Elsevier

The Lancet

Volume 361, Issue 9369, 10 May 2003, Pages 1603-1607
The Lancet

Articles
Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients

https://doi.org/10.1016/S0140-6736(03)13310-7Get rights and content

Summary

Background

The importance of spirituality in coping with a terminal illness is becoming increasingly recognised. We aimed to assess the relation between spiritual well-being, depression, and end-of-life despair in terminally-ill cancer patients.

Methods

160 patients in a palliative care hospital with a life expectancy of less than 3 months were interviewed with a series of standardised instruments, including the functional assessment of chronic illness therapy—spiritual well-being scale, the Hamilton depression rating scale, the Beck hopelessness scale, and the schedule of attitudes toward hastened death. Suicidal ideation was based on responses to the Hamilton depression rating scale.

Findings

Significant correlations were seen between spiritual well-being and desire for hastened death (r=−0·51), hopelessness (r=−0·68), and suicidal ideation (r=−0·41). Results of multiple regression analyses showed that spiritual well-being was the strongest predictor of each outcome variable and provided a unique significant contribution beyond that of depression and relevant covariates. Additionally, depression was highly correlated with desire for hastened death in participants low in spiritual well-being (r=0·40, p<0·0001) but not in those high in spiritual well-being (r=0·20, p=0·06).

Interpretation

Spiritual well-being offers some protection against end-of-life despair in those for whom death is imminent. Our findings have important implications for palliative care practice. Controlled research assessing the effect of spirituality-based interventions is needed to establish what methods can help engender a sense of peace and meaning.

Introduction

The importance of spirituality as a central component of psychological well-being is increasingly recognised by doctors and mental-health professionals.1, 2 Among the medically and terminally ill in particular, patients struggle with questions about their mortality, the meaning and purpose of life, and whether a greater power exists, forcing them to grapple with issues they had previously ignored. Kearney and Mount stated that spiritual issues “lie at the very centre of the existential crisis that is terminal illness”.1 Spirituality is perhaps best defined as “the way in which people understand their lives in view of their ultimate meaning and value”.3 Many patients turn to religion for answers to these difficult questions, but others find support through their spiritual beliefs outside the context of organised religion.

Growing data have provided empirical support for the hypothesis that spiritual well-being might help to bolster psychological functioning and adjustment to illness. Results of several studies of medically-ill patients show a strong inverse relation between spiritual well-being—ie, a sense of meaning and purpose in life, faith, and comfort with existential concerns—and depression.4, 5, 6 Coward7 noted that her self-transcendence intervention provided important benefits for a group of women with breast cancer. In studies of physically healthy individuals, similar results have been reported, suggesting that spiritual well-being is a central component of psychological health.8

Because psychological distress happens frequently at the end of life, maintenance or development of a sense of spiritual well-being might be a crucial aspect of coping with terminal illness. Feelings of depression, hopelessness, and anxiety are common reactions of individuals as they approach the terminal phase of an illness.9 Whereas many patients manage to avoid feeling distressed as they approach death, others have a great sense of despair during their final weeks or months of life. End-of-life despair could manifest itself as general feelings of hopelessness or demoralisation, or in the extreme might develop into a desire for hastened death or thoughts of suicide. Although results of studies of terminally-ill populations consistently show a higher risk of suicide, hopelessness, and desire for hastened death than for the general population,10, 11 the link between spiritual well-being and end-of-life despair has not been assessed in the context of other, potentially relevant, effects.

On the other hand, the link between depression and desire for hastened death, suicidal ideation, and hopelessness is consistently seen in studies of medically-ill and terminally-ill individuals. For example, results of studies in cancer patients show that depression is significantly associated with desire for hastened death,10, 12 hopelessness,13 and suicidal ideation.14 In studies of patients with AIDS and amyotrophic lateral sclerosis, researchers have noted closely similar findings,15 lending support to the important role of depression in end-of-life despair.

Unlike these studies of depression, systematic research addressing the relation between spiritual well-being and end-of-life despair is virtually absent. Results of a few studies report an association between spiritual well-being and a sense of hope in the context of a medical illness;6, 16, 17 however, the relation between spiritual well-being and either desire for hastened death or suicidal ideation has rarely been studied. In one of the few such studies, Breitbart and colleagues reported that spiritual well-being was significantly correlated with desire for hastened death in terminally-ill cancer patients.10

The hypothesis that religion could deter people from suicide dates back to the 19th century.18 Results of several empirical studies have identified a relation between religious involvement and suicidal ideation;19, 20 however, these studies focused mainly on the amount of religious affiliation rather than spirituality per se. We aimed to assess the relations between spiritual well-being and end-of-life despair in a large sample of terminally-ill cancer patients. In particular, we sought to investigate the role of spiritual well-being relative to that of other potential effects, such as depression, physical symptoms, and social support, in prediction of hopelessness, desire for hastened death, and suicidal ideation.

Section snippets

Participants

Study participants were recruited shortly after admission to a palliative care hospital in New York, NY, USA. Recruitment took place between December, 2000, and June, 2002. All participants were diagnosed with cancer and had a life expectancy of less than 3 months. To be eligible for study participation, we first asked individuals to complete a brief cognitive assessment with the mini-mental state examination (MMSE).21 Those who obtained a score of 19 or less were excluded from the study

Results

During the 18-month study period, 3212 patients were admitted for end-of-life care. Of these, 2352 (73%) were ineligible to participate because severity of their medical disorder precluded provision of meaningful informed consent or study data—eg, they were comatose, severely cognitively impaired, or otherwise too ill to participate— or they died almost immediately after admission. Of the remaining 868 patients who underwent the cognitive screening test (MMSE), 266 scored less than 20 and were

Discussion

Results of our study show spiritual well-being was a strong correlate of end-of-life despair, providing a unique contribution to the prediction of hopelessness, desire for hastened death, and suicidal ideation even after controlling for the effect of depressive symptoms and other relevant variables. Although much research addressing psychological adjustment in terminal illness has focused on depression, spiritual well-being might be a more powerful effect. In fact, in virtually every analysis,

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