Skip to main content Accessibility help

Frequency, intensity, and correlates of spiritual pain in advanced cancer patients assessed in a supportive/palliative care clinic

  • Marvin Omar Delgado-Guay (a1), Gary Chisholm (a2), Janet Williams (a1), Susan Frisbee-Hume (a1), Andrea O. Ferguson (a1) (a3) and Eduardo Bruera (a1)...



Regular assessments of spiritual distress/spiritual pain among patients in a supportive/palliative care clinic (SCPC) are limited or unavailable. We modified the Edmonton Symptom Assessment Scale (ESAS) by adding spiritual pain (SP) to the scale (0 = best, 10 = worst) to determine the frequency, intensity, and correlates of self-reported SP (≥1/10) (pain deep in your soul/being that is not physical) among these advanced cancer patients.


We reviewed 292 consecutive consults of advanced cancer patients (ACPs) who were evaluated at our SCPC between October of 2012 and January of 2013. Symptoms were assessed using the new instrument (termed the ESAS–FS).


The median age of patients was 61 (range = 22–92). Some 53% were male; 189 (65%) were white, 45 (15%) African American, and 34 (12%) Hispanic. Some 123 of 282 (44%) of ACPs had SP (mean (95% CI) = 4(3.5–4.4). Advanced cancer patients with SP had worse pain [mean (95% CI) = 5.3(4.8, 5.8) vs. 4.5(4.0, 5.0)] (p = 0.02); depression [4.2(3.7, 4.7) vs. 2.1(1.7, 2.6), p < 0.0001]; anxiety [4.2(3.6, 4.7) vs. 2.5(2.0, 3.0), p < 0.0001]; drowsiness [4.2(3.7, 4.7) vs. 2.8(2.3, 3.2), p < 0.0001]; well-being [5.4(4.9, 5.8) vs. 4.5(4.1, 4.9), p = 0.0136]; and financial distress (FD) [4.4(3.9, 5.0) vs. 2.2(1.8, 2.7), p < 0.0001]. Spiritual pain correlated (Spearman) with depression (r = 0.45, p < 0.0001), anxiety (r = 0.34, p < 0.0001), drowsiness (r = 0.26, p < 0.0001), and FD (r = 0.44, p < 0.0001). Multivariate analysis showed an association with FD [OR (95% Wald CI) = 1.204(1.104–1.313), p < 0.0001] and depression [1.218(1.110–1.336), p < 0.0001]. The odds that patients who had SP at baseline would also have SP at follow-up were 182% higher (OR = 2.82) than for patients who were SP-negative at baseline (p = 0.0029). SP at follow-up correlated with depression (r = 0.35, p < 0.0001), anxiety (r = 0.25, p = 0.001), well-being (r = 0.27, p = 0.0006), nausea (r = 0.29, p = 0.0002), and financial distress (r = 0.42, p < 0.0001).

Significance of results:

Spiritual pain, which is correlated with physical and psychological distress, was reported in more than 40% of ACPs. Employment of the ESAS–FS allows ACPs with SP to be identified and evaluated in an SCPC. More research is needed.


Corresponding author

Address correspondence and reprint request to Marvin Omar Delgado-Guay, Palliative Care and Rehabilitation Medicine, Unit 1414, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030-4009. E-Mail:


