briggs Institute guidelines for mixed-method systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted (PROSPERO ID: CRD42021216693).

Data sources and methods

Eight databases, including PubMed, Embase, and CINAHL, were searched without time restrictions. The search string was built using the search Palliative cAre Literature rEview iTeraTive mEthod (PALETTE) framework. Eligible studies focused on (1) hospital clinicians and (2) perceived barriers and facilitators regarding the exploration and monitoring of the VWN of adult patients in the palliative phase. Two researchers independently selected articles and evaluated the quality. Findings were synthesized using a convergent integrated approach.

Results

In total, 29 studies were included: 14 quantitative, 13 qualitative, and 2 mixed methods. Five synthesized findings were identified: (1) the clinician's professional manners, (2) the image formed of the patient and loved ones, (3) the human aspect of being a clinician, (4) the multidisciplinary collaboration, and (5) the contextual preconditions. Most studies seemed focused on communication about treatment decision making.

Conclusion

A patient-centered approach seems lacking when clinicians discuss the patient's VWN, since most studies focused on treatment decision making rather than on the exploration and monitoring of the multidimensional well-being of patients. This review emphasizes the need for the development and integration of a systematic approach to explore and monitor the patients' VWN to improve appropriate palliative care in hospitals.

Effects of Music Therapy on Spiritual Well-Being among Patients with Advanced Cancer in Palliative Care: A Meta-Analysis of Randomized Controlled Trials

PURPOSE

Patients with advanced cancer in palliative care often experience physical and psychological symptoms that negatively impact their quality of life (QoL) and spiritual well-being. Music therapy can be used for symptom management in these patients. However, the effectiveness is uncertain. To determine the effectiveness of music therapy on spiritual well-being, QoL, pain, and psychological distress using randomized controlled trials (RCTs).

DATA SOURCE

A systematic search was conducted in EMBASE, PubMed, Cochrane Library, CINAHL, Web of Science, and the ClinicalTrial.gov registry up to September 2022.

CONCLUSION

The meta-analysis included seven RCTs with a total of 747 advanced cancer patients. Music therapy was found to significantly improve spiritual well-being with a mean difference of 0.43 (95% CI: 0.25 to 0.61, P < .001) in the intervention group compared to the control group. However, no significant group differences were found between the intervention and control groups for QoL (SMD: 0.53, 95% CI: -0.12 to 1.13, P = .11), pain (MD: -0.81, 95% CI: -2.06 to 0.44, P = .20), and psychological distress (SMD: -0.05, 95% CI: -0.41 to 0.32, P = .81). Music therapy can effectively improve the spiritual well-being of palliative care patients. However, its beneficial effects on QoL, pain, and psychological distress were minimal.

IMPLICATIONS FOR NURSING PRACTICE

Music therapy interventions can be introduced to help patients deal with spiritual/existential needs. Future studies should identify optimal characteristics of music therapy interventions to aid in enhancing the quality of palliative care for patients with advanced cancer.

The integrated process model of loss and grief - An interprofessional understanding

Despite the vast developments in research on loss and grief, dominant grief models fall short in reflecting the comprehensive issues grieving persons are facing. Three causes seem to be at play: grief is usually understood to be connected to death and other types of loss are under-researched; the majority of research is done from the field of psychology and on pathological forms of grief, hardly integrating research from other disciplines; and the existential suffering related to grief is not recognized or insufficiently integrated in the dominant models. In this paper, we propose an integrated process model (IPM) of loss and grief, distinguishing five dimensions of grief: physical, emotional, cognitive, social, and spiritual. The integrated process model integrates therapies, tools, and models within different scientific theories and paradigms to connect disciplines and professions. The comprehensive and existential understanding of loss and grief has relevance for research, clinical settings and community support.

The spiritual dimension of parenting a child with a life-limiting or life-threatening condition: A mixed-methods systematic review

BACKGROUND

Spirituality refers to the dynamic dimension of human life that relates to the way that persons experience meaning, purpose, and transcendence. The complex task of parenting a child with a life-limiting condition may raise existential questions, which are easily overlooked by healthcare professionals.

AIM

We explored how the spiritual dimension becomes manifest in parents of children in pediatric palliative care.

DESIGN

A mixed-methods systematic review was conducted, registered in Prospero (2021 CRD42021285318).

