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https://doi.org/10.1177/0269216318772267
Palliative Medicine
2018, Vol. 32(7) 1167 –1179
© The Author(s) 2018
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DOI: 10.1177/0269216318772267
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What is already known about the topic?
Terminal patients are vulnerable to spiritual distress, which has caused concern in palliative care.
High spiritual well-being helps patients cope with serious diseases in a positive way in palliative care.
An increasing number of clinical trials have examined the effects of spiritual care, but the findings are inconsistent.
What this paper adds?
Seven types of spiritual care interventions with the specific goal of providing spiritual support have been implemented
to date in patients with terminal illness.
In this narrative synthesis, spiritual care was found to have a potential beneficial effect on global quality of life (QOL) and
spiritual well-being.
All the reviewed studies were rated as moderate in quality. This paper points out that more studies with rigorous designs
are warranted in the future research.
The effects of spiritual care on quality of
life and spiritual well-being among patients
with terminal illness: A systematic review
Jingyi Chen1, Yazhu Lin1, Jie Yan1, Yong Wu2 and Rong Hu1,3
Abstract
Background: Terminal illness not only causes physical suffering but also spiritual distress. Spiritual care has been widely implemented
by healthcare professionals to assist patients coping with spiritual distress. However, the effects of spiritual care need to be clear.
Aim: To evaluate the effects of spiritual care on quality of life and spiritual well-being among patients with terminal illness.
Design: Systematic review according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses guidance.
Data sources: A comprehensive search was conducted in nine electronic databases from date of inception to May 2017. Hand
searches of the bibliographies of relevant articles were also performed. The studies were independently reviewed by two investigators
who scored them for methodological quality using the Cochrane Risk of Bias Tool.
Results: No statistical pooling of outcomes was performed and a narrative summary was chosen to describe the included studies. A
total of 19 studies with 1548 participants were identified in the systematic review, corresponding to seven kinds of interventions. The
risk of bias for these studies were all rated as moderate. A majority of studies indicated that spiritual care had a potential beneficial
effect on quality of life and spiritual well-being among patients with terminal illness.
Conclusion: It is suggested that healthcare professionals integrate spiritual care with usual care in palliative care. When providing
spiritual care, healthcare professionals should take into consideration patients’ spiritual needs, preference, and cultural background.
More multicenter and disciplinary studies with rigorous designs are needed in the future.
Keywords
Palliative care, spiritual therapies, terminal care, quality of life, spirituality, systematic review
1School of Nursing, Fujian Medical University, Fuzhou, China
2 Department of Hematology, Fujian Medical University Union Hospital,
Fuzhou, China
3 Department of Medical Nursing, School of Nursing, Fujian Medical
University, Fuzhou, China
Corresponding author:
Rong Hu, Department of Medical Nursing, School of Nursing, Fujian
Medical University, Fuzhou, Fujian Province, 350108, China.
Email: hurong1246@126.com
772267PMJ0010.1177/0269216318772267Palliative MedicineChen et al.
review-article2018
Review Article
1168 Palliative Medicine 32(7)
Implications for practice, theory, or policy
Healthcare professionals play an important role in spiritual care to help patients cope with illness-related spiritual
distress.
It is suggested that healthcare professionals provide spiritual care as a part of the healthcare treatment plan in palliative
care.
Healthcare professionals should take into consideration patients’ spiritual needs, preference, and cultural background
when providing spiritual care.
Introduction
Terminally ill patients are defined by The Leeds Oncology
Working Party as those for whom treatment goals change
from curative to palliative.1 If there is a broad agreement
among health professionals that one’s life expectancy is
limited, we consider this person to be having a terminal
illness,2 which usually includes advanced cancer, organ
failure, AIDS, and so on. Terminal stage illness not only
causes physical suffering but also spiritual distress. Almost
half of the patients in the palliative care unit are found to
have spiritual distress.3 For patients facing a terminal ill-
ness and possible premature death, increased spiritual dis-
tress often exacerbates the perception of anxiety, futility,
meaninglessness, sense of loss, and being unsupported.4–7
It is reported that a higher spiritual well-being level is pos-
itively correlated with patients’ well-being8 and negatively
correlated with symptoms of depression,9 pain,10 end-of-
life despair, and hopelessness.11 Spiritual well-being is
identified as one of the most important influences on QOL
at patients’ end of life.12 In palliative care, as we take spe-
cial care of patients’ physical health, we should also pay
enough attention to their spiritual well-being.
