REVIEW

CURRENT
OPINION The supportive roles of religion and spirituality in
end-of-life and palliative care of patients with
cancer in a culturally diverse context: a literature
review
Hector E. Lopez-Sierra a and Jesus Rodrguez-Sanchez b

Purpose of review
This is a literature review of the supportive roles of religion and spirituality (R/S) in end-of-life (EoL) and
palliative care of patients with cancer in a culturally diverse context. This review examines 26 noteworthy
articles published between August 2013 and August 2014 from five well supported databases.
Recent findings
Current evidence shows that R/S evokes in patients the sources to find the necessary inner strengths, which
includes perspective thinking, rituals for transcending immediate physical condition and modalities of
coping with their oncological illnesses. R/S are not a monolithically experience for they always manifest
themselves in diverse cultural settings. As such, R/S provide the individual and their families with a
practical context and social memory, which includes traditions and social family practices for maintaining
meaning and well-being. Nonetheless, although various dimensions of R/S show a link between cancer risk
factors and well being in cancer patients, more specific dimensions of R/S need to be studied taking into
account the individuals particular religious and cultural contexts, so that R/S variables within that context
can provide a greater integrative structure for understanding and to move the field forward.
Summary
Behavioral, cognitive and psychosocial scientists have taken a more in-depth look at the claims made in the
past, suggesting that a relationship between R/S, cultural diversity and health exists. Case in point are the
studies on EoL care, which have progressively considered the role of cultural, religion and spiritual diversity
in the care of patients with oncological terminal illnesses. Beyond these facts, this review also shows that
EoL supportive and palliative care providers could further enhance their practical interventions by being
sensitive and supportive of cultural diversity.
Video abstract
http://links.lww.com/COSPC/A10
Keywords
cultural diversity, death and dying, EoL cancer patients supportive care, religion, spirituality, transcendence

INTRODUCTION ethnicity, belief systems, ages, behaviors, among

Psychiatrist Elizabeth Kubler-Ross (19262004), in
her book, On death and dying, elaborated what
popularly came to be known as the crisis stages of
the terminally ill patient [1]. Although most con-
temporary scholars initially questioned and resisted
Kubler-Ross theory, her model has survived her
critics and her popular stages on death and dying
have permeated most disciplines to this day [2]. The
papers reviewed in this article show that although
Kubler-Ross stage model reached immense popular-
ity, its universal claims did not consider key vari-
ables such as the role of cultural diversity, sex,
other key variables, which are deemed significant
a
Social Sciences and Liberal Arts Department and bSchool of Theology,
Inter-American University of Puerto Rico, Metropolitan Campus, San
Juan, Puerto Rico, USA
Correspondence to Hector E. Lopez-Sierra, PhD, Professor of Sociology,
Social Sciences and Liberal Arts Department, Inter-American University
of Puerto Rico, Metropolitan Campus, P.O. Box 191293, San Juan,
PR 00919-1293, USA. Tel: +1 787 644 1785; fax: +1 787 250 0782;
e-mail: hlopez@intermetro.edu
Curr Opin Support Palliat Care 2015, 9:8795
DOI:10.1097/SPC.0000000000000119

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Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

Supportive care and psychological issues around cancer
KEY POINTS

Different cultures can provide the necessary social
networks and cultural practices that can assist patients
receiving EoL care.

Healthcare providers with patients receiving EoL care
can tap into the patients social networks and cultural
practices to enhance their care.

R/S in general have a positive outlook on EoL care.

R/S provide patients receiving EoL care with inner
strengths and the means of transcendence.
today in the scientific understanding of EoL and the
palliative care process of patients with cancer. Thus,
the purpose of this review, as shown in Table 1, is to
provide an updated overview of the role of religion
and spirituality (R/S) in EoL and palliative care of
patients with cancer in a cultural diverse context.
CONCEPTUAL DEFINITIONS
Supportive and palliative care describes the process
which improves the quality of life (QoL) of cancer
patients and their families in its culturally diverse
context [3]. Cultural diversity can be understood as
the embodiment of uniqueness and plurality of
identities and worldviews of groups and societies
making up humankind [4].
METHOD
A simple systematic search of peer-reviewed litera-
ture published from August 2013 through August
2014 in standard databases [Medline, EBSCO, Psyc-
INFO (OVID) and Google Scholar] was undertaken
using a combination of relevant terms. The search
was limited to articles published in English. The
articles were selected after applied recognition of
significant terms approach to papers abstract and
conclusions.
REVIEW PAPERS
As Table 2 shows, the 26 articles reviewed addressed
directly the relationship between culture, R/S as
three significant variables with a direct impact on
EoL care of patients with cancer. However, although
some articles focused on all three variables simul-
taneously, some focused on others. Nonetheless, it
should be noted that the articles that did not address
directly a given variable did so indirectly. That is,
although some focused primarily on the role of R/S
alone, implicitly they also focus on cultural
88 www.supportiveandpalliativecare.com
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diversity, being that they were speaking from a
specific cultural context. In light of Table 2, and
the previous comments above, it can be said that
the 26 articles fall into two main categories as
follows.
Articles supporting the roles of cultural
diversity, R/S in EoL and palliative care
Within this domain, and speaking from the African-
&&
American perspective, Shores [9 ] studied the
spiritual interventions and the impact of a faith
community nursing program in an African-
American community and found that the faith
community nursing program studied was a key
connection between the spiritual and physical
health or among the body, mind and spirit. Thomp-
&&
son et al. [10 ] studied the utility of cancer-related
cultural constructs to understand colorectal cancer
screening among African-Americans. The study con-
cludes that the Multiconstruct African American
Cultural Survey, identified through item response
theory analyses, can be used by community health
researchers interested in determining the relevance
of cultural constructs, which considers the role of
R/S in the design and implementation of colorectal
cancer screening programs in the African-American
community.
&
In a case study report, Borneman et al. [11 ]
presents an ethnic/cultural Jew suffering a life-
threatening illness of advanced lung cancer who
reflected Jewish religious and spiritual values and
ideas; nonetheless, the patient did not subscribed to
the notion of a personal God who cares about each
individual. This case study illustrates the broad
differences in beliefs among Jews and suggests
that clinicians/chaplains should not make assump-
tions based upon the patients identification as
Jewish.
Taking into account the role of cultural diversity
&&
(or community) and R/S, Balboni et al. [12 ] found
that terminally ill patients who are well supported
by religious communities access hospice care less
and aggressive medical interventions more near
death, whereas spiritual care and EoL discussions
by the medical team reduced aggressive treatment,
highlighting spiritual care as a key component of
EoL medical care guidelines. Broadening the con-
&
cept of community support, Barrera [13 ] studied
the meaning and role of hope in parents of children
with life-threatening illnesses. The ethnic demo-
graphic variables considered in this study were
Canadian, African, Middle Eastern and Aboriginal.
The finding suggests that focusing on positive out-
comes and experiences, spirituality and social
support facilitated being hopeful.
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Supportive roles of R/S in EoL care of patients with cancer in culturally diverse context Lopez-Sierra and Rodrguez-Sanchez

