A Comparative Study of Spiritual Needs of Thai Terminal Ill Cancer Patients

Purpose Thai terminal ill cancer patients have spiritual distress and need spiritual care. They are in need of palliative care in the long term to alleviate suffering, achieve good spirituality, and to be ready to face with terminal ill conditions. This study aimed to investigate spiritual needs and compare differences in spiritual needs. Methods A quantitative design was used for data collection and data analysis. The participants were Thai terminal ill cancer patients from Thai seven hospitals in northern, northeast, central, and southern regions; 322 participants were purposively selected. Instruments used was a spiritual needs scale. The instrument’s validity was validated by 17 experts, a Delphi technique was performed, the Cronbach’s alpha of 0.89 was found. Statistical analysis was F-test for one-way analysis of variance. Results The overall spiritual needs of terminal ill cancer patients were at the moderate level. The highest mean was found in the ‘prepare for death’ dimension, followed by ‘have meaning, values, and life purposes’ and ‘have opportunity to pursue most important things in life’ dimensions consecutively and had different spiritual needs among status, number of family members, living with family, and spiritual anchor at the statistical signicance level of .05. Conclusion: The study results provide insight into spiritual needs of terminal ill cancer patients. That assists in improving the provision of holistic care to let the patients be happy at end-of-life phase.


Introduction
Currently, worldwide economic, social, and health conditions change rapidly. Also, there is a problem related to important health system in Thailand: There is continuing growth in the number of older adults, patients with chronic diseases, and cancer patients. Based on the National Cancer Institute of Thailand, 130,000 new cancer cases are found yearly. 39.96% of these cases were people aged 60 and over. In addition, cancer was the number one cause of death: there were 107.9%, 113.7%, and 119.3% per 100,000 persons in 2014, 2015, and 2016 consecutively [1].
Moreover, patients are generally diagnosed as having incurable disease if cancer develops to the advanced stage. That affects the patients in all aspects of their lives, including physical, mental, psychosocial, and spiritual. Accordingly, terminal ill cancer patients are in need of palliative care in the long term to alleviate suffering resulted from the disease and burden of care the family carry [2][3].
Palliative care is an important care provided for terminal ill cancer patients -focuses on physical, mental, social, and spiritual care [4]. In addition, this science involves knowledge of holistic care built on an integration concerning healthcare individuals, community, and public policy aiming to alleviate suffering and promote quality of life of patients [5].
According to the aforementioned information, it is important that healthcare professionals becoming aware of the magnitude of holistic care provision for terminal ill cancer patients, speci cally spiritual Page 3/13 care. That is to serve care needs in all areas as well as to help the patients spend the rest of their lives with peace [3]. If any terminal ill cancer patient has developed the perception and achieve good spirituality, they will have positive experience of the illness and be ready to face with terminal ill conditions [5][6]. Therefore, registered nurses must have understanding of the spiritual needs of terminal ill cancer patients and families to provide e cient palliative care.
However, there is lack of speci c health care systems for terminal patients in the context of the provision of care for terminal ill cancer patients in Thai hospitals. There is no agency mainly in charge of palliative care provision, particularly in the dimensions of mental and spirituality of patients. The overall picture of care in Thailand is the provision of care in general, primarily focus on the physical dimension [7,8]. Accordingly, terminal ill cancer patients do not receive su cient and e cient spiritual care [9,10], the researcher aims to study spiritual needs of terminal ill cancer patients in the context of Thai culture to gain insight about their spiritual needs and compare differences in spiritual needs.

Conceptual Framework
The conceptual framework of this study based on the following the concept about palliative care which showed an important care provided for terminal ill cancer patients and holistic care to alleviate suffering of patients [4][5].

Study design
This study is a descriptive research. The participants were purposively selected based on the following criteria: Thai terminal ill cancer patients from Thai seven hospitals in northern, northeast, central, and southern regions who did not respond to the treatment, both male and female, admitted in the hospital, aged 40 and over, had the performance score of 40 -70%, had full consciousness, could communicate normally, and were willing to participate in this study. The sample size was determined applying rule of thumb: Number of multivariable was 10-20 times greater than the number of observable variables. Also, the research team added 15% of the sample size to increase the reliability; subsequently the sample size of 322 was derived.

