CHAPTER I

THE PROBLEM AND ITS BACKGROUND

Rationale
Death has a thousand faces, but dying has a million ways. Death is ubiquitous and
universal. Death attitudes affect how we live. How we view death and how we cope with death
can profoundly affect every aspect of our lives---either positively or negatively.
Most of us have images of death that are negative and disturbing, and that evoke feelings
of fear and anxiety. Death is the only certainty in life. All living organisms die; there is no
exception. However, human beings alone are burdened with the cognitive capacity to be aware of
their own inevitable mortality and to fear what may come afterwards. Furthermore, their capacity
to reflect on the meaning as life and death creates additional existential anxiety.
Palmer (1993) interviewed many people from different cultures about death and dying,
and he concluded that they havent found acceptance, but they havent mired themselves in anger
or depression and more often than not one of the ways they handle death is to give it a
recognizable face. Thus, he proposed that dying can be a positive and rewarding experience; it
can be a time of personal freedom and growth. But dying well begins with death acceptance.
According to Elisabeth Kubler-Ross, a pioneer in death and dying studies, dying people
often experience 5 emotional stages. These stages generally occur in the following order: Denial,
Anger, Bargaining, Depression, and Acceptance. Denial is usually a temporary response to
overwhelming fears about loss of control, separation from loved ones, an uncertain future, and
suffering. Anger may be expressed as sense of injustice: Why me?. Bargaining can be a sign of
reasoning with death---that is, seeking more time. Depression develops when dying people
realize that bargaining and other strategies are not working. Acceptance, sometimes described as
facing the inevitable, may come after discussions with family, friends, and health care providers.
Acceptance involves a willingness to let go and detach ourselves from events and things
which we used to value. A positively oriented acceptance also entails the recognition of the
spiritual connection with a transcendental reality and the vision of sharing spiritual life with love
ones for all eternity.
Pathways to death acceptance are Life Review, Self-acceptance, Religious/Spiritual
Beliefs, Embracing ones own life, and Death Education. Life Review is important in bringing
order and coherence to life and maintaining ones identity (Wong, 1995). Self-acceptance is
discovering who we really are before we die and connecting with the inner essence of our being.
In religious/spiritual belief, there is a difference between intrinsic and extrinsic religiosity. There
is a connection between spirituality and the quest for meaning. Kubler-Ross (1997) emphasized
the importance of religiously based death acceptance. Embracing ones own life is living life to
the full. Death education is contemplating our life that leads to death.

Preparing for death often means finishing a lifes work, setting things right with family
and friends, and making peace with the inevitable. Preparing for death is hard work, with many
emotional ups and downs. Spiritual and religious are important to many dying people and their
families.
Spirituality is a word used in an abundance of contexts that means different things for
different people at different times in different cultures. According to Swinton, spirituality has
broadened in meaning into a more diffuse human need that can be met quite apart from
institutionalized religious structures. He identifies it as the outward expression of the inner
workings of the human spirit and has defined it as the aspect of human existence that gives it its
humanness. It concerns the structure of significance that give meaning and direction to a persons
life and helps them deal with the ___cissitudes of existence. As such, it includes such vital
dimensions as the quest for meaning, purpose, self-transcending knowledge, meaningful
relationships, love and commitment, as well as sense of the Holy amongst us.
Spirituality is a persons way of being, thinking, choosing, and acting in the world in light
of that persons ultimate values (Savary, 2006). Spirituality is a fundamental quality that
contributes to health and wellness, life satisfaction and coping, healing, recovery, hope and wellbeing, psychosocial adjustments and sense of coherence and quality life in general (Brillhart, et
al:2005).
There are 5Rs of Spirituality. According to Govier (1999), they are Reason, Reflection,
Religion, Relationships, and Restoration. Reason and reflection, the search for meaning in life
experiences has been viewed as an essential universal trait (Cobb and Robshaw, 1998). Religion
can serve as a vehicle for expressing spirituality through a framework of values, beliefs and ritual
practices and for some, provides the answers to the essential questions surrounding life and death
issues (Ross, 1994). Oldnall (1996) regards relationships with ourselves, others and God as being
at the centre of the spiritual dimension. Labun (1988) identified meaningful, purposeful or
creative work as an expression of spirituality and indicated that service to others might also
fulfill spiritual needs. Carson (1989) observes the need for a continuous interrelationship
between the inner being of the person and the persons horizontal relationships with self, others
and the environment. Restoration refers to the ability of a persons spirituality to have a positive
influence on the physical aspects of a person. Certain life events can cause an inability to restore
the body to a spiritual equilibrium, resulting on spiritual distress (Burnard, 1988).
Cancer patients are prone to spiritual distress upon facing with their diagnosis, change in
disease stage and the difficulties of ending their lives. This is because they suffer from lack of
meaning, value and purpose in their lives due to severe physical and functional damages
accompanying the disease. However, anyone may have his or her own interpretation of the
concept of spirituality. Also, the persons age, sex, race, culture, previous personal experiences,
and the stage of life, which the person is experiencing, affect the expression of his spirituality.
Spirituality can be expressed through rituals, meditation, guided imagery, visualization,
practicing gratitude, spending time in nature, viewing and engaging in art, and through various
other endeavors that have meaning to the patient or client. To simplify how individuals express