Table 1. Studies included in the literature review

First author Date Publication Population Sample Method and measures techniques

Balboni et al. 2013 JAMA Intern Religious communities influenced 343 Descriptive correlational study/multivari-
[12 ] Med with terminally ill patients and able regression analyses
&&

medical care and quality of life

near death
Barrera et al. 2013 Cancer Nurs Parents of children with life- 35 Qualitative description and analysis/
[13 ] threatening illnesses line-by-line coding of transcripts,
&

comparison was used to examine

relationships within and across codes
and categories and grounded theory
Borneman et al. 2013 J Palliat Care Ethnic/cultural Jews with a life- 1 Phenomenological case report studies/
[11 ] threatening illness of advanced case and clinical experience analysis
&

lung cancer
Darby et al. 2014a Cancer Nurs Parents of children with cancer 16 Descriptive correlational study/phenomen-
Pract ological study with semi-structured inter-
views with young and their parents, and
two focus groups with ward staff; eight
parents and eight oncology clinical staff
Darby et al. 2014b Cancer Nurs A study focused on spiritual and 17 Descriptive correlational study/semistruc-
Pract religious needs of young people tured interviews with nine young people
with cancer and eight onchology staff
Gaston- 2013 Oncol Nurs African American women with 17 Descriptive correlational study/Hospital
Johansson Forum breast cancer Anxiety and Depression Scale; Sense of
et al. [27 ] Coherence scale; Functional Assessment
&

of Chronic Illness Therapy

Spiritual Well Being, Brief Religious
Coping Inventory and Coping
Strategies Questionnaire
Hamilton et al. 2013 Oncol Nurs A study determining whether 77 Descriptive correlational study/Fishers
[32 ] Forum psychosocial factors predict exact and Wilcoxon rank-sum tests to
&

depression among older African levels of depression and multivariate

American patients with cancer linear regression statistics to identify
psychosocial factors predicting higher
depression scores
Hiruy et al. 2013 Nurs Ethics African patients and their families N/A Phenomenological case report
[16 ] in Australia study/case study
&&

Ho et al. [14 ] 2013 Age Ageing Older Chinese palliative care 16 Qualitative description and
&&

patients in Hong Kong analysis/Empirical Dignity Model

Holt et al. [26 ] 2014 Am J Health African Americans, with a focus 2370 Descriptive correlational/Religiosity Scale
&

Behav on the mediator of religious previously validated with African Amer-

coping win a national sample ican and Brief RCOPE (Religious coping)
scale
Jang et al. 2013 Psychooncol- Korean women with breast cancer 284 Descriptive correlational study/Duke
[15 ] ogy undergoing surgery Religious Index; MontgomeryAsberg
&&

Depression Rating Scale; Hospital

Anxiety Depression Scale, and the
European Organization for the Research
and Treatment of Cancer Quality of Life
Questionnaire Core 30 and the Mini
International Neuropsychiatric Interview
Kulkarni et al. 2014 Indian J A study in Pune, India, examining 3440 Descriptive correlational study/a survey
[28 ] Palliat provision of EoL care among the people around Pune above
&

Care the age of 18: 1457 men, 1983

women
Lee et al. [33 ] 2013 Prog Palliat A study exploring the experience 4 Descriptive correlational study/qualitative
&

Care of dignity in palliative care in interviews, semistructured interviews

Singapore with advanced
cancer and their primary family
caregiver

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Supportive care and psychological issues around cancer

Table 1 (Continued)

