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DSM-IV Religious and Spiritual Problems

LESSON 2.5 Terminal and Life-Threatening Illness

Description Associated Clinical problemsTreatmentCase ExamplesWWW Library

Although listed here as a religious problem, both religious and spiritual beliefs and practices can influence the ways patients react to illness. This is particularly true in the case of terminal illnesses that raise fears of physical pain, the unknown risks of dying, the threat to integrity, and the uncertainty of life after death. In addition, religious and spiritual changes often occur during terminal illness related to feelings of loss, alienation, abandonment, anger, suffering; and dependency. Issues such as forgiving others, discovering peace, discussing death, grieving, and planning the funeral often involve religion. Loss of hope and meaning of life evident in some patients, and the transitions from living to dying are essentially spiritual, and clearly not solely physiological, psychological, or social.[1]

Religious coping is one of the main strategies used to address these fears, along with exercising self-control and talking to friends and family about them. In her research on narrative life story therapy with the elderly, Viney [2] found that prayer was particularly helpful for dying persons: "Talking with God can provide opportunity to make the pain meaningful, confront the risks, confirm the integrity and give more certainty about life after death" (p. 165).

(See ICISH Research Summary of religion and the elderly)

Associated Clinical Problems
The nursing diagnostic nomenclature specifically notes that Spiritual Distress can be related to the inability to practice religious rituals, and the conflict between religious or spiritual beliefs and prescribed health regimen[3] (as illustrated in the case example below). Religious beliefs, participation in religious rituals, and affiliation with a religious community can all be affected by serious illness. Loss or questioning of faith, anger at God, guilt over "sins", and discontinuation of religious practices are frequent sequelae of terminal and life-threatening illness.

In hospices, treatment of the terminally ill has been generally recognized to include a spiritual dimension. Hospice philosophy and accreditation standards require that spiritual care be a component of hospice care. Spirituality is useful in addressing "why me?" questions that patients frequently raise, and therapists and caregivers should actively support and facilitate spiritual thinking in terminally ill patients. Millison [4] maintains that "The caregiver needs to understand the power of spiritual beliefs in helping the patient cope with dying, and needs to be aware of the ways that spiritual striving can be helped, hindered, or undermined." Many terminal patients return to their childhood religious beliefs and practices, while others search for new forms of spirituality. Treatment often includes working with or consulting with a religious professional. For many with a serious or life-threatending illness, the same questions and concerns arise.

Conducting a Religious and Spiritual History is usually an important part of this type of clinical work. (See lesson on Assessing Spirituality)

Case Examples
A woman hospitalized with a spinal injury following an automobile accident showed symptoms consistent with a depressive disorder, and the consulting psychiatrist found that she missed the religious and spiritual practices that were part of her life before the hospitalization. The consultant recommended psychotherapy to explore her religious belief's in light of her accident, and helped her obtain a tape player so she could listen to religious music. A clergy member of her faith was contacted and made several hospital visits to provide support. The authors concluded, "Although religious interventions are not substitutes for therapeutic interventions, 'religious prescriptions' are ethically sound and may complement more traditional therapies" (p. 475).
Waldfogel S, Wolpe PR. Using awareness of religious factors to enhance interventions in consultation-liaison psychiatry. Hosp Community Psychiatry 1993 May;44(5):473-7

This is case study of a patient who experienced "losing God" as a Hodgkin's disease survivor with metastatic prostate cancer and severe coronary artery disease. His caregivers were able to provide the sense of community in which he could re-establish his faith. Health care providers do not have to be religious in order to help patients deal with a spiritual crisis. The clinical skills of compassion need to be deployed to diagnose and respond to spiritual suffering. Acknowledging and addressing anger or guilt, common sources of suffering, are essential to adjustment. Simply being there for the patient and being open to their hurt can help resolve their spiritual crisis.
Penson RT, Yusuf RZ, Chabner BA, Lafrancesca JP, McElhinny M, Axelrad AS, Lynch TJ Jr. Losing God. Oncologist 2001;6(3):286-97

WW LIBRARY of Religion and Spirituality
The WWW LIBRARY of Religion and Spirituality contains articles on spiritual issues in dying, interviews with Elizabeth Kubler-Ross MD and Stephen and Ondrea Levine.

Spiritual Care


According to the authors of Losing God, what factors confound spiritual aspects of cancer care? a) nebulous language b) distrust c) dogma d) all of the above.

Record your answer for later insertion into the Quiz.

Aldridge, D. (1993). Is there evidence for spiritual healing? Advances, 9(4), 5-21.

2 Viney, L (1993) Life stories: Personal construct therapy with the elderly.NY: Wiley.

3 Kim MJ, McFarland G, McLane A (eds): Classification of Nursing Diagnoses: Proceedings of the Fifth National Conference. St. Louis, CV Mosby, 1984.

4 Millison, M. (1988). "Spirituality and the caregiver: developing an underutilized facet of care." The American Journal of Hospice Care: 37-44.



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