DATA SOURCES

PubMed, CINAHL, Embase, PsycInfo, and Cochrane were searched for articles published between January 1, 2015 and January 1, 2023. We included original empirical studies that reported on spirituality of parents of seriously ill children, from parents' perspectives.

RESULTS

Sixty-three studies were included: 22 North-American, 19 Asian, 13 European, 9 other. Studies varied in defining spirituality. We identified five different aspects of spirituality: religion, hope, parental identity, personal development, and feeling connected with others. All aspects could function as source of spirituality or cause of spiritual concern. Sources of spirituality helped parents to give meaning to their experiences and made them feel supported. However, parents also reported struggling with spiritual concerns. Several parents highlighted their need for professional support.

CONCLUSIONS

Although studies vary in defining spirituality, reports on spirituality focus on how parents connect to their faith, others, and themselves as parents. Healthcare professionals can support parents by paying attention to the spiritual process parents are going through. More research is needed into how healthcare professionals can support parents of seriously ill children in this process.

Advancing Trauma-Informed Care Education for Hospice and Palliative Staff: Development and Evaluation of Educational Videos

Nurses play an essential role in managing mental health conditions, such as posttraumatic stress disorder (PTSD), especially in rural areas where access to mental health care is limited. Posttraumatic stress disorder may emerge at the end of life and complicate health care and is a particular concern for aging Vietnam veterans. We describe the development of 3 videos that illustrate how to recognize PTSD, respond to trauma disclosures, and manage PTSD in cognitive impairment during an in-home hospice nurse visit. Through problem identification and needs assessment, we identified 6 goals and 28 specific content objectives presented through cinematic action with flashbacks or voice-over narration with graphics. Videos were evaluated through a survey (N = 155) and analysis of "chat" responses (N = 186) to targeted questions during a webinar presentation to clinicians (N = 345). Approximately 75% rated videos as "very much" relevant to needs, having helped learn something new, and realistic. Analysis of chat responses showed videos conveyed most content objectives (92%). In addition, participants stated videos were helpful in demonstrating nursing skills of listening, responding, and displaying empathy, as well as showing case presentations involving cognitive impairment and the patient experience. Participants expressed a desire for longer videos/more information including a wider range of PTSD presentations and comorbidities.

Factors Associated With Distress Related to Posttraumatic Stress Disorder at the End of Life Among U.S. Veterans

CONTEXT

Posttraumatic stress disorder (PTSD) may emerge or re-emerge at end of life (EOL), increasing patient suffering. Understanding factors associated with PTSD at EOL may assist clinicians in identifying high risk veterans.

OBJECTIVES

To determine rates of and variables associated with PTSD-related distress at EOL.

METHODS

Retrospective observational cohort study including veterans who died within a Veterans Affairs (VA) inpatient setting between October 1, 2009 and September 30, 2018 whose next-of-kin completed the Bereaved Family Survey (BFS; N = 42,474). Our primary outcome was PTSD-related distress at EOL, as reported by veteran decedents' next-of-kin on the BFS. Predictors of interest included combat exposure, demographic variables, medical and psychiatric comorbidity, primary serious illness, and palliative care support.

RESULTS

Veteran decedents were majority male (97.7%), non-Hispanic white (77.2%), 65 years or older (80.5%), without combat exposure (80.1%). Almost one in ten (8.9%) veteran decedents experienced PTSD-related distress at EOL. In adjusted analyses, combat exposure, younger age, male sex, and non-white race were associated with PTSD-related distress at EOL. High overall medical comorbidity, dementia, and psychiatric comorbidities including both substance use disorder and depression, were also associated with PTSD-related distress at EOL. Palliative care consultation and emotional support were associated with decreased odds of PTSD-related distress, while pain was associated with increased odds of PTSD-related distress at EOL.

CONCLUSION

Trauma and PTSD screening, pain management, and providing palliative care and emotional support at EOL, particularly in at-risk groups such as veterans from racial/ethnic minority backgrounds and those with dementia, are critical to decreasing PTSD-related distress at EOL.