First author Date Publication Population Sample Method and measures techniques

Meisenhelder 2013 J Relig Health An ambulatory patients study 158 Descriptive correlational study/Hodges
et al. [20 ] comparing faith attitudes versus intrinsic religious motivation scale,
&

behaviors for their relationship Benson & Spilkas concept of God scale
to mental health in current
cancer patients and survivors
Newberry et al. Oncol Nurs A longitudinal study of a sample Descriptive correlational study/face-to-face
[25 ] Forum of 50 family caregivers of or telephone interviews
&

patients with primary malignant

brain tumors, who experienced
changes in their perceived level
of spirituality along the course
of the disease trajectory
Paiva et al. [5 ] 2013 J Relig Health Brazilian breast cancer patients 27 Descriptive correlational study/Brazilian
&

during chemotherapy Religious Practice Questionnaire

Pedersen et al. 2013 J Relig Health Prevalence of religious faith 3128 Descriptive correlational study/Statistical
[6 ] among Danish women with analysis, SPSS 16.0.1
&

breast cancer
Penman et al. 2013 Int J Nurs Explicates the essence of spiritual 14 Qualitative description and analysis/in-
[24 ] Pract engagement from the perspect- depth interviews employing Van Man-
&

ive of palliative care clients and ens hermeneutic phenomenological

their caregivers approach
Pessagno et al. 2013 Omega 3rd and 4th year medical students 20 Qualitative description and analysis/
[23 ] in the US confronting patient NVivo8 qualitative software, techniques
&

loss from interpretative phenomenological

and grounded theory analyses
Peteet et al. 2013 CA Cancer J Analysis of the role of spirituality 1 Qualitative description and analysis
[19 ] Clin and religiosity in adjusting to
&

cancer treatment
Qualitative description and analysis/narra-
tive analysis
Razban et al. 2013 Int J Palliat Oncology and ICU nurses from 140 Descriptive correlational study/a self-admi-
[17 ] Nurs three hospitals in south-east nistered questionnaire
&

Iran, Kerman University of

Medical Science
Seibaek et al. 2013 Evid Based Danish women who underwent 10 Phenomenological case report study/qual-
[7 ] Comp- final diagnostics, surgery and itative research interviews
&

lement chemotherapy for ovarian

Alternat cancer
Med
Selman et al. 2013 Health Qual Patients with advanced cancer in 284 Descriptive correlational study/African Pal-
[34 ] Life Out- sub-Saharan Africa liative Outcome Scale
&

comes
Shores [9 ] 2014 Issues Ment Faith community members, clergy 52 Qualitative description and analysis/Roy
&&

Health representatives and faith com- Adaptation Model; 35 faith community,

Nurs munity nurses with a researcher- members, six clergy representatives and
developed demographic tool 11 faith community nurses
Thompson et al. 2013 J Public Colorectal cancer screening pro- 1021 Descriptive correlational study/29 items of
[10 ] Health Res grams in the African-American the Multiconstruct African American
&&

community Cultural Survey, identified through item

response theory (IRT) analyses; 683
women, 338 men
Thune-Boyle 2013 Psychooncol- UK woman newly diagnosed with 125 Descriptive correlational study/Likert scales
et al. [8 ] ogy breast cancer
&

Wright et al. 2014 BMJ EoL analysis of medical care after 386 Descriptive correlational study/Secondary
[30 ] death of patients analysis of a prospective, multiinstitution,
&

longitudinal study of patients who died

of advanced cancer

EOL, end of life.

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Supportive roles of R/S in EoL care of patients with cancer in culturally diverse context Lopez-Sierra and Rodrguez-Sanchez

Table 2. Articles addressing and/or supporting the roles of culture, R/S in EOL care

Cultural
First author Date Publication diversity R/S Country of origin

Balboni et al. [12 ] 2013 JAMA Intern Med X X USA

&&

Barrera [13 ] 2013 Cancer Nurs X X Canada

&

Borneman et al. [11 ] 2013 J Palliat Care X USA

&

Darby et al. 2014a Cancer Nurs Pract X UK

Darby et al. 2014b Cancer Nurs Pract X UK
Gaston-Johansson et al. [27 ] 2013 Oncol Nurs Forum X USA
&

Hamilton et al. [32 ] 2013 Oncol Nurs Forum X X USA

&

Hiruy et al. [16 ] 2013 Nurs Ethics X X Australia

&&

Ho et al. [14 ] 2013 Age Ageing X X China

&&

Holt et al. [26 ] 2014 Am J Health Behav X X USA

&&

Jang et al. [15 ] 2013 Psychooncology X X Korea

&&

Kulkarni et al. [28 ] 2014 Indian J Palliat Care X X India

&

Lee et al. [33 ] 2013 Prog Palliat Care X X Singapore

&

Meisenhelder et al. [20 ] 2013 J Relig Health X USA

&

Newberry et al. [25 ] 2013 Oncol Nurs Forum X X USA

&

Paiva et al. [5 ] 2013 J Relig Health X Brazil

&

Pedersen et al. [6 ] 2013 J Relig Health X Denmark

&

Penman et al. [24 ] 2013 Int J Nurs Pract X Australia

&

Pessagno et al. [23 ] 2013 Omega X USA

&

Peteet et al. [19 ] 2013 CA Cancer J Clin X USA

&

Razban et al. [17 ] 2013 Int J Palliat Nurs X X Iran

&

Seibaek et al. [7 ] 2013 Evid Based Complement X Denmark

&

Alternat Med
Selman et al. [34 ] 2013 Health Qual Life Outcomes X X South Africa
&

and Uganda
Shores [9 ] 2014 Issues Ment Health Nurs X X USA
&&

Thompson et al. [10 ] 2013 J Public Health Res X X USA

&&

Thune-Boyle et al. [8 ] 2013 Psychooncology X UK

&

Wright et al. [30 ] 2014 BMJ X X USA

&

EOL, end of life; R/S, religion and spirituality.

