Faith and Spirituality-Palliative Cares and Life Quality for Cancer Patients : Information Archeology with Statistics Table as from a Systematic Review

Background: The faith and spirituality in palliative cares started to be used in medical community in the last decade of the XX century. The faith is known as a synonym of trust and hope being considered a positive emotion which helps the individual to enlarge tolerance, moral, growing creativity and building of new expectations. And the spirituality is related to psychological experiences of religiousness, associated individual idea. Such themes are inserted in the assistance to the palliative cancer patient.


Introduction
The World Health Organization (WHO) highlights the cancer as being one of the most non-transmissible deceases responsible for the population illness profile change, estimating that, in 2030, it's expected 27 million incident cancer, 17 million cancer deaths and 75 million living people, annually, suffering from cancer.The biggest effect of this increase will happen in low income countries, as a result, considering cancer a global health problem [1,2].
Thinking of diagnosed population and cancer treatment, a group of scientists of São Paulo's Medicine Regional Council (CREMESP), 2002, described that most of the deceases are incurable, thus, the treatment aims its evolution control and turns this illness chronic.They use the word "cure" as a truth slightly worked in Medicine.Within this theme holding that the patient becomes out of "cure possibility" reflects two situations; every patient should be under palliative care, or it would only be addressed to palliative care according to medical team criteria when they state that the patient is living his last life hours.The second situation implies in a misconception, thinking that palliative care can be summarized only to the provided care to the final phase of life, when there is nothing else to be done [3].
The palliative approach teamwork added to a healing treatment is the most viable possibility, to develop palliative actions in the diagnoses phase and in treatment, evaluating that as the decease progresses, and the treatment doesn't provide any expected improvement to the patient and therapeutics possibilities get scarce, the palliative care grow in meaning, coming up a real necessity to interventions in the symptoms control not only biologics but also emotional ones, so that the patient and their relatives understand the decease process [3].Said that, in the advanced phase of a decease the patient and their relatives analyze that the death process is getting closer, they start to understand that the palliative care is able to provide procedures, medicaments, and approaches for physical and emotional well-being until the end of the life [3].
The applicability of palliative care will happen when the diagnoses is presented, when there is a health problem facing moment associated to the death risk, dealing with sorrow prevention and relief throughout premature identification, impeccable evaluation about the pain treatment and other spiritual, psychosocial and physical problems [4].In this perspective, it can be a "mistake "thinking that palliative care is a therapeutics to be applied only when there is an imminent death risk.To be diagnosed with cancer the patient longs for a treatment provided by a multi-professional team, at this moment the patient is submitted to a huge emotional stress.Situation which should be evaluated and stu-categories worked in this study considering at a time an improvement of physiological and psychological symptoms, of immunologic and social relations during the palliative treatment.[Conclusion]: the studies involved in this review refer to the human factor which is related directly to the patient care, in special health teams, needs to be trained to deal with care concepts about the patient faith and spirituality.Therefore, trainings are needed for these professionals enabling them to deal with this so fragile population which requires therapeutic techniques well applied and respect for each one's individuality.died cautiously, as studies refer to treatment effectiveness depending on the patient emotional state.As soon as the patient is diagnosed he refers to a brief death reaction moment, starting to elaborate unconsciously the grieving process [3,5].When referring to the grieving, it is related to the loss of physical health, at this first moment the patient denies the diagnoses, the problem existence or the situation.He seems not to believe in what is being informed about, tries to forget it, not to think, and also searches for evidences or arguments for the new reality [4].
According to Harvard studies developed by Vaillant [6], limbic experiences of faith (internal or external), are so remarkable, unforgettable and real as any other deep emotional experience, the limbic experiences produce the same sensation as inner calmness, pleasure and hope feelings (waiting for something better), taking moments of faith and spirituality discussions as refuge, support and a venue where the patient can trust to process and express his conflicts, fears, fantasies, and anguish related to the decease, to the treatment or his death [6,7].
The patients who are experiencing the palliative care have the need to be heard and have better quality of life.In this context the palliative care definition by Canadian Palliative Care Association Standards Committee (1995) and WHO (2002), considering the patients in their spiritual needs [8,9].Facing this, faith and spirituality have been identified being intrinsically linked to the treatment, providing to the patient a reflection opportunity, self-perception as an individual and a beginning of strategy elaboration to cope with this new life condition.
According to Veit and Castro [7] the religious and spiritual factors have been associated to various aspects of adequacy to the diagnoses and cancer treatment, pointing its importance for the patient's health and recovery.Being the faith described as trust and safety, having its origin in three sources: a conscious one (neocortical) and two are unconscious (limbic), these sources depict the cognitive certainty need, the social need of community and emotional need of trust [6,7].This study chose to amplify the knowledge about the need of faith and spirituality, bringing its relation to oncologic patient life quality in palliative care [8].