The World Health Organization (WHO) has identified
spirituality as the fourth dimension of health.13 Yet there is
no consensus about what the term “spirituality” exactly
means. One view is that there are two main forms of spir-
ituality—the “old” and the “new.”14 The “old” traditional
form of spirituality is based on religious and theocentric
descriptors. People may meet their needs of spirituality by
participating in formal religious activities and belief in
god. The “new” form contains infinite descriptors such as
belief and faith, finding meaning for experiences, and cre-
ativity. The European Association for Palliative Care
(EAPC) task force suggests that spirituality is related to a
persons’ experience, expression, and seeking for meaning,
purpose, and transcendence and the way they connect to
the moment, individuals, nature, and the sacred.15
The call for spiritual care to meet spiritual needs in ter-
minal patients has been strengthened. In a study with a
sample of 285 cancer patients, 93.8% of the patients
reported at least one spiritual need, especially the needs for
inner peace and actively giving.16 Patients largely desire to
get spiritual care from the medical system in the face of
terminal illness.17 However, many healthcare profession-
als experience barriers to deliver effective spiritual care to
patients, such as low resources, not having the right vocab-
ulary, lack of time and training, and cultural or institu-
tional factors.18–23 Healthcare professionals need to think
about how to respond to such patients’ spiritual needs and
overcome the barriers of spiritual care delivery. Since pal-
liative care highlights holistic care, including the spiritual
aspect, there have been increasing researches on spiritual
care for patients with terminal diseases. These include
yoga,24 meditation,25–27 and multidisciplinary interven-
tions that aim to facilitate spiritual awareness by support-
ive interventions.28–30 Previously, in some randomized
controlled trials (RCTs), transcendental meditation27 and
spiritual therapy31 were proved to promote overall QOL
and spiritual well-being. However, the results of the clini-
cal trials about the effects of spiritual care were inconsist-
ent. A study of the effects of spiritual history taking
demonstrated that there were no significant effects on
spiritual well-being and QOL among palliative patients in
home care.32 Various reviews have been conducted to syn-
thesize the effects of spiritual care. A systematic review
showed that religious and spiritual interventions (RSI),
such as meditation and psychotherapy, could substantially
reduce anxiety symptoms and decrease stress and
depression.33 Another systematic review conducted in
2012 including five RCTs synthesized the effects of RSI
on the well-being of adults with terminal illness. There
were two types of RSI included in this review: meditation
and multidisciplinary palliative care. The conclusion was
that there was limited evidence to answer the question that
RSI may or may not enhance well-being of patients with
terminal phase of diseases.34 To date, there are limited
publications that provide a structured review focusing on
spiritual care and its effectiveness on QOL and spiritual
well-being. Therefore, we conducted this systematic
review to systematically summarize the characteristics of
studies related to spiritual care and to synthesize their
effectiveness on QOL and spiritual well-being among
patients with terminal illness.
Chen et al. 1169
Aim
The aim of this review is to examine the strength of evi-
dence regarding the effects of spiritual care on QOL and
spiritual well-being among patients with terminal illness.
Methods
We conducted this systematic review according to the
Preferred Reporting Items for Systematic Reviews and
Meta-Analysis (PRISMA) Statement.35 The protocol for
this systematic review was registered on PROSPERO
(CRD42016038195),36 an international prospective register
of systematic reviews. No meta-analyses were conducted,
due to the diversity of interventions and measurements of
the included studies.
Eligibility criteria
Types of participants. Studies were eligible if the patients
were in the terminal phase of any type of diseases (e.g. can-
cer, organ failure, and AIDS), life expectancy ⩽6 months,
or in the palliative treatment. There was no restriction on
age, sex, or ethnicity of patients.
Types of interventions. Eligible interventions include those
that aim to benefit the spiritual well-being or have a spiritual
aspect, such as spiritual therapy, narrative therapy, meaning-
centered psychotherapy, life review, dignity therapy, medi-
tation, and mindfulness-based stress reduction (MBSR).
Yoga, which was not purely in the physical forms, was also
eligible.
Types of outcomes. Eligible studies should measure at least
one aspect of QOL and spiritual well-being with a vali-
dated questionnaire.
Types of study design. Studies using random assignment of
participants to spiritual care and control groups were eligi-
ble. Clinical controlled trials were eligible as well. Clinical
controlled trials use quasi-random method of allocating
participants to different groups. Reviews, case reports,
cohort studies, opinion articles, or letters were excluded.
Search strategy
We searched studies published in EMBASE, MEDLINE,
CINAHL, AMED, Cochrane Central Register of Controlled
Trials, PsycINFO, and three Chinese databases (WanFang
Data, China National Knowledge Infrastructure and China
Biology Medicine disc) up to May 2017. By holding coun-
sel with an experienced librarian, J.C. developed the search
strategies using MeSH subject headings combine with free-
text terms: (‘Spirituality’[MeSH] OR ‘Spiritualism’[MeSH]
OR ‘Spiritual therapies’[MeSH] OR ‘Pastoral care’[MeSH]
OR ‘spiritual care’ OR ‘dignity therapy’ OR ‘life review’
OR ‘narrative therapy’ OR ‘Meditation’[MeSH]) AND
(‘Palliative care’[MeSH] OR ‘Terminal care’[MeSH] OR
‘terminal illness’ OR ‘terminal* ill*’ OR ‘terminal dis-
ease*’ OR ‘advanced adj6(disease* or cancer or illness)’
OR ‘end of life’ OR ‘Neoplasms’[MeSH]). The search was
run on May 2017. Only studies written in either English or
Chinese language were included. A further search was also
conducted from the references of all included studies
related to the theme.