&&
Ho et al. [14 ] argues that in the Chinese
cultural context, living and dying with dignity man-
ifested differently than in other cultures, for a sense
of generativity/legacy, resilience/fighting spirit,
enduring pain, moral transcendence, spiritual sur-
render and transgenerational unity are themes
engrained in Chinese society. From the Korea point
&&
of view, Jang et al. [15 ] examine the role of reli-
giosity, depression and QoL in Korean patients with
breast cancer subscribed to the Buddhist, Catholic
and Protestant faith traditions and argue that the
religious groups did not differ significantly with
respect to the prevalence of depression or scores
on psychiatric measures at either baseline or 1 year.
Hence, Jang et al. argue that religiosity plays an
important role in the emotional state and QoL of
Korean women with breast cancer. However, its
clinical meaning may differ according to the type
of religious affiliation and the stage of illness.
&&
Hiruy et al. [16 ] article on a phenomenological
case study of EoL cancer patient provides insights
into the sociocultural EoL experiences of Africans
in Australia and their interaction with the health
services in general and EoL care in particular.
It considers an ethical, religious and spiritual
framework that includes Afro-communitarian
ethical principles to enhance the capacity of current
health services to provide culturally appropriate
care.
From a culturally informed educational process,
Razban et al. analyzed the nursing and medical
science discipline attitudes toward general palliative
care in southeast Iran. Findings suggest that edu-
cational designers should include specific courses
and clinical experiences about death and palliative
care from a religious and cultural receptive perspect-
ive in undergraduate and postgraduate nursing and
& &
health care curricula [17 ,18 ].