and experience spirituality, we look at expression of feelings, forgive, or are forgiven, have
connections to others or a higher power, find meaning in life, and have hope.
The spiritual rituals or prayer, meditation, guided imagery, gratitude, spending time in
nature, and art can all help people connect to their inner being, to others and to a divine spirit or
higher power. As part of spiritual and cultural traditions, rituals help to provide awareness,
meaning, intention, and purpose in life. There are various types of prayers that clients may
engage in. Rituals on the other hand, are practices that are often repeated and can provide a way
for people to make life experience meaningful.
Nowadays, spirituality includes many studies that demonstrate the connection between
spirituality and health improvement. Many are becoming interested in the role of spirituality in
their health and health care. This may be because of dissatisfaction with the impersonal nature of
our current medical system, and the realization that medical science does not have answers to
every question about health and wellness.
Spirituality influence health by improving coping skills and social support, foster feelings
of optimism and hope, promote healthy behavior, reduce feelings of depression and anxiety, and
encourage a sense of relaxation. By alleviating stressful feelings and promoting healing ones,
spirituality can positively influence immune, cardiovascular, hormonal, and nervous systems.
An example of a religion that promotes a healthy lifestyle is Seventh Day Adventists.
Those who follow this religion, a particularly healthy population, are instructed by their church
not to consume alcohol, eat pork, or smoke tobacco. In a 10 year study of Seventh Day
Adventists in Netherlands, researchers found that Adventist men lived 8.9 years longer than the
national average, and Adventist women lived 3.9 years longer. For both men and women, the
chance of dying from cancer or heart disease was 60-66% less, respectively, than the national
average.
The health benefits of spirituality do not stem solely from healthy lifestyles. Many
researchers believe that certain beliefs, attitudes, and practices associated with being a spiritual
person influence health. In recent study of people with AIDS, those who had faith in God,
compassion toward others, a sense of inner peace, and were religious had a better chance of
surviving for a long time than those who did not live with such belief system. Qualities like faith,
hope, and forgiveness, and the use of social support and prayer seem to have a noticeable effect
on health.
Faith is the most deeply held beliefs of a person that strongly influence his or her health.
Some researchers believe that faith increases the bodys resistance to stress. In a 1988 clinical
study of women undergoing breast biopsies, the women with the lowest stress hormone levels
were those who used their faith and prayer to cope with stress. Hope is a positive attitude that a
person assumes in the face of difficulty. In a 35 year clinical study of Harvard graduates,
researcher found that those graduates who expressed hope and optimism lived longer and had
fewer illnesses in their lifetime. Forgiveness is a practice that is encouraged by many spiritual
and religious traditions; it is a release of hostility and resentment from past hurts. In 1997, a
Stanford University study found that college students trained to forgive someone who had hurt

