JAMA publishes major review of research about spirituality and serious illness

George Fitchett, DMin, PhD

Department of Religion, Health & Human Values, Rush University Medical Center

Last month JAMA published the paper, “Spirituality in Serious Illness and Health” (Balboni et al., 2022). The paper is one of the most important contributions to the literature about religion/spirituality (R/S) and health of the past twenty years. The paper is the report of a project that was led by Tracy Balboni, Tyler VanderWeele, and Howard Koh at Harvard’s Medical School and T.H. Chan School of Public Health; the project was supported by the John Templeton Foundation. In the citation for the paper below you will see the names of the other co-authors; some of these names will be familiar to those of you who follow the research in this area. I was privileged to be included in the project and was glad to represent our spiritual care profession. In this article I will provide a brief overview of the paper, discuss how it can be used to advance the integration of spiritual care in health care, and discuss the article’s importance for research literacy and research about spiritual care in healthcare.

The project focused on two areas: issues related to R/S for people with serious illness (and their caregivers), and issues related to R/S and health among healthy people living in the community. The paper refers to this second area as health outcomes. The project had two phases. The first phase included rigorous systematic reviews of the research in both areas. In the second phase, the findings from each systematic review were given to a panel of experts in that area (13 experts for serious illness, 15 for health outcomes). Using what is known as a Delphi process, these experts generated summaries of the evidence and recommendations for clinical practice or public health based on the research. The panels then voted on the degree to which they believed the research supported the recommendations. The results were 3 recommendations in each area that the panelists felt had strong support in the research. Because the research and recommendations related to serious illness are very relevant for the work of most chaplains, I will focus the rest of this article on them. The research and recommendations related to health outcomes are interesting and important and I hope you will take note of them when you read the article.

In this project, serious illness was defined as “terminal, late-stage, or catastrophic illness,” as well as end-of-life and palliative care. After reviewing high quality evidence about R/S and serious illness, the expert panel rated a number of statements that summarized the evidence. The panel rated these eight statements as having “strong evidence” to support them (See Table 3):

1. Spirituality is important for most patients
2. Spiritual needs are common
3. Spiritual care is frequently desired by patients
4. Spiritual needs are infrequently addressed in medical care
5. Spirituality can play a role in medical decision-making
6. Spiritual care is infrequent in medical care
7. Unaddressed spiritual needs are associated with poorer patient QOL
8. Provision of spiritual care is associated with better patient end-of-life (EOL) outcomes

The panel also evaluated a number of statements about the implications of the research. The top three implications of the research about spirituality and serious illness were (See Table 5):

1. Routinely incorporate spiritual care into the medical care of patients with serious illness.
2. Include spiritual care education in the training of all members of the interdisciplinary medical team caring for the seriously ill.
3. Include specialty practitioners of spiritual care (e.g., chaplains) in the care of patients with serious illness.

Spiritual care managers and practitioners should familiarize themselves with the paper and especially with these statements summarizing the research and its implications. They are an extraordinary resource for advocacy for the integration of spiritual care for patients with serious illness, and their caregivers. The vast majority of clinical leaders and healthcare executives will be unfamiliar with the research about R/S and health. They will not be aware of the extent or quality of that research. Most will not be aware of this report or these recommendations. Spiritual care managers should share the report widely and discuss it with institutional leaders who are champions for spiritual care. Together with these allies, spiritual care managers should think about the best ways to inform their institutional colleagues about the report and its recommendations. These might include presentations in grand rounds or webinars, discussions in journal clubs, or brief presentations in key committees. Featuring the report in local Spiritual Care Week activities (October 23-29, 2022) should be considered.

The published report is an important resource for advocating for better integration of spiritual care, especially for people with serious illness and their caregivers. The supplemental appendices, available for download from JAMA’s website, are an incredible resource for research about R/S and serious illness and health outcomes. The research that was included in the systematic review about R/S and serious illness is reported in eAppendix 3A. To be included in this review the studies had to be published between 2000 and 2020 (a supplemental review of research from 2020 to May 2022 was also conducted). The studies had to have at least 100 subjects, use validated measures of R/S, and fit specific criteria for study design. A total of 371 studies were selected. These studies were then graded for possible bias using standard criteria; studies with serious or critical risk of bias are included in the appendix but they were excluded from the review of evidence and summaries of the implications of the research.

The serious illness studies were organized into one of five categories:

1. The role of R/S in serious illness (128 studies with low or moderate risk of bias)
2. R/S needs in serious illness (37 studies)
3. Spiritual care in serious illness (82 studies)
4. R/S in patient medical decision-making in serious illness (32 studies)
5. Spiritual interventions in serious illness (30 studies).

EAppendix 3A has separate tables, for patients and caregivers, of the articles that were included in each of these five areas. Each table is preceded by a summary of the research in that area. Advancing research in R/S and serious illness, as in any area, begins with familiarity with the existing research. For spiritual care providers and colleagues who are interested in advancing research about R/S in serious illness, this appendix is an exceptional resource. The appendix can also be used in research literacy education for spiritual care providers. Research literacy includes being familiar with the scope of the research that has been conducted, as well as being able to critically read that research. Reviewing the tables and summaries in this Appendix will help spiritual care providers develop familiarity with the breath of existing research about R/S and serious illness.

With its rigorous review of the research and expert panel recommendations, this paper makes  important contributions both to integrating spiritual care in care for patients with serious illness and to future research about R/S and serious illness. Spiritual care leaders, managers, and practitioners should familiarize themselves with its contents and recommendations and share the paper widely with their colleagues. To help you become more familiar with the paper, Transforming Chaplaincy will host a webinar about it, featuring Tracy Balboni, on August 31. See the announcement in the August Newsletter for further details about the webinar.

References

Balboni TA, VanderWeele TJ, Doan-Soares SD, Long KNG, Ferrell BR, Fitchett G, Koenig HG, Bain PA, Puchalski C, Steinhauser KE, Sulmasy DP, Koh HK. Spirituality in Serious Illness and Health. JAMA. 2022 Jul 12;328(2):184-197.doi: 10.1001/jama.2022.11086.