Total pain and social suffering: marginalised Greenlanders' end-of-life in Denmark

With a focus on socially marginalised Greenlanders in Denmark, this study explores the significance of the concept of social suffering for the concept of total pain. Greenland is a former Danish colony and Greenlanders retain the right to Danish citizenship with all the benefits of access to the resources of Denmark as any other Danish citizen. However, Greenlanders are overrepresented amongst the most socially disadvantaged in Denmark. They have a disproportionately high risk of early death, often undiagnosed and untreated. This study reports on research conducted with socially marginalised Greenlanders and some of the professionals who work with them. It interrogates the concept of total pain as developed by Cicely Saunders, the founder of modern palliative care. Saunders noted that pain at the end-of-life was not adequately explained by symptoms of a disease process because it was more like a situation that engulfed every aspect of the patient and those close to them; it included physical, psychological, spiritual, and social dimensions. We agree with other scholars that the social dimension of the total pain experience is underexplored. By drawing on the theoretical and methodological lens of intersectionality, our work with marginalised Greenlanders has enabled us to describe the multiple and intersecting social forces that create social suffering for this group. This leads us to conclude that social suffering is not entirely an individual experience but a product of social harm and disadvantage, poverty, inequality, and the various legacies of colonialism, which combine to place some citizens in a harmed condition. Our findings also draw us into a discussion with the concept of total pain and its neglect of the socially constructed nature of social suffering. We conclude by indicating ways in which the concept of total pain can be informed by a more thoroughgoing concept of social suffering. We conclude, with others, that there is a problem of inequity in the way that end-of-life care is currently distributed. Finally, we point to ways in which an understanding of social suffering can help to address the exclusion of some of the most vulnerable citizens from appropriate end-of-life care.

Ponderings, Pleas and Prayer: A Qualitative Content Analysis of Danish Hospital Chapel Guest Books

In Denmark, religious behavior is usually very private. Little is known of religious and spiritual needs of patients and family during critical illness and hospitalization. We aimed to explore contemporary thoughts and prayers related to critical illness and hospitalization expressed in hospital chapel Guest Books. Qualitative content analysis of written texts was performed on Guest Books completed from 2005-2019. We identified the main themes of health and illness, life and death, and science and religion. Visitors welcomed the Guest Books as a place to express religious and spiritual thought, even in a nominally nonreligious society.

Adaptation and psychometric evaluation of the Chinese version of the functional assessment of chronic illness therapy spiritual well-being scale among Chinese childhood cancer patients in China

Background

Spiritual well-being is a strength for childhood cancer patients to cope with cancer. The availability of a valid and reliable instrument for assessing spiritual well-being is crucial. This study translated and adapted the Functional Assessment of Chronic Illness Therapy Spiritual Well-being scale (FACIT-Sp) for Chinese childhood cancer patients and examined the psychometric properties and factor structure in this population.

Methods

This was a methodological study. The FACIT-Sp was translated into Chinese. Adaptation was based on our qualitative study. For psychometric evaluation, a convenience sample of 412 were recruited based on the suggested sample size for the exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Childhood cancer patients were included if they aged 8-17 years, with parental consent to participate, able to communicate that they were being treated for cancer, and able to communicate and read Chinese. Participants answered the Chinese version of the adapted FACIT-Sp, the Center for Epidemiology Studies Depression Scale for Children (CES-DC), and the Pediatric Quality of Life Inventory 3.0 Cancer Module (PedsQL). Content validity, convergent validity, internal consistency and test-retest reliability were examined. Both EFA and CFA assessed the structural validity of the adapted FACIT-Sp.

Results

The content validity index values for items ranged 0.8-1.0 and that for the scale was 0.84, indicating appropriate content validity. The scale had good internal consistency, with a Cronbach's alpha of 0.815. The FACIT-Sp scores positively correlated with the CES-DC scores, and negatively correlated with PedsQL scores, suggesting that the Chinese version of the adapted FACIT-Sp had reasonable convergent validity. EFA yielded a four-factor (meaning, peace, faith, and connection with others) model. The CFA results revealed that the four-factor model achieved a better fit than the original three-factor model (Chi-Square Mean/Degree of Freedom = 2.240 vs. 3.557, Comparative Fit Index = 0.953 vs. 0.916, Goodness of Fit Index = 0.909 vs. 0.884, Root Mean Square Error of Approximation = 0.078 vs. 0.112).

Conclusion

The Chinese version of the adapted FACIT-Sp is a reliable and valid instrument for assessing spiritual well-being among Chinese childhood cancer patients. This instrument can be applied in clinical settings for routine assessment.