them were significantly less angry, more hopeful, and better able to deal with emotions than
students not trained to forgive. Love and social support---a close network of family and friends
that lends help and emotional support has been found to offer protection against many diseases.
Researchers believe that people who experience love and support tend to resist unhealthy
behaviors and feel less stressed. In a clinical study of a close Knit Italian American community
in Pennsylvania, researchers found that the death rate from heart attack was half that of United
States average. Researchers concluded that the strong social support network helped protect this
population from heart disease. Prayer is the act of putting oneself in the presence of or
conversing with a higher power has been used as a means of healing across all cultures
throughout the ages. In a 1996 poll, one half of doctors reported that they believe prayer helps
patients, and 67% reported praying for a patient.
The impact of spirituality on mental health has been studied more extensively than the
impact on physical health. Mental health describes the thinking part of psychosocial health. This
includes the ability to reason, interpret, and remember from a unique perspective. One can
intellectually sort through information, attack meaning, and make decisions. Mentally health
persons think rationally with fairly accurate perceptions of events.
There is abundant evidence that spirituality is associated with positive mental health
outcomes. Koenig and colleagues reviewed 325 studies, and found a significant relationship
between religious involvement and better mental health, physical health and the use of health
services. Williams concluded that spirituality buffered the effects of stress on mental health. In
Cowards study of 107 women with advanced breast cancer, spirituality appeared to improve
emotional well-being. Studies have demonstrated spirituality to be related to well-being in White
Americans, Mexican-Americans, and African-Americans and in different age groups.
Intrinsically religious people internalize their faith, and have higher self-esteem, better
personality functioning, less paranoia and lower rates of depression or anxiety, while
extrinsically religious people use religion to obtain status security, sociability or health. Findings
are mixed about whether spirituality increases or decreases anxiety. Spiritual coping is inversely
related to depressive symptom severity in veterans. However, only two-thirds of the population
considers spirituality to be an important influence in their life.
But despite this, some experts warn that religious beliefs can be harmful when they
encourage excessive guilt, fear, and lowered self-worth. Similarly, physicians should avoid
advocating for particular spiritual practices; this can be inappropriate, intrusive, and induce a
feeling of guilt or even harm if the implication is that ill health is a result of insufficient faith. It
is also important to note that spirituality does not guarantee health. Finally, there is the risk that
people may substitute prayer for medical care or that spiritual practice could delay the receipt of
necessary medical treatment.
In connection to the facts and information provided above, the researchers decided to
conduct further researchers that will address the issues and dilemmas encountered when dealing
with these kinds of patients. We would like to know what is the current mental health status of
these patients as well as their profile variables in relation to their spirituality. Furthermore, we
wanted to establish a relationship between their spirituality and their level of acceptance of their
illness. The researchers believed that these various factors presented have a significant effect on

their spirituality and their acceptance of their illness and death being in the terminal stage of their
disease.
If spirituality and religion are important to patients near the end of life and many patients
would value their physician having a capacity to engage them in at least a limited conversation
regarding these issues, one must consider how best to enhance the quality of end-of-life care
within these considerations. Comprehensive theological or pastoral education for all healthcare
providers is not feasible, nor is it necessary to address this need. Many healthcare institutions and
systems providing end-of-life care have chaplains with clinical pastoral training on staff that can
provide comprehensive spiritual care when appropriate. It is the responsibility of physicians to
learn how to access such spiritual care for their patients and how to work with chaplains and
other clergy as colleagues along with developing their own abilities and sensitivities around
spiritual issues in end-of-life care. Educational interventions assisting physicians in this
development, especially when these spiritual and religious issues are relevant to imminent
medical decision-making for the patient with a life-limiting illness, can greatly enhance the
quality of care given and the possibility of a "good death" for the patient and the family.
Statement of the Problem
This study will focus on determining the relationship of spirituality on mental health of
terminally ill cancer patients, on their level of readiness and acceptance in end of life, and to
their profile.
Specifically, this study will answer the following questions:
1. What is the profile of the terminally ill cancer patients according to:
a. Age
b. Sex
c. Civil Status
d. Economic Status
2. What is the mental health status of terminally ill cancer patients?
3. What is the spiritual status of terminally ill cancer patients?
4. What is the self-perceived level of acceptance of terminally ill cancer patients?
5. Is there a significant difference between the spirituality of terminally ill cancer
patients and their mental health?
6. Is there a significant difference between the spirituality of terminally ill cancer
patients and their profile?
7. Is there a significant difference between the level of acceptance of terminally ill
cancer patients and their profile?
Statement of the Null Hypotheses
Based on the formulated problems, the following null hypotheses will be tested in this study:
1. There is no significant difference between the spirituality of terminally ill cancer patients
and their mental health.
2. There is no significant difference between the spirituality of terminally ill cancer patients
and their profile.
3. There is no significant difference between the level of readiness and acceptance of
terminally ill cancer patients and their profile?

CONCEPTUAL and ANALYTICAL FRAMEWORK

PROFILE of the
terminally ill
CANCER
PATIENTS
according to:
a. Age
b. Sex
c. Civil Status
d. Economic Status

MENTAL
HEALTH
STATUS
Of Terminally Ill
Cancer Patients
SPIRITUALITY

LEVEL OF ACCEPTANCE in the end-of-life

Of Cancer Patients

RECOMMENDATIONS on how to
promote acceptance of death thru
provision of quality spiritual care

