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Special Communication
ܱ12, 2022

Spirituality in Serious Illness and Health

Author Affiliations
  • 1Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 4Human Flourishing Program, Institute for Quantitative Social Science, Harvard University, Cambridge, Massachusetts
  • 5Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 6Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, California
  • 7Department of Religion, Health, and Human Values, Rush University Medical Center, Chicago, Illinois
  • 8Departments of Psychiatry and Behavioral Sciences and Medicine, Duke University Medical Center, Duke University, Durham, North Carolina
  • 9Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
  • 10The George Washington Institute for Spirituality and Health, Departments of Medicine and Health Care Sciences, George Washington University, Washington, DC
  • 11Division of Palliative Medicine, Department of Medicine, Duke University Medical Center, Duke University, Durham, North Carolina
  • 12Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
  • 13Kennedy Institute of Ethics, Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC
  • 14John F. Kennedy School of Government, Harvard University, Boston, Massachusetts
JAMA. 2022;328(2):184-197. doi:10.1001/jama.2022.11086
Key Points

Question How can considerations of spirituality guide health care and health outcomes?

Findings A systematic review and a multidisciplinary Delphi panel assessed the evidence regarding spirituality and health, developed 16 evidence statements, and offered 6 implications regarding incorporation of spirituality in the care of patients with serious illness and in health outcomes.

Meaning This systematic review and process, based on the highest-quality evidence available and expert review, led to consensus-suggested implications for how to address spirituality in serious illness and health outcomes.


Importance Despite growing evidence, the role of spirituality in serious illness and health has not been systematically assessed.

Objective To review evidence concerning spirituality in serious illness and health and to identify implications for patient care and health outcomes.

Evidence Review Searches of PubMed, PsycINFO, and Web of Science identified articles with evidence addressing spirituality in serious illness or health, published January 2000 to April 2022. Independent reviewers screened, summarized, and graded articles that met eligibility criteria. Eligible serious illness studies included 100 or more participants; were prospective cohort studies, cross-sectional descriptive studies, meta-analyses, or randomized clinical trials; and included validated spirituality measures. Eligible health outcome studies prospectively examined associations with spirituality as cohort studies, case-control studies, or meta-analyses with samples of at least 1000 or were randomized trials with samples of at least 100 and used validated spirituality measures. Applying Cochrane criteria, studies were graded as having low, moderate, serious, or critical risk of bias, and studies with serious and critical risk of bias were excluded. Multidisciplinary Delphi panels consisting of clinicians, public health personnel, researchers, health systems leaders, and medical ethicists qualitatively synthesized and assessed the evidence and offered implications for health care. Evidence-synthesis statements and implications were derived from panelists’ qualitative input; panelists rated the former on a 9-point scale (from “inconclusive” to “strongest evidence”) and ranked the latter by order of priority.

Findings Of 8946 articles identified, 371 articles met inclusion criteria for serious illness; of these, 76.9% had low to moderate risk of bias. The Delphi panel review yielded 8 evidence statements supported by evidence categorized as strong and proposed 3 top-ranked implications of this evidence for serious illness: (1) incorporate spiritual care into care for patients with serious illness; (2) incorporate spiritual care education into training of interdisciplinary teams caring for persons with serious illness; and (3) include specialty practitioners of spiritual care in care of patients with serious illness. Of 6485 health outcomes articles, 215 met inclusion criteria; of these, 66.0% had low to moderate risk of bias. The Delphi panel review yielded 8 evidence statements supported by evidence categorized as strong and proposed 3 top-ranked implications of this evidence for health outcomes: (1) incorporate patient-centered and evidence-based approaches regarding associations of spiritual community with improved patient and population health outcomes; (2) increase awareness among health professionals of evidence for protective health associations of spiritual community; and (3) recognize spirituality as a social factor associated with health in research, community assessments, and program implementation.

Conclusions and Relevance This systematic review, analysis, and process, based on highest-quality evidence available and expert consensus, provided suggested implications for addressing spirituality in serious illness and health outcomes as part of person-centered, value-sensitive care.