Identifying, exploring and integrating the spiritual dimension in proactive care planning: A mixed methods evaluation of a communication training intervention for multidisciplinary palliative care teams

BACKGROUND

Patients receiving palliative care value attention given to their spiritual needs. However, these needs often remain unexplored as healthcare professionals lack the skills to identify and explore them and to integrate this information into care plans.

AIM

To evaluate the effects of an interactive communication training intervention for palliative care teams in order to identify and explore the spiritual dimension and integrate it in patients' care plans.

DESIGN

A mixed methods pre-post study, including self-assessment questionnaires, evaluation of videos with simulated consultations (applied competence) and medical record review (implementation).

SETTING/PARTICIPANTS

Three palliative care teams including nurses (N = 21), physicians (N = 14) and spiritual caregivers (N = 3).

RESULTS

The questionnaires showed an improvement on 'Patient and family-centred communication' of the End-of-life professional caregiver survey (+0.37, p < 0.01; the 8-item S-EOLC (+0.54, p < 0.01) and regarding the Spiritual Care Competence Scale, on the three subscales used (+0.27, p < 0.01, +0.29, p < 0.01 and +0.32, p < 0.01). Video evaluations showed increased attention being paid to patient's aims and needs. The medical record review showed an increase in anticipation on the non-somatic dimension (OR: 2.2, 95% CI: 1.2-4.3, p < 0.05) and, using the Mount Vernon Cancer Network assessment tool, addressing spiritual issues (OR: 10.9, 95% CI: 3.7-39.5, p < 0.001).

CONCLUSIONS

Our training intervention resulted in increased palliative care professionals' competence in identifying and exploring patients' spiritual issues, and their integration in multidimensional proactive palliative care plans. The intervention directly addresses patients' spiritual concerns and adds value to their palliative care plans.

Resident physician outlook on death, dying and end-of-life care during the COVID-19 pandemic: effect of religion and burnout

OBJECTIVES

Religion and spirituality are important aspects of many physicians and patients' lives and may impact their views of death and the way they interact with terminally ill patients, specifically comfort discussing end-of-life care and death and dying. This study explores the religious and spiritual beliefs of resident physicians, if they affect interactions with their patients and if burnout impedes this interaction.

METHODS

A 28-item questionnaire was administered to residents and fellows at an urban academic hospital.

RESULTS

65 residents and fellows answered the survey. Religiosity but not spirituality correlated with reported comfort interacting with patients dealing with death or dying. Resident specialty, biological sex and spirituality were not associated with comfort and conversations about religion and end-of-life care. The majority (60%) reported that the pandemic has not affected how they speak to their patients about death and dying. Caring for a higher volume of terminally ill patients was not associated with high levels of burnout though 71% reported increased burnout due to COVID-19.

CONCLUSION

Further research can be done to determine whether additional training or resources should be provided to resident physicians to cope with death and dying in the setting of a pandemic.

A Descriptive and Phenomenological Exploration of the Spiritual Needs of Chinese Children Hospitalized with Cancer

Spiritual well-being is the fourth dimension of health, as equally important as physical, mental, and social well-being. The shadow of death associated with cancer triggers children to explore their personal values, meanings, and life goals throughout the illness trajectory, enabling them to identify their unique spiritual needs. Chinese children are generally non-religious, unlike Western children, which affects their spiritual needs. To address the literature gaps, we applied a qualitative, descriptive, phenomenological approach for exploring the spiritual needs of Chinese children hospitalized with cancer. Purposive sampling was conducted in two public hospitals with special wards for pediatric oncology patients in Hunan Province, China. Consequently, 22 children, hospitalized with cancer, were recruited and individually interviewed using a semi-structured interview format. We conducted a thematic analysis of the interview transcripts. Four important themes were identified: the need for self-exploration, inner needs, need for a connection with others, and need for a connection with gods, supernatural powers, and fictional characters. We found that culture significantly influenced the spiritual needs of Chinese children with cancer. Hope was a key factor motivating the children to continue cancer treatment. To address their unique spiritual needs, culturally specific interventions should be developed and incorporated into their care to enhance their spiritual well-being.