Figure 1. The Relationship of Spirituality, Mental Health and Profile of Respondents to their
Self-Perceived Level of Acceptance of End-of-Life
Spirituality influence health by improving coping skills and social support, foster feelings of
optimism and hope, promote healthy behavior, reduce feelings of depression and anxiety, and
encourage a sense of relaxation. An example of a religion that promotes a healthy lifestyle is
Seventh Day Adventists. Those who follow this religion, a particularly healthy population, are
instructed by their church not to consume alcohol, eat pork, or smoke tobacco. In a 10 year study
of Seventh Day Adventists in Netherlands, researchers found that Adventist men lived 8.9 years
longer than the national average, and Adventist women lived 3.9 years longer.
A vast literature consistently shows that older people are more likely to pray than younger
individuals. For example, Barna (39) reports that across six separate nationwide surveys, older
people are more likely than younger people to pray during the typical week. Once again, if
prayer is beneficial for health, then this relationship may be most evident among those who pray
the most--older people. It is crucial to realize how individual and unique these spiritual needs are
for every person, and how this variability increases with age, life experience, and health
condition. Belief in God ranges from 85% in teens aged 13 to 17 to 95% of adults over age 75;
weekly religious attendance is reported by 41% of teens to 60% of those over age 75; and
religion/faith is pretty or very important in 51% of teens to 75% of older adults.
(http://www.thefreelibrary.com/Spirituality+across+the+lifespan.-a0155098593)
Another profile variable included in our study is the respondents gender preference.
From a cross-sectional nation-wide study, examining multiple socio-demographic and
personality factors and health locus of control that gives emphasis on the gender differences of
Greek centenarians. Concerning personality variables, females were more reward-dependent and
adaptable than men, while men were more optimistic than women. No differences were found on

health locus of control profile between the genders. Positive correlations between self-directness
and spirituality with internal locus of control in men and negative correlations between optimism
and external locus of control in women emerged as the main gender disparities in the correlation
analyses. Self-directness in men and optimism in women were consistently correlated with the
two HLC subscales.
There is abundant evidence that spirituality is associated with positive mental health
outcomes. Koenig and colleagues reviewed 325 studies, and found a significant relationship
between religious involvement and better mental health, physical health and the use of health
services. Williams concluded that spirituality buffered the effects of stress on mental health.
One of the variables used in the study have focused on the spirituality of the respondents
as it affects their acceptance of death. A study by McClain, Rosenfeld, and Breitbart (2003)
attempted to assess the relationship between spiritual being and end of life despair. 160 cancer
patients with a life expectancy of 3 months or less were studied over an eighteen month period.
Results showed that spiritual well-being was strongly associated with desire for hastened death
in patients who experienced low spiritual well-being but not for those who experienced high
levels of spiritual well-being. Studies also suggest that religiously involved persons at the end of
life are more accepting of death, unrelated to belief in an afterlife. Finally, intrinsic religiosity
and religious involvement are associated with less death anxiety.
Scope and Delimitation
This study will cover only the terminally ill cancer patients in Nueva Vizcaya. The study
was primarily concerned with the relationship of spirituality on mental health of terminally ill
cancer patients, level of acceptance in end of life, and to their profile.
The weakness of this study is that the subjects are only limited to terminally ill condition,
it does not include the newly diagnose cancer patients nor cancer patients under
rehabilitation.
Significance of the Study
Nurses/Clinicians -would benefit from this study by providing them the necessary and
essential information on how they can help in boosting a patients spirituality as a
significant member of the health care team. Information gathered in the study will enable
them to come up with various strategies they can do in order to improve their
performance in delivering holistic care giving special attention in improving their skills
of providing acceptable spiritual care that is parallel to the clients traditions, beliefs and
practices.
Nurse Educators-will benefit from this study by helping them be aware of the things that
should be given much attention due to the fact that it is one of most nurses weaknesses:
that is to give and be aware of the clients spiritual needs. More often than not nurses
would only be more concerned with physical symptoms rather than concerning
themselves with the clients social and spiritual suffering. This would guide our nurse
educators to find ways on how they can effectively improve future nurses assessment
skills not just physically, mentally, socially, emotionally but also spiritually.

 Community-would benefit from the study by keeping them be more aware of the needs of
a cancer patient thru cancer awareness programs being conducted. Educating the whole
community where these cancer patients live increases the possibility of establishing a
more caring and more empathetic environment that can understand the things these
cancer patients need to go through before they can face the reality of having such
disease.
Cancer Patients-would benefit from the study by increasing their knowledge and level of
awareness as to what are the various factors that would affect their spirituality and how
these factors would affect their readiness and acceptance of their disease and its future
outcomes. This can be a source of data to see on what areas/ factors greatly affects their
readiness and acceptance of the disease. They would be knowledgeable on what specific
areas of concern they need to strengthen and what areas of concern need to be
maintained.
Student Nurses-would benefit from this study by increasing their awareness and
advocacy in giving holistic care with special emphasis on patients spiritual health as part
of his/her daily needs. We need to start inculcating in their minds the great value of
giving attention to a clients spiritual care specially in the case of cancer patients due to
the fact that most of the time this domain is usually overlooked and not given enough
attention to be prioritized at the moment.
Future Researchers- they would be benefit from this study by using the results of the
study as their basis to guide them in conducting future studies that has similar focus and
line of interest that also deals with cancer patients and or oncologic nursing. With this
study, they would also be able to understand the essence of knowing the different factors
that might affect cancer patients spirituality.

