Uncertainty and cancer care: should primary care providers routinely screen for cancer patients' spirituality needs?

Spirituality and Uncertainty in the Primary Care of the Cancer Patient

Zackary Berger, MD, PhD

Johns Hopkins General Internal Medicine

INCLUDE LOGO AND SLIDE

Spirituality and Health Initiative Mercy Medical Center

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This program made possible in part by a generous grant from the Foundation for Spirituality and Health

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Objectives

• Introduce spirituality, its definitions, and various reactions to it in the health care setting

• Summarize the literature on spirituality and cancer

• Discuss the relationship between spirituality and uncertainty, and the role the PCP might play

• Propose next steps

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A case

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William James, 1902: what is he referring to?

“The feelings, acts and experiences of individual[s] in their solitude”

04/13/2023 Morning Sun, Edward Hopper, 1952 6

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Spirituality vs. Religion – as often understood today

• Religion: narrower institutional concept

• Spirituality: broader concept speaking to a basic human need

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Quotes from Facebook: spirituality is not always uncontroversial

• “I would be horrified if a healthcare provider mentioned spirituality.”

• “I'm not religious and would not want spirituality mentioned to me - spirituality questions have always felt to me like, "well , you're not religious, so you've got to be SOMETHING!". Nope. I don't.”

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04/13/2023 Pew Foundation Faith Matters survey 11

Don’t assume your patient is religious or spiritual!

• 65% of U.S. adults describe themselves as religious (in addition to being spiritual or not)

• Nearly one-in-five say they are spiritual but not religious (18%)

• About one-in-six say they are neither religious nor spiritual (15%).

04/13/2023 Maslow’s Hierarchy of Needs 12

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Psychosocial needs in patients with cancer

• Sense of identity• Body image• Spiritual needs• Practical issues

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Spirituality as a need in cancer care

• What needs does spirituality serve in patients with cancer?

• Association in meta-analyses between spirituality and well being

• Positive/negative religious coping vs. positive/negative psychological adjustment

Garssen et al., J Relig Health 2014

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Spirituality and uncertainty

• Evidence-based medicine can fail to provide useful answers to patients

• Patients often have difficulty formulating values and preferences

• Uncertainty: the perception of ignorance that accompanies a range of possible decisions in which there is no single right answer

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Uncertainty and the role of the PCP in cancer care

• Uncertainty in diagnosis• Uncertainty in prognosis• Uncertainty in goals of

care

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Spirituality, uncertainty, and the role of the PCP

• Meeting psychosocial needs• Providing hope• Decentering from the decision• Acceptance• Viewing problems from distance• Reframing

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What is the role of the PCP in spirituality and uncertainty?

• Does a PCP have an obligation to meet unmet “medical” needs of the patient?– Expanding areas of concern– Economic– Social– Sexual– Psychological

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Can spirituality help navigate uncertainty? Is that our job?

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What about patients who find spirituality uncomfortable?

•Addressing psychosocial needs

•Providing hope•Allowing questions

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Future research needs

• Does spirituality work in cancer care?

• Can it be implemented as an intervention?

• Should it be universally offered even to “non-spiritual” people?

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Future education needs

• How can we best offer spirituality?– Universal one-question screen (“Do you

need a chaplain?”)?– Question about psychosocial needs?– Question about general unmet needs?

• How can providers assess patients’ needs and achieve competence?

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Future needs in quality improvement

• How do we meet the psychosocial needs of the patient with cancer?

• How do we do so in a way which is individually appropriate?

• How do we individualize quality-improvement metrics?