Data extraction
A two-step assessment was employed. First, two research-
ers (J.C. and Y.L) independently screened titles and
abstracts judged by the inclusion criteria and then obtained
full texts where those titles and abstracts met the inclusion
criteria or where there was any uncertainty. Then the two
researchers assessed the full texts of potentially eligible
studies according to the eligibility criteria. A senior
researcher (R.H.) was consulted if there were any disa-
greements or doubts. Data extraction was undertaken inde-
pendently by the two researchers (J.C. and Y.L) using a
form developed for this review. Then two data forms were
compared by the researchers to identify if there were any
discrepancies in order to get the corresponding data finally.
Where information was lacking, we attempted to make
contact with the trial authors to get further information.
Data items
Data extracted from included studies were (1) author, (2)
year of publication, (3) country, (4) study design, (5) type
of intervention, (6) profession of the person who per-
formed the intervention, (7) settings, (8) type of patients,
(9) number of samples, (10) primary study outcome, (11)
instrument used to measure the outcome, and (12) follow-
up time.
Quality assessment
The Cochrane Collaboration’s tool for assessing risk of
bias was used to assess the risk of bias on adequacy
of sequence generation, allocation concealment, blinding
of patients and personnel, blinding of outcome assessment,
reporting on incomplete outcome data, selective outcome
reporting, and other sources of bias. The risk of bias for
each outcome was summarized into three levels: low, high,
and unclear. Working independently, the two researchers
(J.C. and Y.L) assessed the quality of included studies.
Disagreements were resolved by discussion, or if unsuc-
cessful, by consulting the senior researcher (R.H.).
1170 Palliative Medicine 32(7)
Data synthesis
No statistical pooling of outcomes was performed, because
the interventions, study design, and measurements of the
included studies were heterogeneous.37 Therefore, a narra-
tive summary was chosen to describe the content of the
included studies. At the beginning, a descriptive summary
of the characteristics of the included studies was formu-
lated. Then the effects of spiritual care on QOL and spirit-
ual well-being among terminal patients were synthesized
by collating the interventions, participants, and outcome
measures in a narrative way.
Results
The search identified 7420 articles from all databases com-
bined. After removal of duplicates, 5063 articles remained.
By screening the titles and abstracts independently by two
researchers (J.C. and Y.L), 4927 articles were excluded
because they did not meet the inclusion criteria. Then we
obtained the full texts of 136 articles that were potentially
eligible. After reading the full texts, we further excluded
117 studies and finally only 19 studies met the inclusion
criteria. Reasons for exclusion were recorded. A senior
researcher (R.H.) was consulted if there were any disa-
greements or doubts during the selection process. The
detailed selection process is shown in Figure 1.
Description of the included studies
The 19 included studies were published between 2005 and
2016. The general characteristics of the selected articles
are shown in Table 1. The characteristics of the included
studies are summarized below:
1. Participants
A total sample of 1548 patients was included in the 19
studies. Diagnoses included breast cancer (32.56%), colo-
rectal cancer (3.49%), advanced cancer without a detailed
description (37.21%), AIDS in the late stage (1.87%), hos-
pice or palliative care patients at the end of life (7.17%), a
progressive and life-threatening disease (3.55%), and life
expectancy ⩽ 6 months (14.15%).
2. Interventions
Seven different kinds of interventions were contained in
the 19 studies: meaning-centered psychotherapy (n = 3),
spiritual therapy intervention (n = 3), life review (n = 3),
dignity therapy (n = 2), yoga (n = 3), meditation (n = 4),
and MBSR (n = 1). Depending on the characteristics of the
interventions, we described them, respectively, as follows.
2.1 Spiritual interventions using a narrative approach.
2.1.1 Group spiritual interventions.
Group spiritual interventions were identified as time-
efficient, effective, and economical. In meaning-centered
group psychotherapy (MCGP), groups of 8–10 partici-
pants were formed and then randomly assigned to either
MCGP or control group. MCGP consisted of eight ses-
sions, and each session addressed specific themes such as
the relationship of cancer and meaning, the historical con-
text of meaning, and the hope for the future. Patients were
asked to reflect to their life, discuss, and respond to some
questions about the themes. The focus of each session of
MCGP was on issues of finding sources of meaning and
purpose in the face of terminal illness. Spiritual group
therapy consists of several sessions such as talking about
and sharing the concept of spirituality, listening to the
inner voice, feeling the relationships with oneself, with
others and with God, discussing death, and thanksgiving.