DEFINITION of TERMS

To facilitate better understanding of the terms used in this study, the researchers have
lifted the following terms from authoritative sources and have defined them conceptually and
operationally.
Level- degree of moral, intellectual, or social elevation; rank (Webster
Comprehensive Dictionary, 2005). In this study, it refers to the degree of readiness
and acceptance of terminally ill cancer patients.
Readiness- the quality or state of being ready (Webster Comprehensive Dictionary,
2005). In this study, it refers to the preparedness of terminally ill cancer patients to
face death.
Acceptance- the state of believing in (Webster Comprehensive Dictionary, 2005). In
this study, it refers to the awareness of terminally ill cancer patients about their
impending death.
Terminally ill- the cancer patients in their terminal stage of illness
Spirituality- the state of being spiritual that which belongs to the church or to an
ecclesiastic (Webster Comprehensive Dictionary, 2005). In this study, it refers to the
holism and faith of terminally ill cancer patients.
Health- general condition of the body or mind, as to vigor and soundness (Webster
Comprehensive Dictionary, 2005). In this study, it refers to the mental condition of
terminally cancer patients.
Profile-a set of data often in graphic from portraying the significant features of
something (Miriam Webster Dictionary, 2002). In this study, it refers to the age, sex,
civil status, and economic status of terminally cancer patients.
Relationship-an aspect or quality (as resemblance) that connects two or more things
or parts as being or belonging or working together or as being of the same kind
(Miriam Webster Dictionary, 2002). In this study, it refers to the connection between
spirituality, health and level of acceptance in the end of life and profile of terminally
ill patients.

CHAPTER II
REVIEW OF RELATED LITERATURE
AND REALTED STUDIES
Death has a thousand faces, but dying has a million ways. Death is ubiquitous and
universal. Death attitudes affect how we live. How we view death and how we cope with death
can profoundly affect every aspect of our lives---either positively or negatively.
Most of us have images of death that are negative and disturbing, and that evoke feelings
of fear and anxiety. Death is the only certainty in life. All living organisms die; there is no
exception. However, human beings alone are burdened with the cognitive capacity to be aware of
their own inevitable mortality and to fear what may come afterwards. Furthermore, their capacity
to reflect on the meaning as life and death creates additional existential anxiety.
Palmer (1993) interviewed many people from different cultures about death and dying,
and he concluded that they havent found acceptance, but they havent mired themselves in anger
or depression and more often than not one of the ways they handle death is to give it a
recognizable face. Thus, he proposed that dying can be a positive and rewarding experience; it
can be a time of personal freedom and growth. But dying well begins with death acceptance.
According to Elisabeth Kubler-Ross, a pioneer in death and dying studies, dying people
often experience 5 emotional stages. These stages generally occur in the following order: Denial,
Anger, Bargaining, Depression, and Acceptance. Denial is usually a temporary response to
overwhelming fears about loss of control, separation from loved ones, an uncertain future, and
suffering. Anger may be expressed as sense of injustice: Why me?. Bargaining can be a sign of
reasoning with death---that is, seeking more time. Depression develops when dying people
realize that bargaining and other strategies are not working. Acceptance, sometimes described as
facing the inevitable, may come after discussions with family, friends, and health care providers.
A good death and a death with dignity may be achieved when death is congruent with the
personal values of the patient. It behooves the practitioner to recognize these values and to cater
to them. A good death is achieved when symptoms are controlled and when patients and family
recognize death as a unique living experience to be treasured as any other living experience. A
death with dignity brings healing, that is always possible even when cure is out of reach.
Patients and practitioners values may be at odd in face of controversial issues including
euthanasia, assisted suicide and terminal sedation. Open communication and reflective listening
even in presence of disagreements are the venue of healing. The study of death and dying
requires novel approaches including personal narrative and qualitative research to complement
traditional research instrument, such as questionnaire that cannot embrace the whole human
dimension. (http://annonc.oxfordjournals.org/)
Preparing for death often means finishing a lifes work, setting things right with family
and friends, and making peace with the inevitable. Preparing for death is hard work, with many
emotional ups and downs. Spiritual and religious are important to many dying people and their
families. Acceptance involves a willingness to let go and detach ourselves from events and things
which we used to value. A positively oriented acceptance also entails the recognition of the

