Conception of spirituality of cancer patients undergoing antineoplastic treatment

Abstract

In addition to being a way of coping with and attributing new meanings to suffering and conceiving life, spirituality is a source of hope and confidence for cancer patients. From these premises, the aim of this study was to present the perception of spirituality of cancer patients undergoing antineoplastic treatment in order to understand its influence on how patients cope with the disease. This is a descriptive and qualitative study carried out in the outpatient chemotherapy clinic of a Brazilian public hospital. The study sample consisted of 18 cancer patients undergoing outpatient chemotherapy, over 18 years of age, of both genders. Thematic content analysis was used, which revealed two thematic categories: 1) spirituality as a source of hope and confidence; and 2) spirituality as a source of new meanings to suffering and of a renewed view of life.

Spirituality; Neoplasms; Qualitative research; Religion; Medical Oncology

Resumo

Além de ser uma modalidade de enfrentamento, ressignificação do sofrimento e concepção de vida, a espiritualidade é fonte de esperança e confiança para pacientes oncológicos. Com base nessas premissas, objetivou-se desvelar a concepção de espiritualidade de pacientes oncológicos em tratamento antineoplásico a fim de compreender sua influência no enfrentamento da doença. Trata-se de estudo descritivo, de delineamento qualitativo, realizado no ambulatório de quimioterapia de um hospital público brasileiro. A amostra foi composta por 18 pacientes oncológicos submetidos a sessões de quimioterapia, em tratamento ambulatorial, maiores de 18 anos, de ambos os sexos. Para confecção dos resultados, utilizou-se a análise de conteúdo temática, que revelou duas categorias: 1) espiritualidade como fonte de esperança e confiança; e 2) espiritualidade como fonte de ressignificação do sofrimento e de uma renovada concepção de vida.

Espiritualidade; Neoplasias; Pesquisa qualitativa; Religião; Oncologia

Resumen

Además de ser una modalidad de afrontamiento, resignificación del sufrimiento y concepción de la vida, la espiritualidad es una fuente de esperanza y confianza para los pacientes oncológicos. Partiendo de estas premisas, el objetivo de este trabajo fue desvelar la concepción de la espiritualidad de los pacientes con cáncer sometidos a tratamiento antineoplásico para comprender su influencia en el afrontamiento de la enfermedad. Se trata de un estudio descriptivo de diseño cualitativo, realizado en el ambulatorio de quimioterapia de un hospital público brasileño. La muestra se compuso de 18 pacientes oncológicos sometidos a sesiones de quimioterapia, en tratamiento ambulatorio, mayores de 18 años, de ambos sexos. Para confeccionar los resultados, se utilizó el análisis de contenido temático, que reveló dos categorías: 1) la espiritualidad como fuente de esperanza y confianza; y 2) la espiritualidad como fuente de resignificación del sufrimiento y de una concepción renovada de la vida.

Espiritualidad; Neoplasias; Investigación Cualitativa; Religión; Oncología Médica

Cancer is a serious public health issue and the second leading cause of death in most Western countries. The Brazilian National Cancer Institute (INCA) estimates that 625,000 new cases of cancer will occur in the 2020-2022 triennium¹ . Cancers are understood as a sign of the end of life and proximity to death, leading diagnosed individuals to nurture all kinds of uncertainties about the future and seek coping strategies that increase their chances of survival, such as the search for or reconnection with spirituality and religion² , ³ .

Spirituality is understood as the personal quest to understand the meaning and finitude of life, as well as the awareness, or belief, that there is something sacred in the world that transcends the limits of religious rituals. Among the practices that characterize religion are prayers and the collective or individual reading of sacred books⁴ . Both practices involve individuals searching for meaning in life, particularly for those diagnosed with a serious illness.

The benefits of spirituality include improved self-esteem, sense of well-being, hope, optimism and greater emotional and social support, besides a decrease in fear, anxiety, stress and depression³ , ⁵ - ⁸ .

We may thus conclude that spirituality is relevant throughout the cancer treatment process, since diagnosed patients may undergo aggressive therapies such as chemotherapy, which are usually frightening for them and their families due to their unpleasant side effects. From the moment treatment begins, the undesirable effects cause damage to the patients’ autonomy and self-image, which invariably lead to a drop in their expectations for improvement⁹ , ¹⁰ .

Hence, the nursing team must be aware of the spiritual dimension in cancer patient care. Nurses should therefore act humanely and maintain efficient communication, acknowledging moments of suffering and pain, and offering palliative measures for coping with a process that can be compared to martyrdom¹¹ , ¹² .

Based on the premise that an individual is a whole made up of physical, psychological, biological, social, and spiritual aspects, we sought to answer the following questions: How do patients undergoing cancer treatment experience spirituality? What role does spirituality play in the process of coping with the diagnosis and treatment of the disease?

