Spirituality - Toolkit - Brown University

SPIRITUALITY

Overview

One of the key concerns of dying patients that needs to be supported is their spirituality. The need for attentiveness to patients’ spiritual concerns has been well recognized by many authors, some of whom are included for reference (Conrad 1985, Moberg 1982, Byrne 1979, Gartner 1991, Larson 1991, Moberg 1965, Poloma 1991). The term "spirituality" has been used in different ways by different authors (Burkhardt 1989). A broad, inclusive definition is: spirituality is that which gives meaning to one's life and draws one to transcend oneself. Spirituality is a broader concept than religion, although that is one expression of spirituality. Other expressions include prayer, meditation, interactions with others or nature, and relationship with God or a higher power. Spirituality was cited as integral to the dying person's achievement of the developmental task of transcendence and important for health care providers to recognize and foster (Highfield. Mudd, Millson 1992): "The physician will do better to be close by to tune in carefully on what may be transpiring spiritually, both in order to comfort the dying to broaden his or her own understanding of life at its ending"(Leighton 1996).

Some spiritual identifiers that one could assess in patients in the last month of life are: 1) is there purpose to their life as they suffer, 2) are they able to transcend their suffering and see something or someone beyond that, 3) are they at peace, 4) are they hopeful or do they despair, 5) what nourishes that sense of value of themselves: prayer, religious commitment, personal faith, relationship with others, 6) do their beliefs help them cope with their anxiety about death, with their pain, and with achieving peace. Finally, one needs to assess how well the patient's spiritual needs are being met: 1) do the health care providers listen to their beliefs, faith, pain, hope or despair, 2) are they able to express or develop their spirituality through prayer, art, writing, reflections, guided imagery, religious or spiritual readings, ritual, or connection to others and God.

Literature Review

A literature review of the Medline, Cancerlit and Bioethics database was conducted with the search terms spirituality, spiritual, religiousness, religious, religiosity, transcendence, quality of life and palliative care or terminal care. In addition, the psychology search program on Aladdin was used to find specific articles on religiousness measures. In addition we received articles from studies conducted by Dr. L VandeCreek. We found 74 articles published between 1967 and 1997.

I. Listing of Potential Instruments

Based on review of these 74 articles, we found 25 potential instruments for consideration. These are divided into four groups of scales which measure: 1) quality of life, 2) attitudes, 3) religiousness, and 4) spirituality.

1. Quality of Life

Nine of these are quality of life measures which are mostly functional. Some of these have two or three questions related to spirituality. However, for the most part they are functional assessments and therefore will not be described in depth here but just listed:

a. McGill Quality of Life Questionnaire (Cohen 1995): 3 of 20 questions relevant to spirituality.

b. Missoula-VITAS Quality of Life Index (Byock 1995)

c. McMaster Health Index Questionnaire (Chambers 1982): 3 questions of 24 are spiritual.

d. McAdam and Smith index of quality of life (McAdam 1987): section on spirituality in an index designed for the terminally ill.

e. QL Index, HIRC-QL, Uniscale QL (Morris 1986) National Hospice Study

f. Ferrans and Powers Quality of Life Index (Ferrans 1985): 4 of 34 questions relevant to spirituality.

g. The Hospice Index (McMillan 1994): 3 of 26 questions relevant to spirituality

2. Attitude Indices

a. Death Attitude Profile (Gesser 1987): A 21 item self-administered questionnaire for administration to a general population.

b. Life Attitude Profile: a 36 item multidimensional profile developed and tested in a college population and more recently in hospitalized patients and out patients. This is an excellent instrument for assessing spiritual needs but may need to be modified for a terminally ill population.

c. McCanse Readiness for Death Instrument (McCanse 1995): a 28 item structured interview questionnaire tested and verified in a terminally ill population. Four conceptual categories are included: withdrawal from internal and external environment, decreased social interaction, increased death acceptance behaviors and increased admission of readiness to die.

d. Templer's Death Anxiety Scale (Aday 1984): a 15 true false item structured interview questionnaire tested in a college age population.

e. Purpose in Life Test(PIL) (Crumbaugh 1964): a 20-item attitude scale with emphasis on the need for purpose and meaning in life. Used in patients with acute leukemia in the later stages of their disease. This was developed to test the concepts of logotherapy developed by Victor Frankl.

f. The Seeking of Noetic Goals Test (SONG) (Crumbaugh 1977): a 20-item scale which assesses the respondent's motivation to find additional meaning in his or her life.