Method
It aims a qualitative systematic review about faith and spirituality themes, since it enables summarizing the already concluded researches and reach conclusions from a topic of interest.A well done systematic review demands the same standard of rigor, clarity and replication used in primary studies.Said that, a Cochrane Handbook Collaboration guide adaptation was used for qualitative analyses, 2001 [10,11].For this paper, PICOS strategy was chosen (participants/patients, intervention, comparison, "outcome" and study kind of "Stude") [12].It is a strategy which enables a guiding research questioning for review: how can faith and spirituality facilitate situations that promote the patients' life quality who are experiencing palliative care?, with determiners for exclusion and inclusion criteria, driving the study and the organization of logics reasoning [10,11].In this paper, the study did not use the C component (comparison) of PICOS strategy, once there isn't stablished standardized treatment.
The search for the material was widely done using descriptors Medical Subject Headings (MeSH): "neoplasm", "spirituality", "palliative care", suitable for index the articles from Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed) and Scopus database.Apart from the key-word "faith", once that, even not composing a MeSH descriptor, it is often used to describe studies of this review theme.Search strategy correlated the descriptors as follows: 1) "faith" AND "palliative care" AND "neoplasms"; 2) "spirituality" AND "palliative care" AND "neoplasms".The search occurred in February/2015, with indexed studies in the last twelve years (2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014), considering that the redefinition of palliative care by WHO dates of 2002 [8].The papers selection occurred mainly through titles and reviews analyses.After identifying the articles, they were independently evaluated by the authors, considering the following inclusion criteria: (1) Studies which evaluated the faith/spirituality roles as a facilitator and/or strategy to obtain oncologic patients life quality experiencing the palliative care process; (2) Articles which had in the title or in the abstract at least a descriptor combination in the search strategy; (3) Considered articles that referred to oncologic patients in palliative care; (4) There wasn't restriction due to the published articles language, when there wasn't domain (English, Portuguese and Spanish languages) article translation was required to translators.In order to avoid idiom bias; (5) Prospective or retrospective studies of observational feature (analytical or descriptive), clinic and qualitative trials, containing terms Faith and spirituality in the process to evaluate palliative care and life quality being psychological well-being and /or adaptation, symptoms control.Exclusion criteria: editorials, case story, brief comments, digest, News or letter linked to scientific papers and thesis, monographs, essays, systematic review articles, congress productions, (synopsis, expanded synopsis, or complete texts), chapters of books and books.The articles that didn't present available access to the full text on CAPES database (Coordination for Student Improvement in Academic Research), and that were not sent by authors after being required by email.

Results
The characterization data of scientific production about Faith and spirituality in oncologic patients is presented in absolute frequency with statistics percentages (Table 1).The article selection process was well elaborated, as PICOS refined strategy was used and inclusion criteria (Figure 1).For the duplicated studies removal was used the criteria to keep the base study of data which contained the most detailed study.Thus, after detailed reading, it was chosen to keep the studies that were in the Scopus electronic database which brought fifty-five (82,1%) of eligible publication for this review.
Here are presented the identified studies about faith and spirituality in oncologic patients who ex-perienced palliative care.Sixty seven articles were identified related to the proposed theme, considered eligible ones for the final phase.The data was extracted in a standardized way of filtered and evidenced studies, developed characterization tables (Table 2, Table 3, Table 4, Table 5).The results suggest that while religious and spiritual beliefs may marginally increase the coping with the disease and approaching death, they do not affect levels of anxiety and depression in patients with advanced cancer.Douglas, S.L., Daly, B.J. [19] The impact of patient quality of life and spirituality upon caregiver depression for those with advanced cancer Palliative and Sipportive Care