Hide All
Alcorn, S.R., Balboni, M.J., Prigerson, H.G., et al. (2010). “If God wanted me yesterday, I wouldn't be here today”: Religious and spiritual themes in patients' experiences of advanced cancer. Journal of Palliative Medicine, 13, 581588.
Arnold, B.L. (2011). Mapping hospice patients' perception and verbal communication of end-of-life needs: An exploratory mixed methods inquiry. BMC Palliative Care, 10, 1.
Astrow, A.B., Wexler, A., Texeira, K., et al. (2007). Is failure to meet spiritual needs associated with cancer patients' perceptions of quality of care and their satisfaction with care? Journal of Clinical Oncology, 25(36), 57535757.
Balboni, T., Vanderwerker, L, Block, S., et al. (2007). Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. Journal of Clinical Oncology, 25, 550560.
Balboni, T.A., Paulk, M.E., Balboni, M.J., et al. (2010). Provision of spiritual care to patients with advanced cancer: Associations with medical care and quality of life near death. Journal of Clinical Oncology, 28(3), 445452.
Bruera, E., Kuehn, N., Miller, M.J., et al. (1991). The Edmonton Symptom Assessment System (ESAS): A simple method for the assessment of palliative care patients. Journal of Palliative Care, 7, 69.
Delgado-Guay, M.O. (2014). Spirituality and religiosity in supportive and palliative care. Current Opinion in Supportive and Palliative Care, 8(3), 308313.
Delgado-Guay, M.O., Hui, D., Parsons, H.A., et al. (2011). Spirituality, religiosity, and spiritual pain in advanced cancer patients. Journal of Pain and Symptom Management, 41(6), 986994.
Delgado-Guay, M.O., Parsons, H.A., Hui, D., et al. (2013). Spirituality, religiosity, and spiritual pain among caregivers of patients with advanced cancer. The American Journal of Hospice & Palliative Care, 30, 455461.
Fitchett, G. & Risk, J.L. (2009). Screening for spiritual struggle. Journal of Pastoral Care & Counseling, 62(1–2), 112.
Handzo, G. (2011). Spiritual care for palliative patients. Current Problems in Cancer, 35(6), 365371.
Koenig, H.G. (2005). Faith and mental health: Religious resources for healing. West Conshohocken, PA: Templeton Foundation Press.
Koenig, H.G., King, D. & Carson, V.B. (2012). Handbook of religion and health, 2nd ed.New York: Oxford University Press.
Lunder, U., Furlan, M. & Simonic, A. (2011). Spiritual needs assessments and measurements. Current Opinion in Supportive and Palliative Care, 5(3), 273278.
Mako, C., Galek, K. & Poppito, S.R. (2006). Spiritual pain among patients with advanced cancer in palliative care. Journal of Palliative Medicine, 9, 11061113.
Miller, I., Wickramaratne, P., Gameroff, M.J., et al. (2012). Religiosity and major depression in adults at high risk: A ten-year prospective study. The American Journal of Psychiatry, 169(1), 8994.
Moritz, S., Kelly, M.T., Xu, T.J., et al. (2011). A spirituality teaching program for depression: Qualitative findings on cognitive and emotional change. Complementary Therapies in Medicine, 19(4), 201207.
Nadarajah, S., Berger, A.M. & Thomas, S.A. (2013). Current status of spirituality in cardiac rehabilitation programs: A review of the literature. Journal of Cardiopulmonary Rehabilitation and Prevention, 33, 135143.
Peteet, J.R. (2012). Spiritually integrated treatment of depression: A conceptual framework. Depression Research and Treatment, 2012, 16.
Philip, J., Smith, W., Craft, P., et al. (1998). Concurrent validity of the modified Edmonton Symptom Assessment Scale (ESAS) with the Rotterdam Symptom Checklist and the Brief Pain Inventory. Supportive Care in Cancer, 6, 539541.
Porzio, G, Ricevuto, E., Aielli, F., et al. (2005). The supportive care task force at the University of L'Aquila: Two-years experience. Supportive Care in Cancer, 13, 351355.
Rees, E., Hardy, J., Ling, J., et al. (1998). The use of the Edmonton Symptom Scale (ESAS) within a palliative care unit in the UK. Palliative Medicine, 15, 213214.
Ross, L. & Austin, J. (2015). Spiritual needs and spiritual support preferences of people with end-stage heart failure and their carers: Implications for nurse managers. Journal of Nursing Management, 23(1), 8795.
Stromgren, A.S., Groenvold, M., Peterson, M.A., et al. (2004). Pain characteristics and treatment outcome for advanced cancer patients during the first week of specialized palliative care. Journal of Pain and Symptom Management, 27, 104113.
Watanabe, S.M., Nekolaichuk, C.L. & Beaumont, C. (2012). The Edmonton Symptom Assessment System, a proposed tool for distress screening in cancer patients: Development and refinement. Psycho-Oncology, 21, 977985.
Williams, J.A., Meltzer, D., Arora, V., et al. (2011). Attention to inpatients' religious and spiritual concerns: Predictors and association with patient satisfaction. Journal of General Internal Medicine, 26(11), 12651271.
Yennurajalingam, S., Urbauer, D.L., Casper, K.L., et al. (2011). Impact of a palliative care consultation team on cancer-related symptoms in advanced cancer patients referred to an outpatient supportive care clinic. Journal of Pain and Symptom Management, 41(1), 4956.


Frequency, intensity, and correlates of spiritual pain in advanced cancer patients assessed in a supportive/palliative care clinic

  • Marvin Omar Delgado-Guay (a1), Gary Chisholm (a2), Janet Williams (a1), Susan Frisbee-Hume (a1), Andrea O. Ferguson (a1) (a3) and Eduardo Bruera (a1)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed