Spiritual assessment in heart failure: The blind spot that shattered person-centered care

Spiritual assessment in heart failure: The blind spot that shattered person-centered care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Spiritual assessment in heart failure: The blind spot that shattered person-centered care Stéphane Rivest, Sylvie Lafrenaye, Serge Lepage This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6596513/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Heart failure is a chronic syndrome with serious physical, psychosocial, and spiritual burdens. The symptoms and life-threatening nature of the disease may give rise to spiritual needs and lead to spiritual distress. Caregivers should address spiritual issues with the goal of enhancing quality of life and spiritual well-being. Spiritual needs should therefore be included in person-centered care approaches, especially in more advanced stages of the disease. Methods : The aim of this study was to describe the propensity of Quebec cardiologists to assess the spiritual well-being and spiritual needs of heart failure patients and identify factors that limit or facilitate this assessment. A descriptive exploratory study was carried out with 26 cardiologists working in three main cities of the province of Quebec in Canada. The data collected through online surveys were statistically analyzed and discussed by expert committees. Results : The assessment of spiritual well-being is weak. Spiritual needs assessment is more common. Overall, the needs for inner peace and relationality are more frequently assessed than those related to meaning, purpose and wholeness. Cardiologists affirm that spirituality is different than religion and can be a valid coping mechanism for patients. The vast majority also think that the patient’s spiritual state can influence HF physical symptoms. Among other factors, the clinical context, lack of time and lack of training are barriers to spiritual evaluation. Conclusion : Despite HF patients’ desire to discuss spiritual issues related to their disease, spiritual assessment is not well addressed in the context of a primarily biomedical model of health. Education on spiritual needs and spiritual assessment tools should be offered to cardiologists, as well as to any health professional taking care of seriously ill patients. heart failure spirituality cardiologists spiritual assessment spiritual needs. Figures Figure 1 Background Cardiovascular diseases represent the leading cause of mortality in all countries around the world [1]. Heart failure (HF) alone is a significant cause of death and places substantial strain on healthcare systems, both financially and in terms of resource allocation [2]. It affects up to 10% of people aged 70 and over [3] with a mortality rate that reaches 50% to 75% over a five-year period [4]. Patients hospitalized for HF frequently suffer from comorbidities and present significant functional disabilities. Physical impairments associated with HF are likely to negatively affect people's quality of life as they cause symptoms of depression and anxiety [5]. The prevalence of such comorbidities can reach 22% and 38% to 70%, respectively [6]. The emotional distress experienced by people living with HF has various causes, including the presence of physical symptoms, a loss of autonomy, the grief of lost abilities, and the acceptance of a limited life expectancy [7]. These psychological impacts compromise survival rates [8] and increase health care use [9]. In addition to their physical and psychological needs, people living with HF also experience spiritual needs [10]. Among these are the needs for love, joy, transcendence [11], and hope [12]. Of even greater importance are spiritual needs linked to the search for meaning and purpose , as well asthe search for a reason for their illnes s [13]. There is also an important need for inner peace, relationships, and wholeness. Meeting these needs can enhance spiritual well-being, quality of life, and the coping process and improve adherence to treatment [14]. As stated by Clark and Hunter[15] , the literature does show correlations between spirituality and several mental health and quality-of-life factors. These correlations provide evidence that spiritual well-being affects the suffering experienced by individuals with advanced heart failure (p.12). Spiritual well-being is considered a state that can be clinically assessed via psychometric tools such as the FACIT-SP ( Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being Scale) [16]. The ability to give/find meaning in life, the degree of peace concerning illness, and the propensity to maintain faith and hope can thus be evaluated. For many years, physicians have been advocating for the integration of spirituality in health care [17-18]. Although the World Health Organization [19] affirms that spiritual well-being is an integral part of health and quality of life, such integration