2013
Coping and quality of life The spirituality of patients is critical to your coping and adjusting to cancer.
It is this aspect of the overall quality of life of patients that mediates the improvement of the relationship between their caregivers.It is considered the spiritual welfare the most powerful intervention for depression caregiver may be attending the patient spiritual anguish.
Skeath, et.al.[20] The nature of life-transforming changes among cancer survivors

Qualitative Health Research 2013
Coping and quality of life Discovery of unanticipated personal skills and resources, and that has become very useful in dealing with other challenges beyond cancer.This caused an increase in capacity and personnel resources "life changing" instead of being limited to substantially reduce the problems with cancer.Support Intervention for facilitated positive change processes can reduce suffering and improve psychosocial outcomes and positive spiritual for patients.The study says the link between the physical, psychosocial and spiritual personality with the important implication that an interdisciplinary team approach is required to meet the complex needs of patients in palliative care and their families.Minimizing the physical suffering and grief It showed that psychotherapy groups resulted in significantly greater improvements in spiritual well-being and a sense of meaning.Gains treatment were even more substantial (based on estimates of such great effect) the second follow-up evaluation.Improvements in anxiety and desire for death were also significant (and increased over time).Concluding that this type of therapy seems to be a potentially beneficial intervention for emotional and spiritual suffering of patients at the end of life.Considering both the universality of spiritual pain and the multifaceted nature of pain, it was proposed that when patients report the experience of pain, plus the complexity of the phenomena involved in the treatment and spiritual pain can be considered a contributing factor to the failure of the treatment.The authors say that the spiritual pain is not treated as both hinder the recovery will contribute to the overall suffering of the patient.Spiritual experiences can have a big impact on the physical and emotional well-being and facilitate the process of dying.Music therapy, psychotherapy and spiritual assistance provide essential methods for psycho-oncology and palliative care.A holistic and interdisciplinary approach to help patients in their suffering complex is required.
McClain-Jacobson et.al.[65] Belief in an afterlife, spiritual well-being and end-of-life despair in patients with advanced cancer

Quality of life
The results indicated that the belief in the afterlife was associated with lower levels of end of life of despair (death wish, hopelessness and suicidal thoughts), but was not associated with levels of depression or anxiety.The authors concluded that spirituality has a much more powerful effect on psychological functioning than beliefs about the afterlife.Vilalta A, Valls J, Porta J, Viñas J. [69] Evaluation of spiritual needs of patients with advanced cancer in a palliative care unit.

Quality of life and spirituality
The spiritual needs emerged as the most important issue for patients: their need to be recognized as a person until the end of his life and his need to know the truth about his illness.The least within the spirituality was the continuity and the afterlife; to get rid of obsessions; to achieve freedom from guilt and be able to forgive others; and the need for reconciliation and feel forgiven by others.Concluding that when patients knew the truth about their disease and they were treated with dignity and have better coping.
Patterns of adaptation in patients living long term with advanced cancer.

Psyco-Oncology 2010 Symptom control and quality of life
The current findings suggest that psycho-spiritual adaptation.In this study, it is not uniform but is characterized by heterogeneous trajectories.
The results contribute to the development of better hypotheses about the processes of adaptation in long-term survivors with advanced cancer and to identify potential subgroups of higher risk for poor outcomes.
Alcorn et.al.[72] "If God wanted me yesterday, I wouldn't be here today": religious and spiritual themes in patients' experiences of advanced cancer.

Journal of Palliative Medicine 2010
Quality of life Religion and / or often spiritual play a key role in the wellbeing of the patient maintenance.
Mystakidou et.al.[73] Exploring the relationships between depression, hopelessness, cognitive status, pain, and spirituality in patients with advanced cancer.

Archive Psychiatr Nursing 2007
Symptom control and quality of life Significant associations were found between interference of physical pain and the joy of life and despair, as well as among the worst pain and pain interference items such as depression and cognitive status.Significant correlations were found between despair, depression, and cognitive condition.These results demonstrate the physical, psychological and cognitive cancer patients.
Noguchi et.al.[74] Spiritual needs in cancer patients and spiritual care based on logotherapy.

Support Care Cancer 2006
Quality of life and spirituality The Japanese people generally have no strict and definite religious faith and have a tendency to rely on morality and ethics in their own mind rather than to put importance on religious feeling to believe in "God", which is outside their own mind.
Luhrs et.al.[75] Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.This article is available at: www.intarchmed.comand www.medbrary.com16 It was to investigate whether religious practice can change the quality of life (QOL) of patients during chemotherapy.QOL questionnaire and religious practice mark was evaluated in a group of patients at different times (before, during and after chemotherapy).Acceptance of body image was positively correlated to religious practice and the activity to be praying.This preliminary study suggests the importance of religion to cope with treatment.

McConigley et.al. [77]
The diagnosis and treatment decisions of cancer patients in rural Western Australia.
Cancer Nurs.2011 Quality of life and spirituality Four themes were identified to describe the cancer experience in rural patients.The first three themes, diagnostic experiences and referral, treatment, and manage their own care.The final overall theme, Implicit Faith, described the level of trust that patients have in the health system, often despite the delays and inconveniences.
Utne et.al.[78] The relationship between hope and pain in a sample of hospitalized oncology patients.

Palliative Support Care 2008
Quality of life and spirituality The higher levels of hope in cancer patients with pain reflect a "change response" in the assessment of patients regarding hope.The fact that significant relationships were found between the scores scale of hope and the more psychosocial interference scores, suggesting that hope can be more related to psychosocial effects on pain than in their physical effects.
Sharf BF, Stelljes LA, Gordon HS. [79] A little bitty spot and I'm a big man': patients' perspectives on refusing diagnosis or treatment for lung cancer.

Phyco-oncology 2005 Spirituality
Complaints about the communication with doctors, the health system discontinuities, and the impact of social support.Implications for clinical communication include increased confidence to deliver bad news, understanding the source of resistance to the recommendations, and discuss palliative care.

Discussion
The clarity of this treatment associated to life quality will depend on each individual life story, their beliefs and values about themselves and about the current situation.What emphasizes the need of this study.The PICOS strategy made possible to meet the targets and evaluate evidences about faith and spirituality benefits associated to life quality.Thus, bibliographic search involved two database Pubmed/MEDLINE and Scopus, both with wide coverage that allowed retrieving database filed studies and posteriorly turned into characterization tables for writing and discussing this study.
During the process of articles selection were found three 2002 indexed articles, however they didn't fit the proposed inclusion criteria for this study, described perspectives of cancer terminal patient relatives, review articles about spiritual and existential issues, such as meaning, hope and spirituality in general, in palliative patients and the third excluded article was about the spirituality and religious impact in severity depressive symptoms in a sample of terminal cancer and AIDS (Acquired Immunodeficiency Syndrome) patients.Because it is a focus in oncologic patients our pattern considers studies from 2003 on (Figure 2).
It's noticeable a publishing constant increase focusing the patient being, this fact justified by the health professional concern increase referring to the patient total well-being, as the suffer relief continues to be a challenge for palliative care teams, including those with more symptoms control experience.Spiritual and emotional aspects need inter-disciplinary team dedication [35].Considering that in the last five years there has been an increase of 64,2% of scientific productions about the theme, so it opens a wide field for researches, with multiple experimental design perspectives to define repercussions of positive emotions from faith and spirituality during the palliative care process.
Once the evidenced scientific productions are characterized it was chosen to categorize in five groups: (1) Symptoms control (free of pain and physical symptoms); (2) Quality of life (psychological well-being, maintenance of proud and good family relationship); (3) Spirituality (faith, hope, trust, prayers); (4) Confronting (illness acceptance courage "acceptance", following the treatment, fear and life reassessment); (5) Cultural questions (race/ethnics and e demographic location).Through content analyses it was identified that some articles presented one or more categories.(Figure 3).The search identified, among the 67 studies in this review that, 77,6% of them see the life quality categories a driving force for the palliative treatment followed by the spirituality category at 70,14%.The spiritual intervention resulted in a significant increase of hope, happiness and life satisfaction (P <0,05) [17].The spirituality is one of the main aspects of palliative care.The concept is multidimensional and embraces existential sphere, as well as considerations based in religious values [46].
The symptoms control category (N = 31 = 46,26%) are listed: bone pain, general pain, fatigue, appetite loss, somnolence, dry mouth, tachycardia, and memory disturbs as well as physical symptoms such as depression, anxiety, anguish, sadness, sexuality, faith loss as psychological symptons [19].Correlating this category to spirituality, studies suggest that well-being is an important component in life quality of advanced cancer patients, and is inly related to physical and psychological symptoms of distress, which should be approached in a proper way in palliative care environment [19].
The confronting category (N = 12 = 17,91%) came up while analyzing that many studies brought up that the oncologic patient lived a reflection moment and needed a comprehension of the palliative care context and the sicken process in the moment that there aren't possibilities of cure but control and handling of the symptoms.This review found significant material of spirituality for these patients to face and adjust to this new situation.It's considered a quality of life aspect which mediates social, family and relationship improvement.[19].The confronting moment is guided by Faith and hope, some authors bring faith, hope and trust as synonyms.In this period the patient is able to find spirituality and resilience, the individual becomes adaptable to the new clinical support allowing themselves to recover emotion balance after suffering from physical and psychological pain.In this phase they refer to the capability of wish restoration, recognizing their limitations and longing for a good death [19,20,23].
Studies show that young patients under 60 years old present more physical and psychological suffer and Faith loss.Young patients report difficulty to confront the decease for feeling deprived of autonomy and professional and personal achievement wish.In done studies with children under 12 years old their sickness confronting was reflected in the concern related to their parents and they used to pray for them to feel closer to God.Facing this, the involved therapies for this process have to be planned according to the age rate [21,49].
Two studies have been identified approaching the cultural question category (N = 2 = 2,98%), reflecting about promoting the comprehension of dignity and suffering reduction in the life end, in old patients with advanced cancer in the western.The method used to define the dignity concept in Chinese concept, the death anguish isn't appointed by relatives, they mention themes as resilience/ fighting spirit which is expressed in different ways in the Chinese Family context, resulting in a Family cultural dimension that assists the dignity building.The second study approached patients in Japan and six European countries including concepts which cover religious questions, which are clearly important for different populations with religious beliefs [23,27].
Summarizing this study and recommending interventions in treatment was necessary to retake study about limbic system -the responsible for emotions: happiness, fear, anger, pleasure, and Faith.For this study, a central subjective and peripheral component was distinguished, the emotional behavior.The peripheral component is the way emotion expresses and involves somatic, motor and visceral activity standards, which are characteristic of each kind of species.The religious experiences are complex.They involve emotion and cognition and are distributed in various structures.They are connected to the frontal lobe, the brain part that controls desires; parietal lobe area, which controls our own sense; limbic system, which performs fundamental role in emotions; and, finally, hypothalamus, that is also responsible for emotive reactions [7,80].
In psychiatry and its areas, the neural structure identification related to emotion, has a special interest in the human being behavior comprehension.Therefore, much has been discussed about the possibility of treating scientifically the questions related to emotion, and not only in the Philosophical scope.With the development of neuroscience, postulates that, as perception (afferent) and the action (efferent), the emotion is related to diverse brain circuits.Moreover, the emotions are generally followed by autonomic, endocrine and motor skeletal responses that depend on the subcortial area of the nervous system, which prepare the body for action.It's been learnt that emotions are result of multiple systems of body and brain distributed by the whole person, being impossible to split emotion from cognition neither cognition from body [81].
There is a consensus among many authors that the limbic system has as main structures: cortical gyri, core gray matter and white matter disposed in medial surfaces of both hemispheres and surrounding the third ventricle.These structures, functionally, relate to instincts, emotions and memory and, through hypothalamus, as homeostasis maintaining [80,82].
The "rewarding centre" is related, mainly, to medial forebrain bundle, in core and ventromedial sides of hypothalamus, having connections with septum, tonsil, some thalamus areas and basal ganglia.The "punishing centre" is described as located in the central gray area which surrounds the cerebral aqueduct of Sylvius, in the midbrain, reaching the zones [80].
The happiness induction, response to identification of facial expressions of happiness, to the visualization of pleasant images and/or to induction to happiness of memories, sexual pleasure and well succeed competitive stimulation, promotes the activation of basal ganglia, including the ventral striatum and the putamen [81,82].
The sadness and depression can be seen as "poles" of the same process.The first is considered "physiological", and the second, "pathological", being, for this reason, related in neurophysiological terms.It's each time more often the correlation between emotional dysfunctions and damages of the neurocognitive functions.In fact, the depression is associated to deficits in strategic areas of the brain, including limbic areas.Regardless of related emotional factors, there are many biological determiners involved in its development; watching occurred changes in the immunological system [80,82].
Therefore, the present study pointed a scientific contribution from faith and spirituality themes from anatomy knowledge of emotions understanding how the authors could work with the patient positive emotions from Faith and spirituality communication, such themes which permeated all worked categories in this study taking sometime to an improvement of physiologic and psychological symptoms, of social and immunological relations during the palliative treatment.Proposed actions by this review involve the communication of the team with the patient allied to an increase of life quality, therapy groups, focal therapy, religious presence for comfort and life reflection and about the moment that they are living, art therapy and music.Activities that promote pleasure as visualizing landscapes, photos that reminded good memories, stimulating the positive emotion centre.