spiritual connection with a transcendental reality and the vision of sharing spiritual life with love
ones for all eternity.
End-of-life discussions offer patients the opportunity to define their goals and
expectations for the medical care that they want to receive near death. But these discussions also
mean confronting the limitations of medical treatments and the reality that life is finite, both of
which may cause psychological distress. Studies suggest that physicians and patients are
ambivalent about talking about death and often avoid these conversations.
(http://jama.jamanetwork.com/ on 07/09/2013)
The World Health Organization definition of palliative medicine emphasizes the
psychosocial and spiritual aspects of care. End-of-life care addresses not only physical symptoms
but also psychosocial and spiritual concerns. Terminally ill patients derive strength and hope
from spiritual and religious beliefs. Indeed, terminally ill adults report significantly greater
religiousness and depth of spiritual perspective compared with healthy adults. Greater depth of
spiritual perspective is associated with greater sense of well-being. Studies also suggest that
religiously involved persons at the end of life are more accepting of death, unrelated to belief in
an afterlife. Finally, intrinsic religiosity and religious involvement are associated with less death
anxiety.
Five studies were found that address spirituality among terminally ill cancer patients. A
study by McClain, Rosenfeld, and Breitbart (2003) attempted to assess the relationship between
spiritual being and end of life despair. 160 cancer patients with a life expectancy of 3 months or
less were studied over an eighteen month period. This study examined whether spiritual wellbeing was associated with depression, hopelessness, attitude towards hastened death, functional
support and performance status. Instruments used in the study were Functional well-being Scale,
Mini-mental State Examination, Hamilton Depression Rating Scale, Beck Hopelessness Scale,
Schedule of Attitudes towards Hastened Death, Functional Social Support Questionnaire,
Memorial Symptom Assessment Scale, and Karnofsky Performance Rating Scale. Results
showed that spiritual well-being was strongly associated with desire for hastened death in
patients who experienced low spiritual well-being but not for those who experienced high levels
of spiritual well-being.
Spirituality is a word used in an abundance of contexts that means different things for
different people at different times in different cultures. According to Swinton, spirituality has
broadened in meaning into a more diffuse human need that can be met quite apart from
institutionalized religious structures. He identifies it as the outward expression of the inner
workings of the human spirit and has defined it as the aspect of human existence that gives it its
humanness. It concerns the structure of significance that gives meaning and direction to a
persons life and helps them deal with the ___cissitudes of existence. As such, it includes such
vital dimensions as the quest for meaning, purpose, self-transcending knowledge, meaningful
relationships, love and commitment, as well as sense of the Holy amongst us.
A cross-sectional nation-wide study, examining multiple socio-demographic and
personality factors and health locus of control that gives emphasis on the gender differences of
Greek centenarians. From the study it showed women centenarians outnumbered men by a ratio

of 1.68 to 1. Significant gender socio-demographic differences were noted, with men reporting
less often widowhood, more often centenarian 1st degree relatives and smoking. Higher BMI
score was measured in males than females. Concerning personality variables, females were more
reward-dependent and adaptable than men, while men were more optimistic than women. No
differences were found on health locus of control profile between the genders. Positive
correlations between self-directness and spirituality with internal locus of control in men and
negative correlations between optimism and external locus of control in women emerged as the
main gender disparities in the correlation analyses. Self-directness in men and optimism in
women were consistently correlated with the two HLC subscales.
Spirituality is a persons way of being, thinking, choosing, and acting in the world in light
of that persons ultimate values (Savary, 2006). Spirituality is a fundamental quality that
contributes to health and wellness, life satisfaction and coping, healing, recovery, hope and wellbeing, psychosocial adjustments and sense of coherence and quality life in general (Brillhart, et
al:2005).
There are 5Rs of Spirituality. According to Govier (1999), they are Reason, Reflection,
Religion, Relationships, and Restoration. Reason and reflection, the search for meaning in life
experiences has been viewed as an essential universal trait (Cobb and Robshaw, 1998). Religion
can serve as a vehicle for expressing spirituality through a framework of values, beliefs and ritual
practices and for some, provides the answers to the essential questions surrounding life and death
issues (Ross, 1994). Oldnall (1996) regards relationships with ourselves, others and God as being
at the centre of the spiritual dimension. Labun (1988) identified meaningful, purposeful or
creative work as an expression of spirituality and indicated that service to others might also
fulfill spiritual needs. Carson (1989) observes the need for a continuous interrelationship
between the inner being of the person and the persons horizontal relationships with self, others
and the environment. Restoration refers to the ability of a persons spirituality to have a positive
influence on the physical aspects of a person. Certain life events can cause an inability to restore
the body to a spiritual equilibrium, resulting on spiritual distress (Burnard, 1988).
Cancer patients are prone to spiritual distress upon facing with their diagnosis, change in
disease stage and the difficulties of ending their lives. This is because they suffer from lack of
meaning, value and purpose in their lives due to severe physical and functional damages
accompanying the disease. However, anyone may have his or her own interpretation of the
concept of spirituality. Also, the persons age, sex, race, culture, previous personal experiences,
and the stage of life, which the person is experiencing, affect the expression of his spirituality.
Spirituality can be expressed through rituals, meditation, guided imagery, visualization,
practicing gratitude, spending time in nature, viewing and engaging in art, and through various
other endeavors that have meaning to the patient or client. To simplify how individuals express
and experience spirituality, we look at expression of feelings, forgive, or are forgiven, have
connections to others or a higher power, find meaning in life, and have hope.
The spiritual rituals or prayer, meditation, guided imagery, gratitude, spending time in
nature, and art can all help people connect to their inner being, to others and to a divine spirit or
higher power. As part of spiritual and cultural traditions, rituals help to provide awareness,