2.1.2 Individual spiritual interventions.
Life review and dignity therapy used the similar narra-
tive approach of telling one’s life story. These two inter-
ventions began with a framework of questions. They were
both one-to-one interventions. Dignity therapy was based
on an empirical model of dignity aiming at increasing the
sense of purpose and reducing spiritual distress. Life
review was a process of recalling and reevaluating life
events to facilitate the psycho-spiritual well-being in the
end of life. Patients confirm self-continuity and self-iden-
tity through sharing inner feelings and remembering mem-
ories of their family life and social roles. Individual
meaning-centered psychotherapy (IMCP) was designed to
assist patients in sustaining a sense of meaning, purpose,
and peace in their life. IMCP seven sessions included
experimental exercises, didactics, discussion, and psycho-
therapeutic techniques such as reflection, clarification, and
exploration. These sessions were similar to the MCGP pro-
gram. However, in implementing the intervention pro-
gram, IMCP was more flexible than MCGP because
terminal patients were often absent from group interven-
tions by reason of scheduling or illness-related problems.
2.2 Spiritual interventions using a non-narrative
approach.
Yoga, which was not purely in the physical forms, was
included. This kind of yoga includes yogic breathing tech-
niques and yogic meditation techniques featured by focus-
ing the attention on deep mind relaxation besides muscle
training and gentle stretching. Meditation aimed to relax
the mind and body, relieve negative thoughts, build inner
energy, and develop compassion, love, and forgiveness
through simple body movements combined with music and
positive messages. MBSR was a stress-reducing program
using a combination of mindfulness meditation, body
awareness, and yoga. It usually has three components: (1)
educational materials related to meditation and relaxation,
Chen et al. 1171
Figure 1. Flow diagram of study selection.
(2) practice of meditation in group meetings and home-
work, and (3) discussion among group members about the
barriers.
2.3 Professionals of the interventions.
The interventions were performed by various thera-
pists, mostly trained professionals such as yoga instruc-
tors, spiritual healers, meditation instructors, clinical
psychologists, psychiatrists, and registered nurses. Two
studies gave no specific description of the intervention
practitioners.
3. Control interventions.
Most control groups received standard care25,27,28,31,32,38–42
(n = 10) consisting of healthcare services from medicine,
nursing, social services, dietary, mental health services, and
recreation departments. In one study,26 the control group
received friendly visits that involved either spending time
1172 Palliative Medicine 32(7)
Table 1. Study characteristics.
No. Author Country Study
design
Intervention
(frequency and
duration)
Intervention
performed by
Patients Sample
size
Primary
outcome
Measuring
instrument
Time of outcome
measurement
Settings
Inte1Con2
1 Culos-Reed
etal.45
Canada Pilot RCT Yoga (once 75 min,
7 weeks)
Yoga
instructor
Breast cancer 20 18 QOL EORTC QLQ-C30 Baseline, immediately
after the end
intervention
Cancer
center
2 Cramer
etal.24
Germany RCT Yoga (weekly 90-min
class over a period of
10 weeks)
Hatha yoga
instructor
Non-metastatic
colorectal
cancer
27 27 QOL/
SPW
FACT-C/FACIT-Sp Baseline, immediately
after the 10-week
intervention, 12 weeks
post-intervention
Hospital
3 Williams
2005
USA Pilot RCT Meditation (at
least once daily for
4 weeks)
Meditation
teacher
late stage
disease
13 16 QOL MVQOLI Baseline, weeks 2 and
4 in the intervention
period, 1 month post-
intervention
Nursing
facility
4 Nidich etal.27 USA RCT Transcendental
meditation (twice
a day for 20 min,
average 18 months)
Qualified
instructor
Breast cancer 64 66 QOL/
SPW
FACT-B/FACIT-Sp Baseline, every 6 months
over a 2-year period
Home
5 Zamaniyan
etal.30
Iran Quasi-
RCT
Spiritual group
therapy (12 sessions
in the form of a 120-
min session per week)
Unclear Breast cancer 12 12 QOL/
SPW
WHOQOL-26/
SWB-20
Baseline,
immediately after the
end intervention
Hospital
6 Kim etal.44 Korea RCT Meditation (12
sessions during
6 weeks)
Unclear Breast cancer 51 51 QOL EORTC QLQ-C30 Baseline, immediately