3. Religiousness

a. Religious coping scale (Pargament 1990): a 50-item scale with religious and spiritual as well as non-religious, more psychological coping activities tested in a Christian church population. The authors make some conclusions as to what type of religious coping mechanisms are helpful in difficult situations.

b. Religious Orientation Measure (Allport 1967): a 20-item self-administered questionnaire measuring the extrinsic (religion as a means to self-serving ends) and intrinsic (religion as an end in itself) dimensions of respondents. This is an extremely well-tested and widely used scale in many different populations used to assess religiousness.

c. Quest scale (Batson 1991): a 12-item self-administered questionnaire introducing a third dimension to religiousness in addition to intrinsic and extrinsic: the quest dimension with questions related to life's meaning, meaning of death, and of others. This was tested in a college-aged population and used in the general population, but not specifically in hospital populations.

d. The Religiousness Scale (Stryhorn 1990): a 12-item self-administered scale tested and verified in families of head-start children and subsequently used in the general population, including hospitalized and out patients. A good scale for determining the nature of a person's religion: their commitment, level of participation in their religion and relationship with God.

e. Religious Coping (Koenig 1992): a 3-item index given by interview; each item measures how much the patient relied upon religion to help manage emotional stress associated with an illness. Tested in a VA population of geriatric males and used in studies on depression.

4. Spirituality

a. Spiritual Well-Being Scale (Paloutzian 1982): a 20-item self-administered scale with two dimensions: religious and existential. Tested in a college population.

b. Death Transcendence Scale (VandeCreek 1993, Hood 1983): a 25-item self-administered scale based on the premise that "death is transcended through identification with phenomena more enduring than oneself." This scale has been tested in a diverse adult sample including the hospital setting..

c. Meaning in Life Scale (Warner 1987): 15-item administered by interview, tested in a facility for the chronically and terminally ill. The intent is for the patient to report his or her assessment of the worth of life remaining.

d. Herth Hope Index (Herth, 1990): a 12-item interview containing three dimensions: temporality and future, positive readiness and expectance, and interconnectedness. Tested on family caregivers of terminally ill people and terminally ill persons aswell as in community and hospital patients and family members.

e. Index of Core Spiritual Experiences (INSPIRIT) (Kass 1991): an 18-item interview scale used for spiritual assessment in general population as well as hospital patients.

f. Spiritual Perspective Scale (Reed 1987): a 10-item structured interview or questionnaire format administered in healthy and terminally ill adults shown to be reliable, accurate and relevant in those populations.

g. FACT-Sp (Fitchett 1996): a 12-item scale that can be used alone or with the FACT-G, a general measure developed for cancer patients. Items examine faith and sense of purpose and meaning in life.

II. Review of Potential Instruments

A. The Meaning in Life Scale (ML) (Warner and Williams, 1987).

i. Conceptual and Measurement Model (Does the scale represent a single domain or do model scales measure distinct domains? Is the variability of the scale reported? If so, please document it. What is the intended level of measurement, i.e. ordinal, interval, ratio or category?)

The ML scale is a 15-item interviewer administered scale used for reporting the patient's assessment of the worth of life remaining. There are a number of measures used to rate a patient's satisfaction with life, work etc. The ML scale was designed to reach beyond the dimensions or domains covered by life satisfaction and life measures. The authors define meaning in life as "centered in a sense of purpose, beliefs and statements of faith." The scale was developed in a four phase project using the following groups: patients suffering from chronic disease, patients with a terminal illness, relatives, and health professionals. It was finally tested in a group of 224 residents of facilities for the chronically ill, 61 terminally ill patients, and 59 renal dialysis and myocardial infarct patients. It has been referenced in a number of articles on Spiritual Assessment.

The scale consists of both positive and negative items. For the analysis the negative items were recoded so as to correspond to the positive ones. The scores for the items range from 1, a low negative meaning, to 5, a high positive meaning. Responses were on the positive side of the rating scale but there were clusters of low scores as well.

ii. Reliability (Did they address internal consistency? Did they address reproducibility?)

Internal consistency was assessed: Cronbach alpha was acceptably high (0.78). The test- retest correlations ranged from 0.27-0.58: 5 of the 15 items had stability correlations of 0.40 or less. It was not clear why this was so but the authors agreed these would need further examination.

iii. Validity (How did they address content reliability? Any information on construct related validity? Any information on criterion validity?)