meaning, intention, and purpose in life. There are various types of prayers that clients may
engage in. Rituals on the other hand, are practices that are often repeated and can provide a way
for people to make life experience meaningful.
Nowadays, spirituality includes many studies that demonstrate the connection between
spirituality and health improvement. Many are becoming interested in the role of spirituality in
their health and health care. This may be because of dissatisfaction with the impersonal nature of
our current medical system, and the realization that medical science does not have answers to
every question about health and wellness.
Spirituality influence health by improving coping skills and social support, foster feelings
of optimism and hope, promote healthy behavior, reduce feelings of depression and anxiety, and
encourage a sense of relaxation. By alleviating stressful feelings and promoting healing ones,
spirituality can positively influence immune, cardiovascular, hormonal, and nervous systems.
Cancer ranks among the most dreaded of diseases. A diagnosis can cause extreme fear,
helplessness, and psychologic trauma. The unforeseeable outcome of the treatment compounds
the anxiety and leads to patients feeling powerless. Both cancer patients and their families may
be intimidated and confused by the healthcare delivery system and the technology of modern
treatment. Such a diagnosis challenges every dimension of a person's life: physical, emotional,
and spiritual.
A subsequent study by McClain-Jacobson, et al. (2004) was conducted on 276 terminally
ill cancer patients to determine whether a belief in the afterlife was associated with lower of endof-life despair, anxiety and depression. Patients were asked whether they believe in an afterlife,
whether their beliefs about an afterlife were comforting, and whether their beliefs about afterlife
were distressing. Results showed that most patients (63.4%) reported belief in an afterlife, 17%
reported no belief in afterlife and 19.6% were unsure about their beliefs. Spiritual well-being was
assessed with the Functional Assessment of Chronic Illness Therapy- Spiritual Well-Being Scale.
Depression was measured using the Hamilton Depression Rating Scale and Hospital Depression
Scale. Anxiety was measured using the Hospital Anxiety Scale. Hopelessness was measured
using the Beck Hopelessness Scale. Belief in an afterlife, spiritual well-being and end of-life
despair in patients with advanced cancer were measured using the Schedule of Attitudes toward
Hastened Death. This study concluded that belief in an afterlife was associated with lower levels
of hopelessness, suicidal ideation, and desire for hastened death was not associated with anxiety
or depression.
Spiritual factors play a major role at all ages in dealing with life change and helping
persons to cope with pain, anxiety, and disability of medical illness. Cultural factors influence
how spirituality is used to cope with illness, and clinicians need to know how persons from
different ethnic and religious backgrounds express their spirituality in relationship to health
problems. Spirituality will also differ in its expression depending on the age of the individual, so
that the spiritual needs of children may be different from those of young, middle-aged or older
adults.