after the end
intervention
Cancer
center
7 Downey
etal.26
USA RCT Meditation (once
45 min, twice a week
until death)
Meditation
instructor
Hospice/
palliative care
patients
56 55 QOL Quality-of-life
ratings
Baseline, week 10 in the
intervention period, last
7 days of life
Home/
hospital
8 Lengacher
etal.38
USA RCT Mindfulness-based
stress reduction
(weekly 2-h session
for 6 weeks)
Psychologist Breast cancer 41 43 QOL SF36 Baseline, immediately
after the end
intervention
Cancer
center
9 Vermandere
2016
Belgium RCT Spiritual history taking
(once)
General
practitioners
and RN
A progressive,
life-threatening
disease
28 27 QOL/
SPW
EORTC
QLQ-C15-PAL/
FACIT-Sp-12
Baseline, immediately
after the end
intervention
Home
10 Jafari etal.31 Iran RCT Spiritual therapy
(once for 2–3 h
weekly during
6 weeks)
Spiritual healer Breast cancer 34 31 QOL/
SPW
QLQ-C30/FACIT-
Sp12
Baseline, immediately
after the end
intervention
Cancer
center
11 Chandwani
etal.43
USA RCT Yoga (biweekly during
6 weeks)
Yoga
instructor
Breast cancer 30 31 QOL SF-36 Baseline,1 week,
1 month, and 3
months after the end
intervention
Cancer
center
Chen et al. 1173
No. Author Country Study
design
Intervention
(frequency and
duration)
Intervention
performed by
Patients Sample
size
Primary
outcome
Measuring
instrument
Time of outcome
measurement
Settings
Inte1Con2
12 Ling 201442 China RCT Life review program
(weekly during
4 weeks)
RN Advanced
cancer
36 35 QOL EORTC QLQC30 Baseline, immediately
after the end
intervention
Hospital
13 Hall etal.40 UK Phase II
RCT
Dignity therapy (three
sessions, 2 weeks)
Trained
healthcare
professional
Advanced
cancer
12 14 QOL EQ-5D Baseline,1 and
4 weeks after the end
intervention
Palliative
care
center
14 Xiao etal.41 China RCT Life review program
(weekly during
3 weeks)
Master’s
degree in
nursing + RN
Advanced
cancer
35 37 QOL QLQC -E Baseline, immediately
after the program,
3 weeks after the end
intervention
Hospice
15 Chochinov
etal.39
Canada,
USA and
Australia
RCT Dignity therapy (four
sessions)
Psychologist,
psychiatrist, or
experienced
palliative-care
nurse
A terminal
prognosis (life
expectancy ⩽
6 months)
108 111 QOL/
SPW
Two-item Quality
of Life Scale/
FACIT-Sp
Baseline, immediately
after the end
intervention
Hospital/
hospice/
home
16 Ando etal.28 Japan RCT Short-term life-review
interviews (once
for 30–60 min, two
sessions, weekly)
Therapist,
clinical
psychologist
Cancer patients
with palliative
care
34 34 SPW FACIT-Sp Baseline, immediately
after the end
intervention
Hospital
17 Breitbart
etal.48
USA Pilot RCT Individual
meaning-centered
psychotherapy (1 h,
seven sessions,
weekly)
Clinical
psychologist
or psychology
doctoral
students
Stage III or IV
solid tumor,
cancers, or
non-Hodgkin’s
lymphoma
40 37 QOL/
SPW
MQOL/FACIT-Sp Baseline, immediately
following the end
intervention, and
2 months after
completing treatment
Cancer
center
18 Breitbart
etal.47
USA RCT Meaning-centered
group psychotherapy
(eight sessions,
weekly)
Psychiatrist,
clinical
psychologist,
or social
worker
Stage III or IV
cancer
93 79 QOL/
SPW
MQOL/FACIT-Sp Before and after
completing the
treatment and 2 months
after treatment
Cancer
center
19 Breitbart
etal.46
USA Pilot RCT Meaning-centered
group psychotherapy
(90 mins, eight
sessions, weekly)
Psychiatrist
or clinical
psychologist
Stage III or IV
solid tumor,
cancers, or
non-Hodgkin’s
lymphoma
49 41 SPW FACIT-Sp Before and after
completing the
treatment and 2 months
after treatment
Cancer
center
RCT: randomized controlled trials; QOL: quality of life; EORTC QLQC30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Version 3.0; SPW: spiritual well-
being; FACT-C: Functional Assessment of Cancer Therapy Colorectal; FACIT-Sp: Functional Assessment of Chronic Illness Therapy-Spiritual well-being; MVQOLI: Missoula Vitas QOL Index; FACT-B:
Functional Assessment of Cancer Therapy-Breast; SWB-20: spiritual health scale; WHOQOL-26: World Health Organization Quality of Life Scale; SF-36: 36-item short-form survey; EORTC QLQ-C15-
PAL: The European Organization of Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire—Core 15 Palliative; QLQC-E: The 28-item Quality-of-Life Concerns in the End-of-Life
Questionnaire; MQOL: the McGill Quality of Life Questionnaire; RN: registered nurse.