Correlation matrices were obtained for the ML with other measures. The ML correlated in predicted ways with other scales (pain, social support, activity). Construct validity of this scale is further discussed in a doctoral thesis (Warner, SC "The Measurement of Subjective Variable in Epidemiology: Development and Validation of an Instrument for Quantifying Self-Perceived Meaning in Life among the Chronically Ill Institutionalized Elderly." Ann Arbor, Michigan: The University of Michigan, 1986.)

iv. Responsiveness (Any information? Has the scale ever been used as an outcome measure? If so, what populations?)

No information available.

v. Interpretability (What populations has it been applied to? Is the score translated into a clinically relevant event? Does the score predict outcome events?)

It has been used in the elderly, chronically ill and terminally ill population, but studies have yet to be done to show that their meaning in life can be modified in response to palliative care.

vi. Burden (Any information on cost or time to administer? Does the instrument impact on the respondent? How long does a survey take to complete? Response rates? Any problems with the missing data?)

The scale is short and easy to administer. It is acceptable to clinicians and patients. It is not highly influenced by socially desirable responses.

vii. Alternative forms (What are the modes of administration? Alternatives? If an alternative exists, provide what is known for each of the above categories.)

A visual analog version called the Meaning in Life Uniscale was developed and tested as well. The distribution, means, and standard deviation for the two testings of this scale were nearly identical. The ML however was noted to be more stable over two testings(0.73) than the uniscale (0.59).

viii. Cultural and Language Adaptations (any information?)

It has been translated into French and back into English to test the compatibility of content.

B. Spiritual Well-Being Scale (Paloutzian and Ellison, 1982)

A 20-item self-administered scale designed to measure spiritual well-being in both its religious (RWB) and existential (EWB) senses. Two subscales are included: 1) RWB, 10 religious items contain a reference to God; 2) EWB, 10 items with no reference to God. In order to control for response-set problems, half the items from each subscale were worded in positive and negative directions.

The SWB Scale yields three scores: 1) a total SWB score; 2) a summed score for religious well-being item, 3) a summed score for existential well-being items.

ii. Reliability (Did they address internal consistency? Did they address reproducibility?)

Cronbach's alpha coefficients reflecting internal consistency were 0.89 (SWB), 0.87(RWB) and 0.78 (EWB). The test-retest reliability coefficients were 0.93 (SWB), 0.96 (RWB) and 0.86 (EWB). These are consistent with high reliability and internal consistency.

iii. Validity (How did they address content reliability? Any information on construct related validity? Any information on criterion validity?)

The SWB scale appears to have sufficient validity for use as a quality of life indicator. SWB scores correlated in predicted ways with several other scales. People who scored high on SWB tended to be less lonely, more socially skilled, high in self esteem and more intrinsic in their religious commitment. The SWB, RWB, and EWB all correlated positively with the Purpose in Life Test. It has been used to assess spiritual well being in chronically-ill adults.

iv. Responsiveness (Any information? Has the scale ever been used as an outcome measure? If so, what populations?)

The scale has been used to assess the relationship between loneliness and spiritual well- being in a college populations as well as chronically ill patients. In a study comparing loneliness and spiritual well-being in a healthy versus chronically ill population it was shown that there was a negative correlation between loneliness and spiritual well-being. The ill group also had high SWB and RWB scores than the healthy but similar EWB scores. The authors concluded that chronic illness may be a factor in stimulating the person's valuing religion, having faith in God, and having a relationship with God. No studies on impact of an intervention (eg. chaplain referral) were done.

v. Interpretability (What populations has it been applied to? Is the score translated into a clinically relevant event? Does the score predict outcome events?)

Higher scores indicate spiritual well being and are correlated with less loneliness on the UCLA Loneliness Scale (p 0.06). People who espoused the personal religious commitment score higher on SMB, RWB, and EWB (p 0.01).

vi. Burden (Any information on cost or time to administer? Does the instrument impact on the respondent? How long does a survey take to complete? Response rates? Any problems with the missing data?)

The chronically ill patients were able to answer the 20 questions by themselves without difficulty. No other information available.

vii. Alternative forms (What are the modes of administration? Alternatives? If an alternative exists, provide what is know for each of the above categories.)