It is crucial to realize how individual and unique these spiritual needs are for every
person, and how this variability increases with age, life experience, and health condition. Belief
in God ranges from 85% in teens aged 13 to 17 to 95% of adults over age 75; weekly religious
attendance is reported by 41% of teens to 60% of those over age 75; and religion/faith is pretty or
very
important
in
51%
of
teens
to
75%
of
older
adults
More interventions have focused on prayer than any other facet of religion. As a result, it
is easier to see why prayer might be an especially important way of using religion in clinical
settings. One of the foremost studies on religion was conducted over a century ago by William
James. He maintained that prayer is, "... the very soul and essence of religion" (page 486).
Describing prayer as, "... religion in action ...," James believed that prayer is the arena in which
the "real" work of religion is done. Recent studies on the frequency of prayer are consistent with
the observations of James because this research suggests that prayer may be the most common
form of religious practice.
Some researchers have studied childrens spiritual beliefs in relation to health and
palliative care. Pehler observed that a childs spiritual development parallels His physical and
psychosocial growth. Davies advocated including spiritual assessment of sick children, And of
their parents, grandparents, and siblings, as part of palliative care. Regardless of the patients
age, performing a spiritual assessment can help providers better adapt the plan of
care.A vast literature consistently shows that older people are more likely to pray than younger
individuals. For example, Barna (39) reports that across six separate nationwide surveys, older
people are more likely than younger people to pray during the typical week. Once again, if
prayer is beneficial for health, then this relationship may be most evident among those who pray
the most--older people.
The impact of spirituality on mental health has been studied more extensively than the
impact on physical health. Mental health describes the thinking part of psychosocial health. This
includes the ability to reason, interpret, and remember from a unique perspective. One can
intellectually sort through information, attack meaning, and make decisions. Mentally health
persons think rationally with fairly accurate perceptions of events.
There is abundant evidence that spirituality is associated with positive mental health
outcomes. Koenig and colleagues reviewed 325 studies, and found a significant relationship
between religious involvement and better mental health, physical health and the use of health
services. Williams concluded that spirituality buffered the effects of stress on mental health. In
Cowards study of 107 women with advanced breast cancer, spirituality appeared to improve
emotional well-being. Studies have demonstrated spirituality to be related to well-being in White
Americans, Mexican-Americans, and African-Americans and in different age groups.
Intrinsically religious people internalize their faith, and have higher self-esteem, better
personality functioning, less paranoia and lower rates of depression or anxiety, while
extrinsically religious people use religion to obtain status security, sociability or health. Findings
are mixed about whether spirituality increases or decreases anxiety. Spiritual coping is inversely
related to depressive symptom severity in veterans. However, only two-thirds of the population
considers spirituality to be an important influence in their life.

A cross-sectional study by Bauer-Wu and Farran (2005) compared personal meaning in life,
spirituality, stress and psychological distress in breast cancer patients to a group of healthy
patient. There were 78 women who participated in the study ranging from 35-55 years of age.
Most of the participants had a high socioeconomic status were Caucasian and married. 39 were
breast cancer survivors and 39 had no present history of cancer or other chronic or life
threatening illness. All participants completed questionnaires including 3 measures of personal
meaning; the Personal Meaning Index, the Existential Vacuum, and the Ladder of Life Index at
present. One measure of spirituality, the index of core spirituality index was used. Perceived
stress was measured with the Perceived Stress Scale. Psychological distress was measured using
the belief profile of mood states. The study concluded that there is a correlation between
perceived meaning in life and spirituality. These elements have an inverse correlation with the
psychological distress and perceived stress. Another interesting finding was that personal
meaning in life and spirituality were lower and psychological distress was higher in breast cancer
survivors without children compared to breast cancer patients with children.
A similar study by Krupski, et al (2005) was conducted on prostate cancer patients of low
socioeconomic class to determine whether spirituality is associated with health related quality
life or psychological health. Health related quality of life was measured using the RAND
Medical Outcomes study short form 12-item health survey, version 2. Anxiety was evaluated
using an unnamed instrument validated in leukemia survivors. Emotional well-being was
assessed with the Medical Outcomes Study 5 in Mental Health Index. Symptom distress was
measured using the Symptom Distress Scale. The functional Assessment of Chronic Illness
Therapy- Spiritual Well- Being Scale was utilized to evaluate spiritual well-being. The study
findings show that as spiritual well-being increased, health related quality of life also improved.
Spirituality was associated with higher levels of satisfaction. Men who had lower levels of
spiritual well-being also had lower levels of psychological well-being including increased
anxiety and more symptom distress.
A randomized controlled trial by Chibnall, Videen, Ducko, and Miller (2002) was
completed to identify individual factors associated with death related anxiety and depression and
to evaluate the effectiveness of support on the psychosocial and spiritual well-being of patients
with life threatening conditions. Members of the intervention group attended monthly support
groups for 1 year. 350 people with serious life threatening medical conditions were invited to
participate in the study. Participants were randomly assigned to either an intervention group or a
control group. 67 patients completed the study. Out of those 67 patients, 24% had a diagnosis of
cancer. This study revealed that higher levels of death distress were associated with more
depressive symptoms, less spiritual being, less perceived communication with their physician,
and with living alone. Higher levels of death anxiety and death depression were associated were
correlated with lower levels of spiritual well-being. The sample size was not large enough to
evaluate differences between the intervention group and the control group.

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