Table 1. (Continued)
1174 Palliative Medicine 32(7)
with patients (reading, engaging in conversation, writing let-
ters, and running errands) or alternatively providing respite
or other assistance to the patient’s caregivers. In another two
studies43,44 the patients in the control group received conven-
tional radiation therapy, while the intervention group
received 12 sessions of yoga/meditation during their 6-week
radiation therapy period. Three studies’ control group
received no intervention.24,30,45 Two studies’ control group
received supportive group psychotherapy.46,47 And the other
study’s control group received therapeutic massage.48
4. Outcome measures
In the selected studies, QOL was assessed by various
scales as follows: EORTC QLQ-C30,20 Functional
Assessment of Cancer Therapy Colorectal (FACT-C),49
Missoula-Vitas QOL Index (MVQOLI),50 Functional
Assessment of Cancer Therapy–Breast(FACT-B),51 World
Health Organization Quality of Life Scale (WHOQOL-26),52
36-item short-form survey (SF-36),53 EuroQoL-5D,54
EORTC QLQ-C15-PAL,55 The 28-item Quality-of-Life
Concerns in the End-of-Life Questionnaire (QLQC-E),56
two-item Quality of Life Scale57 and the McGill Quality of
Life Questionnaire (MQOL),58 Spiritual well-being was
assessed by Functional Assessment of Chronic Illness
Therapy-Spiritual well-being (FACIT-Sp)59 and spiritual
health scale (SWB-20).60
Quality of included studies
The Cochrane Risk of Bias Tool was used to assess the risk
of bias. All the studies were rated as B, suggesting the
moderate risk of bias. Even if all the included studies men-
tioned randomization, only 14 studies24,25,28,31,32,39–44,46–48
provided a detailed description of how the random
sequence generation produced. The methods of randomi-
zation described in the included studies included using a
random number table and a computer random generator.
Five studies stated that participants were randomly
assigned, but the details of randomization were not given.
Eleven studies24,25,27,28,32,39,40,42–44,48 reported the allocation
concealment. Most studies were not blinded for patients
because of the nature of spiritual interventions. Five
studies25,27,38,39,41 reported that assessors of outcomes were
blinded to the intervention groups. Four studies reported
no dropouts27,30,31,42. Two studies reported dropout but did
not give the reasons for dropouts.43,45 Other studies gave
the detailed reasons for dropouts. All studies were judged
to be at low risk bias of selective reporting. Risk of bias
within studies is shown in Figures 2 and 3.
Effects of spiritual care
QOL. A total of 17 studies explored the effects of spiritual
care on QOL. Among them, 12 studies27,30,31,38,39,41–45,47,48
representing 1115 participants reported that spiritual care
was significantly associated with improvement of QOL
statistically and clinically. Zamaniyan et al.30 conducted a
study to evaluate the effectiveness of spiritual group ther-
apy on QOL among patients with breast cancer. The results
Figure 2. Risk of bias summary: review authors’ judgments
about each risk of bias item for each included study.
Chen et al. 1175
showed a significant improvement in QOL (F = 13.26, df
= 1, p = 0.002). In this study, the experimental group
received 12 sessions of spiritual group therapy, including
self-consciousness, communication with God, prayer,
faith, and trust. An RCT of the effects of transcendental
meditation on QOL in older breast cancer patients showed
that transcendental meditation can improve overall QOL
(p = 0.037).27 Patients with advanced cancer receiving
IMCP and MCGP both showed significant greater
improvement in QOL.46–48 In addition, Chandwani et al. 43
conducted a study, during which yoga classes were taught
biweekly in the 6 weeks of radiotherapy, to examine the
effectiveness of yoga on QOL among breast cancer patients
undergoing radiotherapy. The results showed that the yoga
group reported significantly better general health percep-
tion (p = 0.05). The effects of spiritual care on subsections
of QOL are described below:
Physical function. Nine studies evaluated the effect of
spiritual care on physical function.24,27,30,31,38,41–44 Seven of
the nine studies with 514 participants found no significant
improvement in physical function.24,27,30,41–44 The other
two studies with 149 participants indicated a significant
effect of spiritual care on improving physical function.
Emotional well-being. Nine studies,24,27,31,38,39,41,42,44,45
including 896 participants, evaluated the effect of spiritual
care on emotional well-being. In the six studies,24,27,31,42,44,45
significant improvement was found in the spiritual care
group compared with controls in emotional well-being.
Two studies39,41 found significant decreases in negative
emotions such as sadness and depressions. In the other
study, the post-test score of emotional well-being of inter-
vention group was higher than control group but not statis-
tically significant (p = 0.1).
Social well-being. Seven studies24,27,31,38,42–44 evaluated the
effect of spiritual care on social well-being. Two studies24,43
adopted yoga intervention showed no significant improvement
in social well-being. One study38 showed that the post-test
score of social well-being of intervention group was higher
than that of the control group but not significant (p = 0.2).
The other four studies showed significant improvement of
spiritual care in social well-being.
Spiritual well-being. Ten studies24,27,28,30–32,39,46–48 reported
the effect of spiritual care on spiritual well-being. Seven of
these studies28,30,31,39,46–48 indicated that spiritual care had a
significantly favorable influence on spiritual well-being.