None.

viii. Cultural and Language Adaptations (any information?)

None.

C. Spiritual Perspective Scale (SPS) (Reed, 1968, 1987 and Belcher, 1989).

i. Conceptual and Measurement Model (Does the scale represent a single domain or do model scales measure distinct domains? Is the variability of the scale reported? If so please document it. What is the intended level of measurement, i.e. ordinal, interval, ratio or category?)

A 10- item self-administered or structured interview formatted scale which measures persons' perspectives on the extent to which spirituality permeates their lives and they engage in spiritually-related interactions. Participants respond to items based on their understanding of spirituality. Responses to each item are selected using a Likert scale of 1 to 6. Descriptive words correspond to each number. It is scored by calculating the arithmetic mean across all items. Scores range form 1 to 6 with 6 indicating the greater spiritual perspective.

ii. Reliability (Did they address internal consistency? Did they address reproducibility?)

Cronbach's alpha coefficient ranged from 0.93 in the hospitalized but not terminal patients to 0.95 in the hospitalized terminal patients and healthy patients. Test-retest reliability ranged from 0.57 to 0.68.

iii. Validity (How did they address content reliability? Any information on construct related validity? Any information on criterion validity?)

Evidence for construct validity was found in the study sample in that those who reported having a religious background scored higher on the SPS. Qualitative data generated by open- ended questions also indicated the validity of the SPS for participants in the study.

iv. Responsiveness (Any information? Has the scale ever been used as an outcome measure? If so, what populations?)

The psychometric properties of this instrument have remained adequate in research on adults of various health conditions including the terminally ill, healthy and non-seriously ill adults. The results of the studies show that terminally-ill adults indicated greater spirituality than both hospitalized non-terminally ill adults and healthy adults. No intervention has been tested.

v. Interpretability (What populations has it been applied to? Is the score translated into a clinically relevant event? Does the score predict outcome events?)

Terminally-ill adults indicated a change toward increased spirituality (p 0.01). Change in spiritual views was found to correlate positively with SPS scores.

vi. Burden (Any information on cost or time to administer? Does the instrument impact on the respondent? How long does a survey take to complete? Response rates? Any problems with the missing data?)

The respondents completed the 10 item questions in interview format. The open-ended questions on change in spiritual views (not part of the scale) were asked after the completion of these 10 questions. Twenty to sixty minutes were required to complete all questions. Terminally-ill patients were particularly interested in expressing their views at the end of the study.

vii. Alternative forms (What are the modes of administration? Alternatives? If an alternative exists, provide what is known for each of the above categories.)

None.

viii. Cultural and Language Adaptations (any information?)

None.

D. Death Transcendence Scale (VandeCreek and Nye, 1993 and 1994).

A 25-item self-administered questionnaire designed to test what ways respondents use to transcend death, with five subscales or modes: religious, mystical, biosocial, creative and nature. There are five items per mode except for biosocial, which contains three items. The items are answered on a Likert scale (1=strongly disagree, 4=strongly agree). Scores of each subscale describe the level of investment attributed to them by the respondent.

ii. Reliability (Did they address internal consistency? Did they address reproducibility?)

Cronbach's alpha was 0.74 ranging from 0.79 for the religious subscale to 0.51 for the nature items.

iii. Validity (How did they address content reliability? Any information on construct related validity? Any information on criterion validity?)

Correlations to the depression, self-esteem and hope scores showed that religious scores were correlated with all these results, most strongly with hope (r=0.43). So DTS measurement of life after death in the religious sense was influenced by such factors as depression, self-esteem and hope. The scores on the religious subscale were related to the marital status of the respondents (p=0.05), as well as to their religious heritage (p=0.000) and pattern of attendance (p=0.000). Nature subscale scores were lower in the urban population as compared to the rural.

iv. Responsiveness (Any information? Has the scale ever been used as an outcome measure? If so, what populations?)

The scale has been used in a diverse population of adults including hospitalized patients but not in the terminally ill. The study was undertaken to gather information on how the patients' search for immortality can assist in providing pastoral care. 86% of respondents believed in life after death. Results indicate that people seek to transcend death through their relationship and influences. The scale is able to explore these desires.

v. Interpretability (What populations has it been applied to? Is the score translated into a clinically relevant event? Does the score predict outcome events?)