Research instruments
The spiritual needs scale The spiritual needs scale used in this study was developed applying a systematic literature review integrated with in-depth interview with terminal patients, family caregivers, and registered nurses with experience in providing care for patients. Content validity was validated by 17 experts, a Delphi technique was performed. The obtained median was 4.84 and interquartile range was 0.82. For reliability testing, Section 1 Personal information: nine multiple-choice questions asking about age, marital status, number of family members, living with family, types of accommodation, religious belief, frequency of prayer, frequency of religious practice, and spiritual anchor. Section 2 Spiritual needs scale: 41-item with 4-point rating scale, including eight dimensions: 1) have meaning, values, and life purposes (6 items); 2) gain love and encouragement from families and close persons (3 items); 3) review of life experience in the past (4 items); 4) have opportunity to pursue most important things in life (6 items); 5) prepare for death (8 items); 6) have opportunity to practice activities related to beliefs and faith was well as perform religious activities/rituals (6 items); 7) live in tranquil environment and atmosphere (4 items); and 8) needs to receive assistance in protecting human dignity (4 items)

Data collection
After getting a certi cate of approval issued by the Institutional Review Board, the research team contacted head nurses and held a meeting with research assistants to clarify the objectives of the study and the measurement procedures. The research assistants were those with the following quali cations: hospital staff who were in charge of palliative care provision, had experience in the care, and had been trained for palliative care. Afterwards, questionnaires, consent forms, and participant information sheets were sent to the research assistants by post. The questionnaires were sent to measure spiritual needs of the participants; subsequently, the completed ones were sent back to the research team upon the due date.
Data analysis 1. Personal information was analyzed applying frequency and percentage.
2. Level of spiritual needs of the participants, both overall and by dimension, was analyzed applying mean and standard deviation 3. Comparing spiritual needs among those with varied age, marital status, number of family members, living with family, type of accommodation, religious belief, frequency of prayer, frequency of religious practice, and spiritual anchor applying an F-test for one-way analysis of variance. Pair comparison was performed when any mean difference was found. as more meaningful and have peace of mind [16].

Results
In addition, explain: if end-of-life needs are ful lled and terminal ill cancer patients feel that hope exists, their quality of life will get better. Also, they will leave this world in peace. Accordingly, registered nurses should provide preparation for end-of-life phase for terminal ill cancer patients and their families [17][18][19].
That is to enable the patients to understand the illness, accept the conditions of the disease, and accept death [17,[20][21]. Thus, spiritual care is an important approach that all registered nurses should keep in mind and provide it for terminal ill cancer patients [22][23].
The study results showed that terminal ill cancer patients with varied marital status, number of family members, living with family, and spiritual anchor differed in spiritual needs at the statistical signi cance level of .05. This can be explained that due to the conditions of incurable diseases, terminal ill cancer patients are enduring physical, mental, social, and spiritual distress. Their spiritual needs are varied in relation to beliefs, customs, tradition and culture, and religions and spiritual anchor that the patients and families have practiced [4]. The provision of holistic care for terminal ill cancer patients, especially the care related to the dimension of spirituality and beliefs of the patients and families is valuable and important in the area of palliative care for terminal ill cancer patients. That is to let the patient be happy at end-of-life phase and live this world with human dignity [6].
Considering the study results: (1) terminal ill cancer patients with married status had higher mean score of spiritual needs than those with widowed status. (2) terminal ill cancer patients with 3-4 family members had higher mean score of spiritual needs than those with 1-2 family members and 5 family members and over. (3) Terminal ill cancer patients who lived with family had higher mean score of spiritual needs than those who lived alone. It can be explained that terminal ill cancer patients feel happy when perceiving that they are valuable to others and families as well as able to perform behaviors that bene t others [24]. These patients are happy with being useful for others, perceive life as valuable, have self-esteem, satisfy with current situation in life, and have better spiritual well-being [24][25].
In addition, (4) Terminal ill cancer patients with 1 spiritual anchor had higher mean score of spiritual needs than those who had none. It can be explained that terminal ill cancer patients who have faith in religions will perform behaviors in line with the principles of their religions. The patients will have faith in rules, custom, tradition, values or culture of the society/sacred objects [3]. This will lead to living together in peace, nd happiness in life, and have better spiritual well-being [5,24].
Moreover, spiritual needs of terminal ill cancer patients are varied depending on experience, culture, tradition, religion, and values. Therefore, having incurable disease is a major factor causing suffering in all areas, especially mental and spiritual distress. Some cases may be unable to accept death and end-oflife phase they are encountering, resulting in spiritual distress and no inner calm [5]. On the contrary, if terminal ill cancer patients develop the perception and achieve good spirituality; they would have positive experience related to their current illness, resulting in better quality of life [26].
In summary, religious beliefs and faith directly in uence quality of life of terminal ill cancer patients. Each individual patient has different religious beliefs and needs [27][28]. When these needs are ful lled, the patients will have peaceful life be able to accept illness' conditions and death better [26,[29][30]].

Limitations of the study
This study used data obtained only from Thai terminal ill cancer patients from Thai seven hospitals in northern, northeast, central, and southern regions who did not respond to the treatment. So, it may can't be generalized to other Thai terminal ill cancer patients who did respond to the treatment.

Practical implications for nursing profession
Nursing professional should investigate about spiritual need and other variables related to spiritual needs of Thai terminal ill cancer patients that encourages Thai terminal ill cancer patients to achieve holistic care in the long term to alleviate suffering and promote good quality of life of patients.

Conclusion
Terminal ill cancer patients are in need of palliative care in the long term to alleviate suffering resulted from the disease and burden of care the family carry.