Commentary.

Understanding, assessing, and addressing spiritual beliefs of patients with chronic, advanced, progressive, life-limiting illnesses are significant components of comprehensive multidimensional palliative care.[1] Spirituality is an aspect which is strongly influenced by a person's sociocultural context and faith.[2] Hence, exploring spirituality involves a cultural formulation which needs to be kept in mind when dealing with this issue, especially in health care. The authors have most rightly and timely highlighted this topic in their article, in which they sought to address assessment of spiritual concerns of patients with chronic, life-limiting illness by their clinicians, using a suitably tailored measure which aims to add unique dimensions of spiritual belief systems in India.[3]

Patient outcomes involving spirituality need to be considered in clinical and research settings. It is important to have a tool which the palliative care clinicians can use readily in their routine practice to be able to screen their patients for spiritual distress and then incorporate managing these concerns/issues in the total management plan. Cultural bias is a hindering factor in adapting tools which are available and devised in the developed countries with Caucasian populations for use in other ethnicities and countries. A recent literature review has addressed this topic and reported that there are nine tools identified which may have cross-cultural utility for research purposes.[2]

The authors of this study have developed a spirituality questionnaire for use by clinicians in a neat and stepwise manner, keeping cultural influence in focus.[345] The questionnaire used has 36 items, with four factors relating to values, support, “spiritual trust,” and “existential blame”.[3] The finding of belief in God or higher power rings true, as is reported in literature as well as in our routine practice. The transcendence of spirituality is reflected in the patients reporting seeking of connection with this higher power through prayers, puja, or chanting. The transcendence is universal; however, the specific way/s of coping. achieving this transcendence is/are very Indian, reflecting the patients’ particular faith (80% of the study population were Hindus), as also reported in other studies in our country.[6] The inclusion of both positive and negative connotations of patients’ spiritual beliefs is captured very well by this tool in this study population.

The authors have also explored the differences in how male and female patients differ in their spiritual beliefs. Gender has been found to be a significant factor influencing spirituality in advanced cancer patients in a different ethnic and cultural context.[7] In a country where gender bias is evident in all sectors, how an illness is interpreted by men and women is understandably different.[8] It is, therefore, all the more vital to explore these differences in routine clinical practice, in order to be able to institute appropriate spiritual care for the patients.

The authors have given their recommendations for undertaking a spiritual history and assessment in caring for the palliative care patients in the Indian cultural milieu. Using the appropriate language for this sensitive task is the key to starting a discussion on spiritual beliefs. The general and specific guidelines put up by the authors can be implemented by palliative care physicians and, indeed, by all other health-care professionals working in this area.

India is the land of multiple faiths and has its very own culture, which seeps into the spiritual beliefs and practices of our patients as well as our clinicians, making the task of learning, and assessing spirituality an even more monumental one. Therefore, the questionnaire developed and used by the authors has 36 items to be able to capture all facets of this dimension from the patients. Further studies for using this questionnaire with other faiths may give us an insight into those specific patient groups. Furthermore, as spirituality is a major component in palliative medicine curriculum, the authors’ contribution in this area takes us a big step forward in continuing professional development for health-care professionals.

Spirituality is a deeply personal concept with unique cultural influences, and to understand our palliative care patients, we have to be spiritually Indian.