The lack of qualitative research on the experience of patients, especially undergoing antineoplastic treatment, among other considerations, justifies this study. We expect that by identifying its benefits, our findings might foster the inclusion of spirituality among the clinical resources available for treating cancer patients.

Method

This descriptive study adopted a qualitative approach, which seeks to understand the phenomenon according to the subject’s point of view, that is, it applies to the study of history, relationships, representations, beliefs, perceptions and opinions; [which are] products of the interpretations humans make about how they live, build their artifacts and themselves, feel and think ¹³ .

The study was carried out in a public hospital located in a city in the state of São Paulo, with a study population of 18 cancer patients undergoing chemotherapy treatment in outpatient care, over 18 years of age, of both genders. Data saturation was the criterion used to decide when to end the interviews¹³ . People with loss or change in the level of consciousness were excluded, as their state would preclude participating in the study.

The study was approved by the ethics committee for research involving human beings of the health institution where the research took place. Complying with the National Health Council’s Resolution No. 466/2012, all participants formalized their agreement to participate by signing the informed consent form¹⁴ . All statements were identified by the letter P, for participant, followed by sequential numbers.

Data collection occurred between August and September 2018 by means of semi-structured interviews, to obtain both objective and subjective data. The interview was a moment of exchange between interviewer and interviewee, in which the latter was able to discuss the topic without limitations¹³ .

Interviews lasted an average of 25 minutes and took place individually in a private environment, on the premises of the participating institution. Participants were posed three open-ended questions addressing the meaning of spirituality and its influence at the time of diagnosis and during the antineoplastic treatment. Participants were also characterized according to the following variables: age, gender, marital status, education level, socioeconomic classification, employment relationship, start of antineoplastic treatment, cancer site, and religion/belief.

Results underwent a thematic content analysis, which allowed contents to be interpreted and inferred based on categories and similarities, systematized in the following stages:

• Pre-analysis: reading of interviews transcripts, based on the principles of relevance, exhaustiveness, homogeneity, and representativeness;

• Exploration of the material: coding based on identification of related themes, keywords, and organization of information into thematic categories;

• Interpretation: treatment of the results, that is, of the inferences and interpretations themselves by describing the main findings¹³ , ¹⁵ .

Results and discussion

Participants averaged 52 years of age and most were women (n=14), living in a stable union (n=12), belonging to the low socioeconomic class (n=10), with no employment relationship (n=15) and had completed elementary school (n=8). Regarding religion, most participants declared to be Christian, with a predominance of Catholics and Evangelicals (56%), with only two non-churchgoers (11%). Antineoplastic treatment lasted between two months and six years, with an average of two years, and the most frequent cases involved ovary, bones, esophagus, intestine, breast, uterus, liver, and prostate neoplasms, and cases of leukemia and metastases.

Two thematic categories emerged from the interviews: 1) spirituality as a source of hope and confidence; and 2) spirituality as a source to reframe suffering and renew the concept of life.

Spirituality as a source of hope and confidence

Spirituality allowed patients to experience feelings of hope and or confidence, which helped in the treatment, either by expressing that suffering does not override faith, or by mentioning people who faced and overcame the disease.

“At the time of diagnosis, I didn’t ask for anything (...) I simply gave thanks. I thanked God before having surgery, because I was sure that I was already healed. God never abandons anyone and never gives us a cross too heavy to bear” (P3).

“I became fortified in God, who is almighty (...). And when you think positively and have a purpose, which, in my case, was to take care of my children and my family, I couldn’t let the disease get me down (...). I believed that everything would end up well, because this mission was given to me by God and this disease will not prevail” (P6).

“I didn’t let myself get down or discouraged because I knew that many people who had this disease, trusting in God, managed to overcome it. I believe that I’ll also be able to conquer it, because I have great trust in God” (P7).

“I’m [a] very spiritual [person] and I have a lot of faith! I talked to God and said: ‘God, I know you will not forsake me, and I thank you because I am sure that I’m a healed person’ (...)” (P16).

We observe in these statements that faith functioned as a source of hope for coping with the diagnosis of the disease. Spirituality and faith offer purpose and designation to the suffering and difficult time the patient is going through, besides generating hope, altruism and idealism, bringing confidence in the treatment and improvement of well-being¹⁶ .

In certain situations, adverse life events lead to protective factors that can transform difficult situations, making them to be perceived as something bearable. Spirituality, based on faith, is a point of resilience in life that allows hope to be nurtured and strength to be developed to fight for life when faced with a serious diagnosis.

In the statements collected, spirituality was considered a positive factor, in conjunction with the beliefs of each participant, as it offered them the conviction that, ultimately, all things would end well. The statements also showed that, through spirituality, one can adopt an optimistic view of one’s condition. Thus, even when aware of and undergoing the necessary medical interventions, participants were not discouraged and believed in the power of healing through the experiences of others.