seems limited in healthcare settings [20]. Our goal in this study was to explore the actuality and reasons behind this state of clinical nonintegration in cardiology with respect to HF patients. Methods Objectives This descriptive study focus on three main objectives that were to 1) describe the propensity of Quebec cardiologists to assess the spiritual well-being and spiritual needs of HF patients; 2) identify factors that limit or facilitate this assessment; and 3) explore cardiologists' understanding and perspective on fundamental issues pertaining to HF patient care: their conception of healing, the care model they use, and the significance they place on spirituality in HF. Creation of the survey The survey, consisting of thirty questions, was developed on the basis of literature on the spiritual needs of HF patients and, more broadly, in patients facing a life-threatening disease. The survey includes questions related to cardiologists’ perspective on making tough discussions (if and when discussions on diagnosis and prognosis took place), the care models they adopt in clinical practice, their perception of healing, and their view regarding their responsibility to mitigate the disease's impact on their patient's personal life. In this paper, we discuss only data related to the objectives described above. To avoid an unfavorable bias regarding the term "spiritual needs", the survey was developed in such a way that the questions did not explicitly mention this term. Rather, they implicitly referred to the existential reality that these needs represent. For example, rather than asking, "How often do you assess the need for inner peace in patients with HF?" ", we asked, "How often do you evaluate a patient’s degree of serenity regarding their future? ". See Table 2 for more details. With respect to spiritual needs, the questions focused on the frequency of assessment of elements such as peace, meaning, hope, identity, wholeness, values, and relationships. The possible answers to these questions varied from “always” to “never”, with intermediate choices “often” and “occasionally”. We also used questions regarding the assessment of spiritual well-being (‘’How often do you assess HF patients’ spiritual well-being?’’), the understanding of spirituality versus religion, the recognition of spirituality as a coping mechanism, the influence that personal beliefs have on medical decisions and, finally, cardiologists’ perceptions of the influence that the spiritual state has on physical symptoms. We also asked what model of care they use in their clinical practice and what their interpretation of the healing concept is. We validated the questionnaire in two distinct phases. We began with a semi directed interview with a cardiologist, with the goal of verifying the relevance of the questionnaire. Second, a group of three cardiologists validated the questionnaire and its use on a digital platform ( Surveymonkey ). We asked cardiologists to answer the online questionnaire via their mobile devices and obtained their comments regarding the user-friendliness of the process. We then discussed the content of the questionnaire and the issues raised by certain questions. Comments from cardiologists were considered, and modifications were made. Data collection Participants were recruited via emails sent to Quebec members of the Canadian Society of Cardiology (SCC) and the Société Québécoise d'Insuffisance Cardiaque (SQIC). A reminder was planned to be made after one month. Data analysis Data analysis was performed via EXELSTAT software. We carried out a descriptive analysis using a flat sort to extract, for each of the questions, the percentages associated with each answer choice. The initial data analysis was then presented to two committees, consisting of HF specialists and spirituality specialists. Explanatory discussions and an exploration of the results took place. The first committee consisted of three senior cardiologists working with HF patients. The second was a theologian, a physician-researcher, a physician-ethicist and a spiritual care worker with a Ph.D. The informal nature of the analysis facilitated the identification of underlying issues and recurrent themes, allowing for the determination of factors that limit or favor the assessment of spiritual needs. Ethical considerations The study received approval by the University of Sherbrooke ethical committee (Ref. 2018-1616). Before filling the online survey, all participants agreed to a consent form stating that their participation was voluntary and anonymous. They were also assured that all data would be securely stored. This study was conducted in accordance with the Declaration of Helsinki. Results Demographic data (target population) A total of n =320 emails were sent. A limited number of questionnaires (n=47) were completed. A total of 21 questionnaires were excluded because the respondents were not cardiologists. Our final sample included n =26 Quebec