This has been applied to adult in- and out-patients. Studies suggest the need for pastoral intervention in patient care as well as with their families.

vi. Burden (Any information on cost or time to administer? Does the instrument impact on the respondent? How long does a survey take to complete? Response rates? Any problems with the missing data?)

No information available.

vii. Alternative forms (What are the modes of administration? Alternatives? If an alternative exists, provide what is know for of the above categories.)

None.

viii. Cultural and Language Adaptations (any information?)

None.

E. Death Attitude Profile (DAP),(Gesser, 1987)

A 21-item self-administered or interview administered scale with four dimensions: fear of death, escape acceptance, approach acceptance, and neutral acceptance. These were tested as four relatively independent death-attitude dimensions. Participants rate each item by means of a five-point agree-disagree, Likert-type scale. Items identified as loading substantially were given unit weights; raw scores were summed to generate subscale scores.

ii. Reliability (Did they address internal consistency? Did they address reproducibility?)

Not addressed.

iii. Validity (How did they address content reliability? Any information on construct related validity? Any information on criterion validity?)

Fear of Death was negatively related to happiness as expected (p 0.001) and positively related to hopelessness (p 0.05). Results failed to support the predicted relationship between Approach-oriented Death Acceptance, and happiness and hopelessness. As expected, Escape-oriented Death Acceptance was positively related to hopelessness but unrelated to happiness. Neutral Acceptance was unrelated to hopelessness but positively related to happiness. This scale has not been used in a terminally-ill population.

iv. Responsiveness (Any information? Has the scale ever been used as an outcome measure? If so, what populations?)

Not used as an outcome measure to date. Used to assess differences in death attitudes across the life span.

v. Interpretability (What populations has it been applied to? Is the score translated into a clinically relevant event? Does the score predict outcome events?)

Not used in clinical settings. Authors infer that the young and middle-aged may have a harder time accepting the reality of death.

vi. Burden (Any information on cost or time to administer? Does the instrument impact on the respondent? How long does a survey take to complete? Response rates? Any problems with the missing data?)

Not addressed.

vii. Alternative forms (What are the modes of administration? Alternatives? If an alternative exists, provide what is know for each of the above categories)

None.

viii. Cultural and Language Adaptations (any information?)

None.

F. Herth Hope Index (HHI) (Herth, 1990)

A 12-item interviewer administered scale designed to gather data concerning hopefulness from patients. Respondents were scored on a 1 to 4 Likert scale creating a score range from 12 to 48. The HHI is composed of three dimensions: temporality and future, positive readiness and expectancy, and interconnectedness. Each domain contains four items.

ii. Reliability (Did they address internal consistency? Did they address reproducibility?)

Cronbach's alpha was 0.88.

iii. Validity (How did they address content reliability? Any information on construct related validity? Any information on criterion validity?)

Hope scores produced a negative correlation with depression and positive relationship to self-esteem, both significant at a p=0.001 level. The only variables that statistically significantly affected the hope scores were education and the patterns of worship. The more educated and those who attended worship more frequently scored higher on the HHI. The HHI has not been used in a terminally-ill population to date.

iv. Responsiveness (Any information? Has the scale ever been used as an outcome measure? If so, what populations?)

This study tested hope in the family caregivers of terminally ill people as well as hope in the terminally ill. In addition, it has tested hope on a population of community persons, family member in a surgical waiting room and hospital patients. Hope scores decreased in the hospital group that had increase depression. Those with higher self-esteem scores scored higher on the HHI. Therefore, the authors concluded that pastoral caregivers may increase hopefulness by encouraging self-esteem.

v. Interpretability (What populations has it been applied to? Is the score translated into a clinically relevant event? Does the score predict outcome events?)

Used in a broad clinical setting and in a terminally-ill population. No significant variation in scores based on age, gender, marital stature, or religious background.

vi. Burden (Any information on cost or time to administer? Does the instrument impact on the respondent? How long does a survey take to complete? Response rates? Any problems with the missing data?)

Especially useful in the chronically- and terminally-ill populations because it is short and easy to administer. It is good for respondents with limited stamina or concentration.

vii. Alternative forms (What are the modes of administration? Alternatives? If an alternative exists, provide what is know for each of the above categories)

None.

viii. Cultural and Language Adaptations (any information?)

None.

To request a copy of this instrument contact Dr. Herth at kaye.herth@mnsu.edu.