Spirituality is inherent in many people, serving as a way to fill in gaps, providing purpose in life. For cancer patients, it can alleviate pain and undesirable side effects, besides contributing to a better acceptance of the diagnosis¹⁷ , ¹⁸ .

In fact, spirituality can be seen as a defense mechanism in oncology, being present in three important moments: when the disease is discovered; during treatment; and in the impossibility of cure. The moment of discovery brings with it uncertainty, fear of the unknown and, for many, a sense of imminence of death¹⁹ .

At each treatment stage, fears of what this disease may cause make many individuals search for something positive that reaffirms the meaning of life and offers them the resilience to cope with the situation. It is precisely at this moment, therefore, that many find spirituality as a resource for restoring their physical and psychological health, as well as their spiritual well-being²⁰ .

Reframing suffering and life through spirituality

One of the common points observed in the study participants’ statements is the comparison of their suffering to Christ’s martyrdom. Like the Messiah, they envision the victory of “resurrection,” that is, they imagine themselves capable of overcoming difficulties and being healed.

“The only thing that helped me greatly was believing in God (...). My suffering would not be less than that of others or of Jesus” (P1).

“I have Jesus as my example, who suffered and was humiliated, but came to prepare us for something better elsewhere (...). So, by believing that, and having Jesus as example, and seeing all His suffering, it brought me a lot of peace” (P4).

“I trust this God who is above all. He can do anything (...). I trust and surrender my illness to Him, and nothing will defeat me. My suffering will disappear” (P13).

“In this world you will have tribulations, the Bible says. Suffering is part of life. But victory comes with suffering, like Christ who died on the cross and resurrected, overcoming death” (P11).

Spirituality and religiosity stand out as important cultural factors, as they give meaning to life and serve as a coping mechanism, especially useful in the case of chronic diseases such as cancer²¹ - ²³ . The impossibility of foretelling uncontrollable situations causes suffering; however, coping strategies are valued in certain stressful situations, acting in a protective and life-renewing manner³ , ⁹ .

To cope with chemotherapy, patients undergoing antineoplastic treatment seek strength in faith and religion, as well as interventions from their brothers and sisters of faith through their prayers, for example. Patients combine religion, faith and spirituality and through these elements, besides prayers and beliefs, they somehow feel protected by the good intentions of their friends, family members, and religious communities.

There is a very strong belief, or feeling, that prayers, as a spiritual activity, establishes contact with the transcendental. Accordingly, prayers are “received” by a superior being, who “sends back” courage and determination to cope with cancer treatment¹⁶ .

Faith can be understood from an anthropological and or religious perspective: in the first case, Faith is related to human values and the meaning attributed to events and relationships; in the second, when allied to its anthropological aspects, faith involves a set of beliefs and dogmas that guide spiritual practice, intrinsically linked to some type of religion⁹ . Combining these two types of faith allows patients to use religious parables and biblical or faith-based stories to reframe suffering.

Spirituality, unlike religion, has a broader definition and can be described as an intimate feeling that may lead people to take a closer look at themselves and the community to which they belong. Spirituality enables patients to experience feelings of guilt, anger, sadness, and hopelessness in a more nuanced manner, as if the reality of illness is challenged by something beyond what can be concretely seen and felt²⁴ . As a source of support and refuge from life’s difficulties, spirituality surpasses all tangible and non-abstract senses, being considered by many as a feeling inherent to humanity.

Final considerations

Participant statements revealed that spirituality is a source of hope and confidence, particularly for healing – but not only, as it also provides the necessary support to cope with treatment adversities. The statements also revealed that spirituality offers the faithful a means of reframing their suffering and view of life, since they relate their suffering and their “victory” to those of Christ.

In short, spirituality showed to be an important way of coping with oncologic diseases, particularly regarding treatment, a crucial period in which patients are extremely debilitated, both physically and psychologically. This study thus contributes to inform and improve oncologic care practices, showing that, although spirituality is not widely included in health care, its benefits to clinical practice are real and effective.

This study has limitations that do not allow generalizing its conclusions, such as having only included patients for whom therapeutic possibilities were available, which, although intentional, hindered examining how spirituality is perceived by people with no chance of cure – a group that can be interviewed in future studies.

Another limitation concerns the fact that the vast majority of participants are Christians, which may have influenced how they experience spirituality, possibly differing from people practicing other religions. Finally, the relationship between treatment time and types of cancer must be considered in future research.

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• Approval CEP-Unip 2.821.689

Publication Dates

• Publication in this collection
  18 Mar 2022
• Date of issue
  Oct-Dec 2021

History

• Received
  8 July 2020
• Reviewed
  14 Oct 2021
• Accepted
  26 Oct 2021