Integrating Spirituality Into Palliative Care Services

A Conversation With Christina Puchalski, MD, MS

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Christina Puchalski, MD, MS

Once we have proof from trials that the spiritual domain is related to the physical domain, people will pay attention.

—Christina Puchalski, MD, MS

Over the past couple of decades, the oncology community has made great strides in mediating the psychosocial needs of our patients. However, a patient’s spirituality is a subjective and uncomfortable issue for many oncologists, which leaves a gap in the continuum of care.

To reach a better understanding of this complex issue, The ASCO Post recently spoke with Christina Puchalski, MD, MS, a pioneer and international leader in the movement to integrate spirituality into the clinical setting and medical education. Dr. Puchalski is the Founder and Director of the George Washington Institute for Spirituality and Health (GWish), and Professor of Medicine at the George Washington University School of Medicine and Health Sciences.

Clinical and Academic Experience

Please tell our readers about your ­background.

A physician by training, I did my undergraduate work at UCLA and earned my medical degree at The George Washington School of Medicine & Health Sciences. I also have an advanced degree in biochemistry and have done some basic research. I am also a Board-certified internist and palliative care physician. Besides my clinical work, I am Professor of Medicine and Health at George Washington University.

Bringing Spirituality to the Bedside

As Founder and Director of GWish, how would you define its worth within the context of the oncology community?

The central mission of GWish is to foster more compassionate and caring health-care systems and restore the heart and humanity to health care. We do this by developing educational programs supported by scholarly and research-based initiatives. These courses provide the practical skills and tools needed by clinicians to bring spirituality to the bedside. By creating an academic field of study, we strongly believe we are improving clinical care and ultimately improving the lives of patients and their families.

An Opportunity for Healing

Have noted researchers looked at the role of spirituality in palliative care?

Yes. There have been numerous studies on the role of spiritualty in the palliative care continuum, such as work by George Fitchett, DMin, PhD, and others who looked at the role of professional chaplains on palliative care teams. Their research has been funded by the National Institutes of Health and published in pastoral, medical, and psychological journals.

In short, the data culled from retrospective studies show a statistical correlation between spirituality—more broadly defined as a search for meaning and purpose and connectedness to the significant or sacred—and mental health, with lower levels of depression and anxiety, and even better social functioning skills.

Other studies have shown that spiritual care models also offer a framework for health-care professionals to connect with their patients; listen to their fears, dreams, and pain; collaborate with their patients as partners in their care; and provide an opportunity for healing through the therapeutic relationship. Healing is distinguished from cure in this context. It refers to the ability of a person to find solace, comfort, connection, meaning, and purpose in the midst of suffering, disarray, and pain.

Steps to Widening Acceptance

It was an uphill battle for palliative care to become accepted as an essential component in the delivery of cancer care. The spiritual care of patients is a relatively new addition to oncologic care services. Is there growing acceptance among the field?

There have been significant strides in palliative care but it has not been broadly accepted in the palliative care community. That said, I think as more positive data emerge, people become more willing to accept its importance. A lot of our work in this area was initially done back in the 1990s, before GWish was formed. We did one of the first classes on spiritualty and health at our medical school, and after that, we worked with the John Templeton Foundation to give grants to medical schools so that we could integrate spirituality more fully in medical school curricula nationwide.

Over the years, we taught our students how to assess and attend to their patients’ spiritual needs, but we realized that it was not happening in the general clinical setting. So that’s when I began working with Betty Ferrell, MD, PhD, RN, to develop guidelines that sought to improve the spiritual domain of palliative care. In 2009, we published a paper on the findings from a consensus conference,1 the goal of which was to identify points of agreement about spirituality as it applies to health care and to make recommendations to advance the delivery of quality spiritual care.

That work has spawned some policy changes on the global level. For instance, the World Health Organization (WHO) just passed a resolution stressing the need to enhance palliative care on a global level to help relieve the suffering from pain and other problems, whether physical, psychosocial, or spiritual. Recognition of a global health issue by the WHO or other organizations does not solve the problem of undertreated symptoms of disease such as cancer, but it is an important step. To me, these are all markers that palliative care, including the spiritual domain of palliative care, is getting more widely accepted.


What did the 2006 palliative care guidelines address?

In the 2009 consensus conference mentioned above, an interprofessional model of spiritual care was developed where all members of the team address spiritual issues of patients and families. Specific clinical recommendations include doing a spiritual screening or spiritual history with all patients, identifying spiritual distress, formulating and assessment and treatment plan that includes the psychosocial and spiritual as well as the physical aspects of the patient, working with trained chaplains as the spiritual care experts. Additonally recommendations were made about developing educational programs in spiritual care, integrating spiritual care in Quality Improvement projects in clinical settings and addressing spiritual needs of patients and families in clinical policies and guidelines.

Taking It to the Next Step

Guidelines developed among academics provide an actionable framework. However, although there’s a growing awareness of the need for early initiation of palliative care, there are large gaps in its implementation across various demographics. How do we remedy this?

It requires a multipronged approach. We certainly need more and better research. For instance, much of the research in spirituality has been in association studies, which have shown the benefit of patients’ spirituality in their health outcomes. However, we have to take it to the next step and start looking at outcomes of spiritual care interventions.

We have existing models that show the vital role of chaplains in palliative care. That said, we need to aggregate our knowledge and build multidisciplinary programs that attend to the whole person as a patient. We’ve seen incredible advances in the physical treatment of disease; now we have to catch up on the delivery of state-of-the art psychosocial and spiritual care. I see the healthful benefits in my own patients who have had their spiritual needs addressed. They tend to take better care of themselves and are more engaged in their treatments.

The other component is education, which I cannot stress enough. I just returned from Europe, where I attended the European CanCer Organisation (ECCO) meeting, and I was very pleased to see the activity and studies presented that looked at cancer patient outcomes within the context of spiritual distress. Much of the work examined whether those who had their spiritual distress managed properly had better outcomes all the way around, even in pain. Once we have proof from trials that the spiritual domain impacts other domains of care including the physical domain, people will pay attention.

Closing Thoughts

Do you have any closing thoughts to share?

As health-care professionals, we need to provide dignity to all of our patients, no matter what stage of disease they are in. We need to reframe the way we look at chronic illness and dying: people can lead meaningful lives; feel they are a gift and not a burden to others; know they still can find meaning in life right up until the end and can be open to the unknown gifts that may happen toward the end of life. ■

Disclosure: Dr. Puchalski reported no potential conflicts of interest.


1. Puchalski C, Ferrell B, Virani R, et al: Improving the quality of spiritual care as a dimension of palliative care: The report of the Consensus Conference. J Palliat Med 12:885-904, 2009.


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