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Supportive care and psychological issues around cancer
As noted earlier, although some articles primar-
ily focus on the role of religion and/or spirituality
alone, implicitly they also focus on cultural diver-
sity, being that they were speaking from a specific
cultural context. Thus, although the following
reviews could be analyzed under the next subhead-
ing, they also can be included under the category of
articles supporting the roles of cultural diversity and
R/S in EoL and palliative care, as follows.
& &
Paiva et al. [5 ] undertake a pilot study address-
ing the impact of religious practice on QoL of
Brazilian breast cancer patients during chemother-
apy and found that religious practices are signifi-
cantly associated with QoL. Thus, the study argues
that body image acceptance is positively correlated
with religious practice and specifically praying
activity, which suggests the importance of R/S in
coping with cancer chemotherapy.
&
Pedersen et al. [6 ] engaged in nationwide study
of faith among Danish and US women treated with
breast cancer in a secular society and concluded that
patients having unambiguous religious faith express
a markedly higher degree of certainty, which may
play a positive role in relation to the course of their
breast cancer and cancer-related QoL when com-
pared with women reporting ambiguous faith.
&
Seibaek et al. [7 ] also studied Danish women,
with a focus on diagnostics, surgery and chemo-
therapy of ovarian cancer. The study found that
although the women experienced their health to
be seriously threatened, they also felt hope, will and
courage amidst their despair. The women dealt with
this in a dialectical manner, so that hope and despair
could be present simultaneously. In the process,
secular, spiritual and religious existential meaning
orientations assisted the women in creating new
narratives while obtaining new orientations in life.
&
Thune-Boyle et al. [8 ] researched the role of R/S
coping resources and their relationship with adjust-
ment in patients newly diagnosed with breast cancer
in the UK. They found that using R/S resources in
the coping process during the early stages of breast
cancer may play an important role in the adjust-
ment process in patients with breast cancer.
&
Peteet et al. [19 ] examine a narrative story and
argue that although spirituality remains difficult to
precisely define, there is general agreement that it
refers to a connection with a larger reality that gives
ones life meaning, experienced through a religious
tradition or, increasingly in secular Western culture,
through meditation, nature or art. Hence, the study
concludes that spirituality is central to the experi-
ence of many patients with cancer and their fami-
lies, and most indicate a desire for help with their
&
spiritual needs. Similarly, Meisenhelder et al. [20 ]
compare faith attitudes versus behaviors and their
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relationship to mental health in current cancer
patients and survivors. The findings suggest that
breast cancer patients and survivors indicated the
importance of faith and frequency of prayer had no
relationship with mental health, whereas the con-
cept of God was a strong correlating factor. Thus,
patients who perceived a loving God had higher
mental health.
Also with an interest in staff caring for cancer
patients, Pessagno et al. [23 ] focused on medical
students experiences with patients death experi-
ences, the meaning of patients death and coping
with patients death. In relation to the three
main sections, the findings suggest that common
coping mechanisms included talking through their
emotions, thrusting themselves into continuing
their rounds, crying, participating in infant death
rituals and turning to religion.
In the same vein, Penman et al. examine the
relation of spiritual engagement in the caring proc-
ess as depicted by palliative care clients and staff of
caregivers. The findings support the phenomenon
of spiritual engagement, which entails distinct
actions such as maintaining relationships with
others, showing and receiving love, praying and
participating in other religious practices for spiritual
engagement was understood to be love in action
& &
[24 ,25 ].
From the African-American perspective, Holt
&&
et al. [26 ] focused on the role of religion and health
in this community and argue that religious beliefs
were associated with greater vegetable consump-
tion, which may be because of the role of positive
and negative religious coping, whereas negative
religious coping played a role in the relationship
between religious beliefs and alcohol consumption.
Taking into account the views of the people of
Pune, India, Kulkarni et al. analyzed the place of
death among his subjects applying a survey
approach. The study demonstrated that human
preferences are similar in many parts of the world,
and there are little differences in the preferences of
people when it comes to the desired place of death
& &
[28 ,29 ]. The study reveals that EoL preferences
(cancer patients included) are not influenced by
geography, politics, religion, economics, medical
facilities or culture. Although patients would like
EoL care at home, not all caregivers are comfortable.
Very often there is little congruence between the
wishes of the patients and those of caregivers.
&
Wright et al.s [30 ] aim was to analyze whether
acculturation influences patients EoL treatment
&
preferences and care [31 ]. Using The United
States Acculturation Scale, the variables of age,
ethnicity, education, health insurance, native
English language, nativity, cancer type, performance
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Supportive roles of R/S in EoL care of patients with cancer in culturally diverse context Lopez-Sierra and Rodrguez-Sanchez
status, religion, institution, survival and caregiver
relationships were considerate. The study suggests
that the scale is a reliable and valid measure associ-
ated with advanced cancer patients EoL preferences
and care.
&
Hamilton et al.s [32 ] descriptive correlational
study examines whether psychosocial factors pre-
dict depression among older African American
patients with cancer (see Table 1 of the cited article).
The study supports the empirical fact that signifi-
cant relationship of increased religious involvement
tend to decreased depressive symptoms being that
emotional support and organized religious activities
may represent protective factors against depression.
&
Lee et al. [33 ] engaged in qualitative interviews
with patients with advanced cancer and their
primary family caregiver from a home hospice
service and found that the experience of dignity
in palliative care in the Singapore context consists
of three factors: social factor; organizational factor
and private sector; and spiritual factor. Selman et al.
&
[34 ] undertook the concept of peace and life-
worth-while as distinct but related measures of
spiritual well-being in African palliative care.
Articles supporting the roles of R/S in EoL
and palliative care but not addressing
directly their relation with cultural diversity
& &
Paiva et al. [5 ], Pedersen et al. [6 ], Seibaek et al. [7 ],
&
and Thune-Boyle et al. [8 ], respectively, focused their
research on Brazilian, Danish and UK women with
breast cancer. In a study focusing on the spiritual and