"My life became more meaningful": confronting one's own end of life and its effects on well-being-a qualitative study

Background

The perception of being closer to death can be experienced due to old age or life-limiting diseases, and can pose profound existential challenges. Actively confronting death-related issues and existential questions may increase psychosocial comfort and stimulate personal growth, whereas dysfunctional coping may lead to existential distress.

To date, research on individual and (semi-)professional approaches to confronting the own end of life and the effects on one’s well-being remain scarce. Therefore, the aim of this study was to explore individual strategies and wishes in order to derive ideas for appropriate support concepts.

Methods

Twenty semi-structured interviews were conducted with people over the age of 80 (n = 11) and with a life-limiting disease (n = 10). The interviews were transcribed verbatim and independently coded by two researchers according to Braun and Clarke's thematic analysis approach.

Results

While the use of (semi-)professional approaches (e.g., therapeutic support) to confronting existential questions in the shape of one’s impending death was rare, individual coping strategies did have a positive impact on psychosocial comfort. There were hardly any significant differences between the participants aged 80 and over and those with a life-limiting disease in terms of individual coping strategies or how they approached the ends of their lives. Both groups reported that theoretical education, preparing for the ends of their lives (e.g., funerals), talking about death-related topics, reflecting on death-related topics, and contemplating death in a spiritual sense had positive effects on their assurance, self-determination and relief. The necessity of confrontation and a desire for low-threshold, accessible and flexible services to meet their existential and spiritual needs were highlighted.

Conclusions

There is both a desire and a need for the addressing of existential questions. Outside of private contexts, however, the participants possessed little awareness of support services that focused on confronting end-of-life issues, and rarely used such services. Efforts to raise awareness for psychosocial and spiritual needs should be implemented within the care system, together with low-threshold support concepts, in order to increase psychosocial well-being. More research evaluating individual approaches to confronting the own end of life are needed to better understand this determinant of well-being and its mechanisms of action.

Trial registration

www.germanctr.de, DRKS-ID: DRKS00020577.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00950-3.

Spiritual Care in Palliative Care: A Physician’s Perspective

Palliative care is defined as ‘an approach that improves the quality of life of patients and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through identification, assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual’. As a palliative care physician, I aim to explore and meet the needs of my patients and their loved ones. As I am specifically trained as a specialist in assessing and treating ‘pain and other physical symptoms’, in psychological, social and spiritual issues, I am a generalist. Two approaches are described to assess spiritual needs in palliative care: The first is adjoining the analytic concept of the four dimensions of palliative care: using an instrument, measuring spiritual well-being or spiritual needs, and measuring the quality of life, with specific attention to spiritual issues. Second, a holistic approach is promoted, with openness to the patients’ narrative of their life, disease and suffering. In the integrity of the clinical encounter, medical, ethical and spiritual issues may be discussed. Broadening our clinical language with ethical, psychosocial, and spiritual vocabulary is mandatory, and self-reflection, interdisciplinary collaboration and specific interdisciplinary training may be supportive to develop such a clinical language.

Hospice and palliative care clinicians' perceptions of posttraumatic stress disorder at end-of-life in military veterans

At the end of life, individuals may re-engage with earlier life trauma as they reflect on life experiences and confront their mortality. As such, posttraumatic stress disorder (PTSD) symptoms at the end of life may worsen the quality of death experience. This is a concern for military veterans, who tend to have more trauma exposures and higher rates of PTSD, and particularly for veterans receiving care in rural areas where access to PTSD specialty services is limited. To better understand this issue, we conducted 10 focus groups with clinicians serving veterans in rural communities across five U.S. states. The aims of this project were to evaluate: (1) do hospice and palliative care providers/staff observe PTSD symptoms in veterans at the end of life? (2) if so, how are symptoms similar to and different from existing DSM-5 criteria for PTSD? We used qualitative content analysis with mixed deductive and inductive approaches to code 151 anonymized statements. Analyses found descriptions of PTSD symptoms aligned broadly with existing diagnostic nomenclature, but descriptions revealed specific presentations relevant to the end of life setting such as resistance to care, agitation, restlessness, and effects of delirium. In addition, some veterans expressed pride in service and openness to discussing military experiences. Further, clinicians noted that PTSD symptoms were relevant to family dynamics. Future research should further characterize these symptom differences through direct patient assessment and develop resources to improve quality of death experience for veterans with PTSD symptoms.