Conclusion
The faith performs in diverse brain areas, mainly in the limbic system, that is responsible for emotions and, spirituality is the way the individual see himself as origin, religion and culture in which is inserted.The spiritual intervention seems to be a potential beneficial intervention to increase mental power among those who suffer from cancer in terminal phase [40].The results suggest hormonal existing changes in immunological system and autonomous and central nervous systems, reducing heart beating, blood pressure and stress.A great amount of studies point that religiousness results in benefits to the health.
The oncologic patient in palliative care when acquires the self-knowledge and acceptance promoted by Faith can change habits, as improving diet, doing exercises that can promote pleasure, (arts, music, reading), having a restful sleep and maintain balance between thoughts and attitudes.The spirituality also helps to combat depression, as it attenuates bitterness feelings, anger, stress and even resentment.Therefore, it seems necessary to consider faith as an important element of treatment and palliative care.
According to studies involved in this review, the human factor is related directly to patient care, in special health team, needs to be capable of dealing with care concept about the patient faith and spirituality.
Still exist gaps of knowledge of the applicability of Faith and spirituality in these patients, there isn't consensus about the indication of proposed therapies along this review, being necessary additional researches focused on the training development for these professionals enabling them to deal with this fragile population which requires well applied therapeutics techniques and respecting their own individuality.
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International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q1 in category Medicine.

Figure 1 :
Figure 1: Flowchart of the selection process stages of included studies in the present review.Santo André, 2015.
reviewing care goals, have their wishes respected, evaluation of re life control symptoms, spiritual welfare and improvement of family relationships.

Figure 2 :
Figure 2: Numerical distribution related to the publication year of selected articles.Santo André, 2015.
mentioned category was "Freedom from pain or physical / psychological symptoms" and less frequently was "Have faith."Thisarticle is available at: www.intarchmed.comand www.medbrary.com6

Table 3 .
Characterization of the database Scopus studies (N = 51) -descriptors (Spirituality and palliative care and neoplasms), Santo André, 2015.The findings show existential and spiritual aspects as interconnected and integral part of daily life of the participants.He concludes with a call for a better understanding of these phenomena in the context of palliative care.