IV. Recommended Scale for Toolkit.

The six highlighted instruments are all valuable tools in this work. The Spiritual Well-Being Scale is excellent to assess spiritual and religious commitment in a person's life. The Spiritual Perspective Scale similarly assesses the importance of spirituality in a person's life, although it does not subdivide the religious and spiritual domains as the former scale does. The SPS however was used in a terminal population. The SWB would need to be tested in this population.

The Meaning in Life Scale is an excellent, easily administered scale, used to assess patients' views on how worthy their life is. It was tested in a broad group of patients including terminally-ill patients. The Death Attitude Profile analyzes fears of death. The Death Transcendence Scale looks at how people transcend death and can be used by the health care professional in guiding patients through their last days. We therefore strongly recommend the DTS. However, it must test with the terminally-ill population.

The Herth Hope Index (HHI) is an excellent scale used to assess the patient's hopefulness. Knowing that a person is hopeful guides the provider in determining ways to sustain that hope. If a person lacks hope, the providers would need to determine what aspects of their life could be drawn upon in order to ignite hope within the dying patient. Given the correlation of low scores on the HHI with depression and low self-esteem, the clinician should assess the patient for depression and self-esteem. This scale has not been used specifically in the dying population.

The drawback with these scales is that only the MIL and the SPS have been used in a terminally population. None of the studies used the scales to measure the effectiveness of an intervention. Practically, one needs to have a scale which is short, easy to answer and gives information regarding the quality of care given to the dying patient with regard to their spiritual needs. Each of the above instruments addresses some of these aspects.

We recommend that we incorporate questions from the following instruments and form a composite, shorter scale which would then be tested in the dying population:

Spiritual Well-Being Scale
The Death Transcendence Scale
Herth Hope Scale
The Meaning of Life Scale

In additions we would recommend adding specific questions regarding how well the patient's spiritual needs are being met. For example: does someone listen to your faith, your pain, your hope; was a chaplain referral made, if appropriate?

VII. Priorities for Future Research

A. We need an innovative instrument to assess spiritual needs in the dying population which incorporates the concepts of death transcendence, spiritual and religious well-being, hopefulness, as well as assess how well those needs are being met.

B. We need to use these instruments to test whether specific interventions (for example, referral to a chaplain, increased attentiveness to a patient's belief) improves their spiritual well-being, increases their hopefulness, and enhances their meaning in life.

References

Aday, R. "Belief in Afterlife and Death Anxiety: Correlates and Comparisons," Omega, 1984 18:67-75

Allport, GW and Ross, MJ "Personal Religious Orientation and Prejudice," J of Personality and Social Psych 1967, 5(4):432-443

Batson, CD and Schoenrade, PA. "Measuring Religion as Quest: 1) Validity Concerns," J for The Sci Study of Religion, 1991 30(4):416-429

Batson, CD and Schoenrade, PA "Measuring Religion as Quest: 2) Reliability Concerns," J for The Sci Study of Religion, 1991, 30(4):430-447

Belcher, AR et. al. "Spirituality and Sense of Well-Being in Persons With AIDS," Holistic Nurs. Pract. 1989, 3(4):16-25

Bergin, A. and Jensen, J "Religiousity of Psychotherapists: A National Survey," Psychotherapy, 27:3-7

Burkhardt, M. "Spirituality: An Analysis of The Concept," Holistic Nursing Practice, May 1989 :60-77

Byock IR. Missoula-VITAS Quality of Life Index (version 25S). VITAS Healthcare Corp, 1995.

Byrne, JT and Price, JH "In Sickness and In Health: The Effects of Religion," Health Education 1979, 10:6-10.

Chambers, LW et. al. "The McMaster Health Index Questionnaire," J Rheumatol 1982, 9:780-784

Clinch, JJ and Schipper, H. "Quality of Life Assessment in Palliative Care," The Challenge of Palliative Med, p. 61-70.

Cohen, SR and Mount, BM "Quality of Life in Terminal Illness: Defining and Measuring Subjective Well- Being in The Dying, J Palliat Care, 1992 8(3):40-45.

Cohen, SR et. al. "The McGill Quality of Life Questionnaire," Palliat Med, 1995 9:207-219.