These seven studies all adopted spiritual interventions
using a narrative approach, including sharing and discuss-
ing meaning and purpose, reviewing one’s story, focusing
on description of inner emotions, and facilitating intimate
relationships with others. Zamaniyan et al.30 found that
spiritual group therapy was beneficial for the spiritual
well-being of breast cancer patients (F = 11.62, df = 1, p
= 0.003). Ando et al.28 examined the effect of short-term
life review intervention on the spiritual well-being among
terminal cancer patients. The FACIT-Sp scores in the inter-
vention group showed significantly greater improvement
compared with that of the control group (F = 16.2, p <
0.001). An RCT investigated the role of spiritual therapy in
improving the spiritual well-being of women with breast
cancer.31 After six spiritual therapy sessions, the mean
spiritual well-being score increased from 29.76 (standard
deviation (SD) = 6.63) to 37.24 (SD = 3.52) in the inter-
vention group (p < 0.001). Chochinov et al.39 conducted an
RCT to examine the efficacy of dignity therapy in termi-
nally ill patients. The spiritual well-being was assessed at
baseline and at the end of the study intervention. This
study showed that dignity therapy was significantly better
in improving the spiritual well-being (χ2 = 10.35, p =
0.006). Studies of IMCP and MGCP46–48 all showed that
this kind of spiritual care had a significant favorable influ-
ence on the spiritual well-being among patients with
advanced cancer. In the studies of yoga24 and meditation,27
no significant group differences for spiritual well-being
scores were found.
Figure 3. Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included
studies.
1176 Palliative Medicine 32(7)
Discussion
Primary findings
This is the first systematic review to assess the clinical
application and scientific effects of spiritual care on
patients with terminal illness by examining the effective-
ness of spiritual care on QOL and spiritual well-being.
Nineteen studies with a sample of 1548 participants met
the inclusion criteria. Noticing the characteristics of spir-
itual care, we divided spiritual care interventions into nar-
rative spiritual care and non-narrative spiritual care. Trial
participants mostly had a diagnosis of advanced cancer,
AIDS, progressive, or life-threatening disease. This sys-
tematic review found that spiritual care had a potential
beneficial effect on global QOL and spiritual well-being.
Our finding of a promising effect on global QOL is con-
sistent with the meta-analysis on spiritual interventions
addressing existential themes that Kruizinga et al.61 con-
ducted in 2015. Three types of interventions were analyzed
in this study: life reviewing interventions, multidiscipli-
nary interventions, and meaning-making interventions.
This study found that spiritual interventions increase
patients’ QOL directly after the intervention, but the het-
erogeneity was high (I2 = 84%). Another Cochrane review
conducted by Candy et al.,34 evaluating palliative care
interventions and meditation, found no significant differ-
ence between those receiving interventions and usual care
on QOL or well-being. This review identified five studies,
and all were undertaken in a single country. The evidence
presented in this review was weak because limited popula-
tions and studies had been taken. In our systematic review,
it is necessary to describe the effects of spiritual care sepa-
rately because of the differences among the intervention
types. Spiritual interventions using a narrative approach
were found to display a promising effect on global QOL,
regardless of whether it was a group intervention or indi-
vidual intervention. It was difficult to answer the question
that spiritual interventions using a non-narrative approach
may or may not increase patients’ QOL. In the two studies
of yoga interventions, one showed significant improve-
ment on global QOL,45 and the other reported significant
differences in general health and physical function but not
in other subscales of QOL.43 In the other study of yoga,
significant differences were found in emotional well-being
but not in global QOL score.24 For the meditation therapy,
two studies27,44 showed that the patients who received
meditation saw improvements in global QOL. However, in
the other study of meditation,25 the meditation combined
with massage group showed significant improvement in
the overall QOL, a change significantly greater than that of
the meditation, massage, and control groups. We are not
entitled to conclude that narrative spiritual interventions or
non-narrative spiritual interventions are more beneficial
for terminal patients, because the aims of these two types
of spiritual interventions are different. Spiritual care using
a non-narrative approach, such as yoga and transcendental
meditation, provides a great pathway for patients to relieve
their stress and acquire inner peace through breathing tech-
nique, relaxation, and meditation. Acquiring peace of mind
is the core intent of this type of spiritual care. Spiritual care
using a narrative approach, such as dignity therapy, life
review, and spiritual group therapy, encourages patients to
express both negative and positive life events. When
patients talk about life events, they may relieve their nega-
tive emotions and try to accept the past.29 In addition, nar-
rative spiritual care helps patients to express love to
relatives, receive and give love, and reconstruct intimate
relations.
In addition, this review showed a favorable influence of
narrative spiritual interventions on spiritual well-being.
The seven studies that showed significant improvement in
spiritual well-being all adopted spiritual interventions using
a narrative approach. Narrative spiritual care was about
actively listening to patient stories, building intimate rela-
tionships, and involved effective communication. Patients
continuously refined their stories about certain events and
discovered their own “multivoice-self.”62 Non-narrative
spiritual care such as yoga, meditation, and MBSR, put
more emphasis on peace of mind and stress reduction. The
focus of these two types of spiritual interventions was dif-
ferent. The choice of tools may have an impact on the
measurement of results. In most included studies, spiritual
well-being was assessed by FACIT-Sp-12. Only in one
study, spiritual well-being was assessed by SWB-20. In
FACIT-Sp-12, most items were relevant to meaning, pur-
pose, achievement, and hope of life and two items were
relevant to inner peace. The items of FACIT-Sp-12 empha-
size more meaning and purpose than peace of mind. So
there is a possibility that delivery of narrative spiritual care
is more beneficial to raise the score of the items about
meaning and purpose of existence when using FACIT-Sp-12.