religious needs of parents with young oncology
patients and the staff caring for the family, Darby
&
et al. [21 ] found that the spiritual needs of parents
included providing the necessary space to be heard
and share stories. Concerning the staff, although the
cumulative effect of loss while caring for child having
cancer is particularly difficult, the study shows that
having sufficient trust, empathy, warmth, accept-
ance and space can help the coping process.
&
In another study also by Darby et al. [22 ], they
analyzed the religious and spiritual needs of young
people with cancer. Their findings suggest that
young patients spiritual needs were classified under
personal issues, relationships and attitudes, and
environment, whereas religious needs were ident-
ified as hope, resilience, ritual and connection, use
of language and worldview. Thus, it is concluded
that young peoples spiritual and religious needs
should be assessed on an ongoing basis, with staff
being supported to undertake such assessment
through the use of relevant tools, activities and a
discussion of appropriate language.
& argues that body image acceptance is positively correlated with religious practice
Gaston-Johansson et al. [27 ] examine the func-
tion of coping strategies, religious coping and
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Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
spirituality in African American women with breast
cancer and found that higher coping capacity was
beneficial, as it was related to less psychological
distress, negative religious coping and catastrophiz-
ing.
CONCLUSION
Behavioral, cognitive and psychosocial scientists
have taken a more in-depth look at the claims made
in the past, suggesting that a relationship between
R/S, cultural diversity and health exists. Cases in
point are the studies on EoL care, which have pro-
gressively considered the role of cultural, religion
and spiritual diversity in the care of patients with
oncological terminal illnesses. Hence, it can be
argued that those early claims made are pertinent
today. Beyond these facts, this review also shows that
EoL supportive and palliative care providers could
further enhance their practical interventions by
being sensitive and supportive of cultural diversity.
Acknowledgements
We would like to thank Franklin Guerrero (Director,
Major Gifts USA for UNHCR The UN Refugee Agency)
and Wilfredo Serrano (Webmaster Inter American Uni-
versity of Puerto Rico, Metro Campus) for the production
of the video presentation.
&
Financial support and sponsorship
This work did not seek financial support.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
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and specifically praying activity, which suggests the importance of religion and
spirituality in coping with cancer chemotherapy.
www.supportiveandpalliativecare.com 93
Supportive care and psychological issues around cancer
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The authors engaged in nationwide study of faith among Danish and United States
women treated with breast cancer in a secular society and concludes that patients
having unambiguous religious faith express a markedly higher degree of certainty,
which may play a positive role in relation to the course of their breast cancer and
cancer-related QoL when compared to women reporting ambiguous faith.
7. Seibaek L, Lise H, Niels CH. Secular, spiritual, and religious existential
& concerns of women with ovarian cancer during final diagnostics and start
of treatment. Evid Based Complement Alternat Med 2013; 2013:111.
A study with Danish woman, focusing in diagnostics, surgery and chemotherapy
ovarian cancer. The study found that although the women experienced their health
to be seriously threatened, they also felt hope, will and courage amidst their
despair. The women dealt with this in a dialectical manner, so that hope and
despair could be present simultaneously. In the process, secular, spiritual and
religious existential meaning orientations assisted the women in creating new
narratives while obtaining new orientations in life.
8. Thune-Boyle ICV, Jan S, Mohammed RSK. Religious/spiritual coping re-
& sources and their relationship with adjustment in patients newly diagnosed
with breast cancer in the UK. Psychooncology 2013; 22:646658.
An analysis of the role of religious/spiritual coping resources and their relationship
with adjustment in patients newly diagnosed with breast cancer in the UK. They
found that using religious/spiritual resources in the coping process during the early
stages of breast cancer may play an important role in the adjustment process in
patients with breast cancer.
9. Shores CI. Spiritual interventions and the impact of a faith community nursing
&& program. Issues Ment Health Nurs 2014; 35:299305.
The author studied the spiritual interventions and the impact of a faith community
nursing program in an African-American community and found that the faith
community nursing program studied was a key connection between the spiritual
and physical health or among the body, mind and spirit.
10. Thompson VLS, Alan B, John PM, et al. The utility of cancer-related cultural
&& constructs to understand colorectal cancer screening among African Amer-
icans. J Public Health Res 2013; 2:e11; 59-65.
A study analyzing the utility of cancer-related cultural constructs to understand
colorectal cancer screening among African-Americans. The study concludes that
the Multi-construct African American Cultural Survey, identified through item
response theory analyses, can be used by community health researchers inter-
ested in determining the relevance of cultural constructs, which considers the role
of religion and spirituality in the design and implementation of colorectal cancer
screening programs in the African-American community.
11. Borneman T, Olga FB, Linda K, et al. Spiritual care for Jewish patients facing a
& life threatening illness. J Palliat Care 2013; 29:5862.
The study presents an ethnic/cultural Jew suffering a life-threatening illness of
advanced lung cancer who reflected Jewish religious and spiritual values and
ideas; nonetheless, the patient did not subscribe to the notion of a personal God
who cares about each individual. This case study illustrates the broad differences
in beliefs among Jews and suggests that clinicians/chaplains should not make
assumptions based upon the patients identification as Jewish.
12. Balboni T, Michael B, Andrea CE, et al. Provision of spiritual support to
&& patients with advanced cancer by religious communities and associations
with medical care at the end of life. JAMA Intern Med 2013; 173:11091117.
The study found that terminally ill patients who are well supported by religious
communities access hospice care less and aggressive medical interventions more
near death, while spiritual care and EoL discussions by the medical team reduced
aggressive treatment, highlighting spiritual care as a key component of EoL
medical care guidelines.
13. Barrera M, Leeat G, Jenny S, et al. The tenacity and tenuousness of hope
& parental experiences of hope when their child has a poor cancer prognosis.
Cancer Nurs 2013; 36:408416.
An analysis of the meaning and role of hope in parents of children with life-
threatening illnesses. The ethnic demographic variables considered in this study