Conrad, NL "Spiritual Support of The Dying," Nursing Clinics of N. America 1985, 20(2):415-426

Crumbaugh, J., The Seeking of Noetic Goals Test (SONG): A Complementary Scale to the Purpose in Life Test (PIL). J Clin Psych 1977 33(3):900-907

Crumbaugh, JC and Maholick, LT. J. of Clin Psychology 1964, 20:200-207

Feifel, H. "Religious Conviction and Fear of Death Among The Healthy and The Terminally Ill," J for The Sci Study of Religion 1974, 18:353

Ferrans, CE and Powers, "Quality of Life Index: Development and Psychometric Properties," MJ. Adv in Nursing Sci 8(1):15-24.

Gartner, J, Larson, DB and Allen, G. "Religious Commitment and Mental Health: A Review of The Empirical Literature," J of Psych and Theology, 1991, 19(1):6-25

Gesser, G et. al. "Death Attitudes Across The Life Span: Development and Validation of The Death Attitude Profile," Omega, 1987, 18(2):113-128.

Grey, A "The Spiritual Component of Palliative Care," Palliat Med 1994, 8:215-221

Hay, M. "Principles in Building Spiritual Assessment Tools,"

Herth, K. Fostering hope in terminally-ill people. J Adv Nurs 1990;15:1250-1259.

Herth, K. Abbreviated instrument to measure hope: development and psychometric evaluation. J Adv Nurs 1992, Oct; 17(10): 1251-9.

Herth, K. Hope in the family caregiver of terminally ill people. J Adv Nurs 1993, Apr; 18(4): 538-48.

Highfield, M.E., & Cason, C. (1983). Spiritual needs of patients: Are they recognized? Cancer Nursing, 6, 187-192. [research]

Highfield, M.F. (1992). Spiritual health of oncology patients: Nurse and patient perspectives. Cancer Nursing, 15(1), 1-8.

Hinton, J "Assessing The Views of The Dying," Soc Sci Med 1971, 5: 37-43

Hoge, D. "A Validated Intrinsic Religious Motivation Scale," J for The Sci Study of Rel 1972, 11:369-376

Hood, R and Morris, R. "Toward a Theory of Death Transcendence," J for The Sci Study of Religion, 1983 22(4):353-365

Kass, J. J for The Sci Study of Rel 1991, 30(2) 203-211

King, D and Bushwick,B "Beliefs and Attitudes of Hospital Inpatients About Faith Healing and Prayer," J Fam Pract 1994 (94):349-352

Koenig, H. et. al. "Religious Coping and Depression Among Elderly, Hospitalized Medically Ill Men," Am J Psych 1992 149(12): 1693-1700

Larson, DB and Larson, SS "Religious Commitment and Health: Valuing The Relationship," Health, Faith and Ethics, 1991, 17(6): 26-40

Leighton, S. "When Mortality Calls, Don't Hang Up," Spiritual Life 1996, 42(3):150-157.

MacAdam, DB and Smith, M. "An Initial Assessment of Suffering in Terminal Illness," Palliat Med 1987, 1:37-47

MacDonald, S and et. al. "Objective Evaluation of Spiritual Care: A Case Report," J Palliat Care, 1993, 9(2):47-49

Maugans, T. "The SPIRITual History," Arch Fam Med 1996 5:11-16.

McCanse, R. "The McCanse Readiness for Death Instrument: A Reliable and Valid Measure for Hospice Care," Hosp J 1995 10(1):15-26.

McMillan, SC and Mahon M, Measuring Quality of Life in Hospice Patients Using a Newly Developed Hospice Quality of Life Index. Qual Life Res 1994, 3:437-447

Miller, JF "Assessment of Loneliness and Spiritual Well-Being in Chronically Ill and Healthy Adults," J of Prof. Nursing 1985, March p. 79-85

Millson, M and Dudley, J. "Providing Spiritual Support: A Job for The Hospice Professionals," Hosp J 1992, 84(4):49-66.

Moberg, DO "Religiosity in Old Age," Gerontologist, 1965, 5:78-87.