Spiritual care was performed by various therapists in
palliative care, mostly trained professionals such as nurses,
psychologists, trained instructors, and chaplains. In fact,
all staff can help in this area. Nurses were often seen to be
the ones to provide spiritual care, because they have the
view of holistic care and they are the most widely acces-
sible care providers to patients. Doctors were expected to
talk about some spiritual issues with patients as well,
although nurses and nursing home physicians identified
spiritual issues more often than doctors did. A mixed group
of multi-professional members is also a good way to pro-
vide spiritual interventions.
Methodology limitations of the studies
Through our searching on a variety of databases and qual-
ity assessment, we found that high-quality evidence of
spiritual care is lacking. Considering that the risk of bias of
all the included studies was rated as moderate, our results
Chen et al. 1177
should be interpreted with caution. The key issue of the
quality was lack of blinding. No study blinded the partici-
pants and only five studies blinded the outcome assessors.
When not blinded to the spiritual care interventions, par-
ticipants may tend to generate the Hawthorne effect. When
not blinded to the process of outcome assessment, the out-
come assessors may be influenced by the subjective con-
sciousness. Although the blind is required, it is really
difficult to achieve the blinding of participants because of
the nature of spiritual care interventions.
Implications for clinical practice and research
Healthcare professionals play an important role in pallia-
tive care to help patients cope with illness-related spiritual
distress. In view of the benefits of spiritual care for QOL
and spiritual well-being, it s suggested that healthcare
professionals should provide spiritual care as a part of
health-care treatment plan in palliative care. Some recom-
mendations may be helpful when a spiritual intervention
is conducted. First, healthcare professionals should make
an appropriate choice of spiritual care interventions for
patients according to their spiritual needs, preference, and
spiritual tradition. Second, an appropriate plan should be
made according to patients’ health condition and a daily
schedule to guarantee the completeness of the interven-
tion. Third, one’s spiritual need is under the influence of
the cultural background. Different cultures should be con-
sidered when providing spiritual care, especially when
providing spiritual interventions that involved religion.
People with religious beliefs are not accustomed to par-
ticipating in activities that do not fit their culture and reli-
gious customs.
This review also reveals suggestions for the future
research. First, high-quality studies with rigorous methods
are needed. Proper randomization and allocation methods
should be followed more adequately. It is difficult to
achieve the blinding of participants because of the nature
of spiritual care interventions. Researchers should make
efforts to achieve blinding of outcome assessment. Besides,
dropout rates should be controlled. Second, under the
premise of ensuring cultural validity, a validated and con-
sistent outcome instrument is recommended for measuring
the same outcome across the studies. In our review, due to
the variety of instruments used in the studies, it is not suit-
able to conduct a meta-analysis because of the heterogene-
ity. Third, multicenter and interdisciplinary researches of
spiritual care have been suggested.
Limitations of the review
Given the risk of bias inherent in the included trials and the
heterogeneity among the different spiritual interventions,
the results should be interpreted and generalized with cau-
tion. First, there was a disparity in the intensity, duration,
and frequency of the interventions, making it difficult to
compare the effectiveness across the interventions. Second,
providing spiritual care in diverse cultural backgrounds
may result in different outcomes, which may limit its
appropriateness and uptake. Third, there were some chal-
lenges to define spiritual care and the terms we used in the
search strategy may have been insufficient to contain all
the relevant interventions. Besides, the option of limiting
the language to English and Chinese may induce publica-
tion and language bias.
Conclusion
In summary, this systematic review displayed promising
effects of spiritual care on the global QOL and spiritual
well-being among patients with terminal illness. We
divided spiritual care into narrative spiritual care and non-
narrative spiritual care according to the characteristics of
the interventions. We are not entitled to conclude that nar-
rative spiritual interventions or non-narrative spiritual
interventions are more beneficial for terminal patients,
because the aims of these two types of spiritual interven-
tions are different. It is suggested that healthcare profes-
sionals integrate spiritual care with usual care in palliative
care. When providing spiritual care, healthcare profession-
als should take into consideration patients’ spiritual needs,
preference, and cultural background. More multicenter
and disciplinary studies with structured and rigorous
designs are needed in the future.
Acknowledgements
The authors thank librarian Lin Feifei for her contribution in the
search strategy and Yu Dehai for his help in the English revision
of the manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Supported by postgraduate student research funds of Fujian
Medical University and the Key Discipline Program of Fujian
Province (No.2013XK004-0000-081596).
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