were: Canadian, African, Middle Eastern and Aboriginal. The finding suggests that
focusing on positive outcomes and experiences, spirituality, and social support
facilitated being hopeful.
14. Ho AHY, Cecilia LWC, Pamela PYL, et al. Living and dying with dignity in
&& Chinese society: perspectives of older palliative care patients in Hong Kong.
Age Ageing 2013; 42:455461.
The authors argue that in the Chinese cultural context, living and dying with dignity
manifested differently than in other cultures for a sense of generativity/legacy,
resilience/fighting spirit, enduring pain, moral transcendence, spiritual surrender
and transgenerational unity are themes engrained in Chinese society.
15. Jang JE, Kim SW, Kim SY, et al. Religiosity, depression, and quality of life in
&& Korean patients with breast cancer: A 1-year prospective longitudinal study.
Psychooncology 2013; 22:922929.
This study examines the role of religiosity, depression, and quality of life in Korean
patients with breast cancer subscribed to the Buddhist, Catholic and Protestant faith
traditions and argues that the religious groups did not differ significantly with respect
to the prevalence of depression or scores on psychiatric measures at either baseline
or at 1 year. Hence, Jang argues that religiosity plays an important role in the emotional
state and quality of life of Korean women with breast cancer. However, its clinical
meaning may differ according to the type of religious affiliation and the stage of illness.
94 www.supportiveandpalliativecare.com
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
16. Hiruy K, Lillian M. End-of-life experiences and expectations of Africans in
&& Australia: cultural implications for palliative and hospice care. Nurs Ethics
2013; 21:111.
The research focused on a phenomenological case studies of EoL cancer patients
and provides insights into the sociocultural EoL experiences of Africans in Australia
and their interaction with the health services in general and EoL care in particular. It
considers an ethical, religious and spiritual framework that includes Afro-commu-
nitarian ethical principles to enhance the capacity of current health services to
provide culturally appropriate care.
17. Razban F, Sedigheh I, Hossein R. Nurses attitudes toward palliative care in
& south-east Iran. Int J Palliat Nurs 2013; 19:403410.
The study analyzed the nursing and medical science disciplines attitudes toward
general palliative care in south-east Iran. Findings suggest that educational
designers should include specific courses and clinical experiences about death
and palliative care from a religious and cultural receptive perspectives in under-
graduate and postgraduate nursing and health care curricula.
18. Munoz-Pino IP. Experience of nursing students upon their first care encounter
& with terminally ill patients. Invest Educ Enferm 2014; 32:8794.
This is a qualitative descriptive study with 65 students during their first EoL care
experience. It examines written testimonies of third and fourth-year nursing
students from a private university in Santiago, Chile. The content analysis reveals
the following significant themes: sense of death, importance of the family, human
communication, physical contact, spirituality, aspects that are often displaced from
what nursing care means. The findings show that the nursing students sampled
had difficulties in facing the care of an individual in the process of death. The article
concludes that educational strategies should be posed to improve undergraduate
formation on EoL care.
19. Peteet JR, Michael JB. Spirituality and religion in oncology. CA Cancer J Clin
& 2013; 63:280289.
The authors made a comparison between faith attitudes versus behaviors and their
relationship to mental health in current cancer patients and survivors. The findings
suggest that breast cancer patients and survivors indicated the importance of faith
and frequency of prayer had no relationship to mental health, while the concept of
God was a strong correlating factor. Thus, patients who perceived a loving God
had higher mental health.
20. Meisenhelder JB, Nancy JS, Jerry Y, et al. Faith and mental health in an
& oncology population. J Relig Health 2013; 52:505513.
This study focused on the spiritual and religious needs of parents with young
oncology patients and the staff caring for the family, Darby K, Paul N and Sally N
[21&] found that the spiritual needs of parents included providing the necessary
space to be heard and share stories. Concerning the staff, while the cumulative
effect of loss while caring for child having cancer is particularly difficult, the study
shows that having sufficient trust, empathy, warmth, acceptance and space can
help the coping process.
21. Darby K, Paul N, Sally N. Parents Spiritual and religious needs in young
& oncology. Cancer Nurs Pract 2014a; 13:1622.
The authors analyzed the religious and spiritual needs of young people with cancer.
Their findings suggest that the young patients spiritual needs were classified under
personal issues, relationships and attitudes, and environment, while religious needs
were identified as hope, resilience, ritual and connection, use of language and
worldview. Thus concluding that the young peoples spiritual and religious needs
should be assessed on an ongoing basis, with staff being supported to undertake
such assessment through the use of relevant tools, activities and a discussion of
appropriate language. Also with an interest in staff caring for cancer patients.
22. Darby K, Paul N, Sally N. Understanding and responding to spiritual and
& religious needs of young people with cancer. Cancer Nurs Pract 2014b;
13:3237.
This study focused on medical students experiences with patient death, the
meaning of patient death and coping with patient death. In relation to the three
main sections, the findings suggest that common coping mechanisms included
talking through their emotions, thrusting themselves into continuing their rounds,
crying, participating in infant death rituals, and turning to religion.
23. Pessagno R, Carrie EF, Robert A. Dealing with death: medical students
& experiences with patient loss. Omega 2013; 68:207228.
The study examine the relational of spiritual engagement in the caring process as
depicted by palliative care clients and staff of caregivers. The findings support the
phenomenon of spiritual engagement, which entails distinct actions such as
maintaining relationships with others, showing and receiving love, praying and
participating in other religious practices for spiritual engagement was understood
to be love in action.
24. Penman J, Mary O, Ann H. The relational model of spiritual engagement depicted
& by palliative care clients and caregivers. Int J Nurs Pract 2013; 19:3946.
The purpose of the study was to determine through an ongoing descriptive, long-
itudinal study, whether a sample of fifty family caregivers of people with primary
malignant brain tumors (PMBTs) experienced changes in their perceived level of
spirituality along the course of the disease trajectory as the characteristics of the care
recipient potentially change, and to examine the impact of spirituality on caregivers
depressive symptoms and anxiety eight months after patients diagnoses. The
findings show no significant differences in spirituality scores reported at baseline
at eight months, suggesting that spirituality may be a stable trait across the disease