Moberg, DO "Spiritual Well-Being of The Dying," in Aging and The Human Condition Lesnoff-Caravaglia (ed) New York :Human Sci Press, 1982, p. 139-155

Moberg, DO(ed) Spiritual Well-Being: Sociological Perspectives, University Press of America, Wash, DC

Morris, JN et .al. "Last Days: A Study of The Quality of Life of Terminally Ill Cancer Patients," J Chronic Dis 1986, 39(1):47-62

Mudd, ER "Spiritual Needs of Terminally Ill Patients," Bulletin of The American Proc. Hosp Assoc. 45(3):1-5

O'Connor, P. "The Role of Spiritual Care in Hospice: Are We Meeting Patients' Needs?" The Am J Hosp Care 1988, July/August 31-37

Paloutzian, RF and Ellison, CW "Loneliness, Spiritual Well-Being and Quality of Life," in Loneliness: A Sourcebook for Current Therapy A Wiley-Interscience Publ. Peplau and Perlman (ed). 1982

Pargament, KI et. al. "God Help Me: (I): Religious Coping Efforts as Predictors of The Outcomes To Significant Negative Life Events," Am J Community Psych 1990, 18(6): 793-824

Poloma, MM and Pendleton, BF "The Effects of Prayer and Prayer Experience on Measures of General Well-Being," J Psychology and Theology, 1991, 19:71-83

Pressman, P. et. al. "Religious Belief, Depression, and Ambulation Status in Elderly Women With Broken Hips," Am J Psych 1990, 147(6):758-760.

Reed, P. "Death Perspectives and Temporal Variables in Terminally Ill and Healthy Adults," Death Studies, 1986, 10:467-478

Reed, P. "Religiousness Among Terminally Ill and Healthy Adults," Research in Nurs and Health, 9:35-41

Reed, P. "Spirituality and Well-Being In Terminally Ill Hospitalized Adults," Research in Nursing and Health, 1987, 10:335-344.

Reker, G. and Peacock, EJ "The Life Attitude Profile (LAP): A Multidimensional Instrument for Assessing Attitudes Toward Life," Can J Behav Sci 1981, 13(3)

Schaefer, CA and Gorsuch, RL. "Situational and Personal Variations in Religious Coping," J for The Sci Study of Rel 1993, 32(2):136-147.

Shaver,P et. al. " Religiousness, Conversion, and Subjective Well-Being: The 'Healthy-Minded' Religion of Modern American Women," Am J Psych 1980 137(12):1563-1568

Smith, D et. al. "Fear of Death, Death Attitudes, and Religious Conviction in The Terminally Ill," Int'l J Psych Med, 1983, 13(3):221-232

Smith, E "Addressing The Psychospiritual Distress of Death as Reality: A Transpersonal Approach," Social Work 1995 40(3):402-413.

Spitzer, W. et. al. "Measuring The Quality of Life of Cancer Patients," J Chron Dis 1981, 34:585-597.

Stepnick, A and Perry, T "Preventing Spiritual Distress in The Dying Client," J Psychosoc Nurs 1992 30(1):17-24.

Strayhorn, JM et. al. "A Measure of Religiousness, and Its Relation To Parent and Child Mental Health Variables," J Community Psych. 1990, 18:34-43

Stryhorn, JM, Wedman, CS and Larson, D., J of Community Psychology 18 34-43 1990 The Am J Hosp Care 1989 Sept/Oct 25-31

VandeCreek, L and Nye, C. "Trying to Live Forever: Correlates To The Belief in Life After Death," The J of Pastoral Care, 1994 48(3):

VandeCreek, L and Smith, D. "Measuring The Spiritual Needs of Hospital Patients and Their Families," The Journal Of Pastoral Care, 1992 46(1): 46-53

VandeCreek, L. "Pastoral Assessment of Selected Attitudes Among Hospital Patients and Family Members," Sciences pastorales, 1992 11:67-80.

VandeCreek, L. and Nye, C. "Testing The Death Transcendence Scale," J For The Sci Study of Religion, 1993, 32 (3): 279-283

VandeCreek, L. et. al. "Where There's Life, There's Hope, and Where There is Hope, There Is...," J of Religion and Health 1994, 33(1):51-59

VandeCreek,L. et al. "Using INSPIRIT To Conduct Spiritual Assessments," The Journal of Pastoral Care, 1995, 49(4): 83-89

VandeCreek,L. et. al. "Assessment of Pastoral Needs Among Medical Outpatients," The Journal of Pastoral Care 1993, 47(1): 44-52

Warner, SC and Williams, JI "The Meaning In Life Scale: Determining the Reliability and Validity of A Measure," J Chrons Dis 1987 40(6)503-512

Zuckerman, DM et.al. "Psychosocial Predictors of Mortality Among The Elderly Poor," Am J Epidem 1984, 119(3)"410-423

Section prepared by Christina Puchalski

Funding for this project was provided by

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