trajectory. It concludes that caregiver depressive symptoms and anxiety were lower
when paired with higher reports of spirituality; this, it argues that understanding the
established role of spirituality during challenging and traumatic situations is relevant
to the current finding.
Volume 9
Number 1
March 2015
Supportive roles of R/S in EoL care of patients with cancer in culturally diverse context Lopez-Sierra and Rodrguez-Sanchez
25. Newberry A, Chien-Wen JC, Heidi SD, et al. Exploring spirituality
& in family caregivers of patients with primary malignant brain
tumors across the disease trajectory. Oncol Nurs Forum 2013; 40:
113.
The purpose of the study was to determine through an ongoing descriptive,
longitudinal study whether a sample of 50 family caregivers of patients with
primary malignant brain tumors (PMBTs) experienced changes in their per-
ceived level of spirituality along the course of the disease trajectory as the
characteristics of the care recipient potentially change, and to examine the
impact of spirituality on caregivers depressive symptoms and anxiety 8 months
after patients diagnoses. The findings show no significant differences in
spirituality scores reported at baseline at 8 months, suggesting that spirituality
may be a stable trait across the disease trajectory. It concludes that caregiver
depressive symptoms and anxiety were lower when paired with higher reports
of spirituality; thus, it argues that understanding the established role of
spirituality during challenging and traumatic situations is relevant to the current
finding.
26. Holt CL, Eddie MC, Katrina JD, et al. Religion and health in African
&& Americans: the role of religious coping. Am J Health Behav 2014;
38:190199.
Based on Pune, India, the study analyzes the place of death among his subjects
applying a survey approach. The study demonstrated that human preferences
are similar in many parts of the world, and there are few differences in the
preferences of people when it comes to the desired place of death. The study
reveals that EoL preferences (cancer patients included) are not influenced by
geography, politics, religion, economics, medical facilities or culture. While
patients would like EoL care at home, not all caregivers are comfortable. Very
often there is little congruence between the wishes of the patients and those of
caregivers.
27. Gaston-Johansson F, Mary EHW, Bobbie R, et al. The relationships among
& coping strategies, religious coping, and spirituality in African American
women with breast cancer receiving chemotherapy. Oncol Nurs Forum
2013; 40:120131.
The aim of this study was to analyze whether acculturation influences patients EoL
treatment preferences and care Using The United States Acculturation Scale,
the variables of age, ethnicity, education, health insurance, native English lan-
guage, nativity, cancer type, performance status, religion, institution, survival, and
caregiver relationships were considerate. The study suggests that the scale is a
reliable and valid measure associated with advanced cancer patients EoL pre-
ferences and care.
28. Kulkarni P, Pradeep K, Vrushali A, et al. Preference of the Place
& of death among people of Pune. Indian J Palliat Care 2014; 20:101
106.
Based on descriptive correlation, the study examined whether psychosocial
factors predict depression among older African-American patients with
cancer (see Table 1 of the cited article). Further, the study supports the
empirical fact that significant relationship of increased religious involvement
tend to decreased depressive symptoms being that that emotional support
and organized religious activities may represent protective factors against
depression.
1751-4258 Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
29. Cowan MM. The lived experiences of the Sikh population of south-east England
& when caring for a dying relative at home. Int J Palliat Nurs 2014; 20:179186.
This study encompasses six semistructured Punjabi or English interviews seeking
to understand the experiences of the Sikh population of southeast England
concerning the caring for a dying relative at home without support from specialist
palliative care. The article concludes that there is a need for health professionals to
reach out to this population to increase awareness of and trust in the services that
are available to support care at EoL. However, an unwillingness to accept
assistance may persist in some cases.
30. Wright AA, Heather S, Yankel MK, et al. United States acculturation and
& cancer patients end-of-life care. PLoS One 2013; 8:110.
This study undertook the concept of peace and life-worthwhile as measures of
spiritual well-being in African palliative care and concluded that peace and life-
worthwhile as distinct but related measures of spiritual well-being in African palliative
care.
31. Johnston G, Adele V, Skylan P. Cultural understanding in the provision of
& supportive and palliative care: Perspectives in relation to an indigenous
population. BMJ Support Palliat Care 2013; 3:6168.
This is a literature review with Mikmas health and culture experts. This article
examines the provision of supportive and palliative care for indigenous people in
Nova Scotia, Canada, to further improve understanding and cultural competency
of nonindigenous care providers. Cultural competency was associated with world-
view, spirituality, the role of family and community relationships and communication
norms, and thereby with the alignment of values and language in the provision of
care. The study concludes that via reflection, nonindigenous healthcare providers
can assess how they might increase their cultural understanding in the provision of
supportive and palliative care.
32. Hamilton JB, Allison MD, Angelo DM, et al. Psychosocial predictors of
& depression among older African American patients with cancer. Oncol Nurs
Forum 2013; 40:394402.
Based on descriptive correlational, study examine whether psychosocial factors
predict depression among older African American patients with cancer (see Table
1 of the cited article). Further, the study supports the empirical fact that significant
relationship of increased religious involvement tend to decreased depressive
symptoms being that that emotional support and organized religious activities
may represent protective factors against depression.
33. Lee GL, Rosaleen O, Ramaswamy A, et al. Exploring the experience of
& dignified palliative care in patients with advanced cancer and families: a
feasibility study in Singapore. Prog Palliat Care 2013; 21:131139.
Based on qualitative interviews with patients with advanced cancer and their primary
family caregiver from a home hospice service. The study found that the experience of
dignity in palliative care in the Singapore context consists of three factors: (1) social
factor; (2) organizational factor, and private sector; and (3) spiritual factor.
34. Selman L, Peter S, Marjolein G, et al. Peace and life worthwhile as measures
& of spiritual well being in African palliative care: a mixed-methods study. Health
Qual Life Outcomes 2013; 11:112.
This study undertook the concept of peace and life-worthwhile as measures of
spiritual well-being in African palliative care and concluded that peace and life-
worthwhile as distinct but related measures of spiritual well-being in African palliative
care.
www.supportiveandpalliativecare.com 95