cardiologists, composed of men ( n =20) and women ( n =6) belonging to various age groups: between 25 and 35 years ( n =4), between 36 and 45 years ( n =9), between 46 and 54 years ( n =5), between 55 and 65 years ( n =6) and 65 years and over ( n =2). Among these 26 cardiologists, the majority described themselves as Caucasian ( n =21). The others described their ethnicity as Asian ( n =2), Hispanic ( n =1), North African ( n =1), or African American ( n =1). The 26 respondents essentially belong to three geographic regions: the National Capital Region ( n =8), the Eastern Township Region ( n =8), the Montreal Region ( n =9), and Mauricie ( n=1 ). The full demographic data of the respondents are shown in Table 1. Table 1. | Demographic variables of the study sample Men ( n =20) Women ( n =6) Total ( n =26) % Age groups 25-35 3 1 4 15% 36-45 6 3 9 35% 46-54 5 - 5 19% 55-65 5 1 6 23% 65 and over 1 1 2 8% Ethnicity Caucasian 16 5 21 81% Asian 2 - 2 8% Hispanic 1 - 1 4% Afro-American 1 - 1 4% North African - 1 1 4% Administrative Region Montreal 8 1 9 35% National capital 5 3 8 31% Estrie 6 2 8 31% Mauricie 1 - 1 4% Total (%) 77% 23% Clinical environment Cardiologists meet patients in three distinct settings: the hospital ( n =2), an outpatient clinic (heart failure clinic and private office) ( n =12), or both (outpatient clinic and hospital environments) ( n =5). Therefore, the majority of encounters take place in an office or a specialized HF clinic. The average time allocated to encounters with patients is approximately 15 minutes. Some meetings last longer ( n =19), and others are shorter ( n =7). Assessment of spiritual needs and spiritual well-being Table 2 shows the distribution of responses to questions regarding the assessment of spiritual needs. The most valued are inner peace and the need for personal relationships. Regarding the need for inner peace, most cardiologists ( n =24) always ( n =7) or often ( n =17) address patients’ concerns regarding their medical condition (“Do you ask patients if they are concerned about their medical condition, the evolution of the disease and the success of the treatment? »). On the other hand, there is a greater disregard for the evaluation of patients' peace of mind concerning their future, as only 62% of cardiologists occasionally evaluate this need ( n =16). Next, the majority of cardiologists always ( n =2) or often ( n =13) discuss the disease’s impact on the patient’s personal relationships. The rest occasionally ( n =10) or never ( n =1) evaluate it. Table 2. | Spiritual needs assessment by cardiologists Spiritual needs Questions Responses ( n =26) Always Often Occasionally Never Wholeness Do you evaluate the impact of the illness on the perception of the sense of their integrity (the fact of feeling like a “subject” to be treated, that is to say a person, rather than an “object” of care? , that is to say a sick body)? 3 (12%) 1 (4%) 10 (38%) 12 (46%) Meaning Do you assess the impact of the illness on the meaning that patients give to their existence? 0 (0%) 5 (19%) 13 (50%) 8 (31%) Purpose Do you evaluate the reasons and motivations that encourage them to live despite the symptoms associated with the worsening of the disease? 0) (0%) 8 (31%) 16 (62%) 2 (8%) Peace Do you ask patients if they are concerned about their medical condition (symptoms, treatments, disease progression, etc.)? 7 (27%) 17 (65%) 2 (8%) 0 (0%) Peace Do you assess their level of serenity about the future? 0 (0%) 9 (35%) 16 (62%) 1 (4%) Identify Do you assess the impact of the illness on their identity (their perception of themselves)? 0 (0%) 4 (15%) 12 (46%) 10 (39%) Relationships Do you assess the impact of the illness on the nature of the relationships that the patient maintains with his family, his friends, and his loved ones? 2 (8%) 13 (50%) 10 (38%) 1 (4%) Hope Do you assess the level of hope that the patient has regarding a better quality of life, an absence of symptoms or suffering? 0 (0%) 11 (42%) 12 (46%) 3 (12%) Spiritual needs related to maintaining identity and personal integrity are much less frequently assessed. Eighty-five percent of cardiologists ( n =22) said that they occasionally ( n =12) or never ( n =10) assessed the impact of the disease on their patient’s identity (self-esteem and self-perception). The same percentage of patients occasionally ( n =10) or never ( n =22) evaluated the impact of the illness on their patients’ sense of integrity ( wholeness ). Thus, only 15% ( n =4) of respondents always or often evaluate the impact of illness on patient identity and integrity. Nineteen percent (n=5) of respondents frequently assess how the illness impacts patients’ search for their life’s meaning, as opposed to the 81% who never evaluate it ( n =8) or who occasionally ( n =13) evaluate it. In addition, the quest for existential significance is the reason for living despite symptoms associated with the disease. Seventy percent of the respondents occasionally ( n =16) or never ( n =2) evaluated this need, whereas 31% ( n =8) often evaluated it. None of the respondents claimed to always evaluate the need for meaning or the reason for living . Finally, the need for hope was often evaluated by 42% of the respondents ( n =11), whereas 58% evaluated hope only occasionally ( n =12) or never ( n =3). The majority of cardiologists ( n =17) never assess the spiritual well-being of patients. A small number ( n =8) evaluate it “occasionally”, and only one ( n =1) said that he evaluates it often. Cardiologists’ conception of healing Cardiologists were asked to choose their definition of healing. They had several options to choose from: physical and psychological well-being, the relief of suffering, the recovery of biological functions and, finally, the ability to conquer the disease. Half of them (n=13) chose physical and psychological well-being. Two (n=2) chose the relief of suffering. Seven (n=7) chose conquering the disease, two (n=2) chose recovering biological functions, and two (n=2) affirmed that none of the definitions offered represented their view of healing. Reference model of care use in the clinical context Cardiologists were asked to choose between biomedical, biopsychosocial, biopsychosocial and spiritual, and integrative medicine to describe the model of care that characterizes their clinical practice. Thirty-one percent of cardiologists (n=8) affirmed that they do not know which model of care best characterizes their clinical practice. Twenty-six percent (n=7) stated that the biopsychosocial model of care was the most accurate. Five cardiologists (19%) affirm that they adopt a biopsychosocial and spiritual model of care. The biomedical model (n=3) and the integrative medicine model of care (n=3) were both chosen by three cardiologists. Perception of spirituality and referral to spiritual care professionals Concerning the understanding and perception of spirituality and its relationship with HF, the data demonstrate that only three ( n =3) cardiologists believe that spirituality and religion are the same. The vast majority ( n =20) affirm that these are two distinct realities. All the cardiologists affirm ( n =26) that patients' beliefs can influence their medical decisions. Almost all of them, 92% ( n =24), believed that the psychological and spiritual state of patients can influence their HF-associated physical symptoms. The majority of cardiologists believe that spirituality can “often” ( n =10), “always” ( n =4), or “sometimes” ( n =11) help patients cope with their disease. Among the information collected on the cardiologists’ profiles, we deliberately omitted asking about personal spiritual or religious allegiances. We wished to respect the intimate nature of the doctor’s spiritual beliefs, which, in our opinion, relate more to their personal lives than to their professional lives, the latter being our main research interest. Other studies have demonstrated the link between the religiousness or intrinsic spirituality of physicians and their positive inclination to address this topic in the context of medical care [21-22]. Approximately half of the cardiologists ( n =14) affirm that they occasionally refer patients to spiritual care professionals. Thirty-five percent ( n =9) said that they never did. Only three of them (12%) often refer patients to spiritual care professionals. None said that they always do. Barriers to Spiritual Assessment in HF Our expert committees identified several barriers to explaining why the formal assessment of spiritual well-being was limited. Some are closely linked to the clinical context: lack of time, the absence of psychosocial and spiritual resources to whom patients can be referred, and the absence of a more personal therapeutic relationship. Overall, it seems that the primary focus of care in HF is largely biomedical. Similar research should be conducted to determine whether this is the case in other chronic conditions and medical specialties or if cardiology and HF are unique cases. Discussion The correlation between spiritual well-being and quality of life in people who suffer from HF appears to be proven [23]. Similarly, since spiritual well-being and depression are inversely correlated[15], it is in the patient's best interest to assess and meet their spiritual needs. As efforts are made to relieve suffering for individuals with advanced heart failure, the inverse correlation between depression (mental suffering) and spiritual well-being lends support to increased efforts to address spiritual needs (p.9) . It is essential to combine biomedical treatments with screening for spiritual needs, with the goal of evaluating the need for spiritual care and intervention [24]. This allows proper referral of patients to spiritual care professionals. In the more advanced stages of the disease, where death anticipation becomes more acute, such interventions are even more relevant, as spiritual needs become more vivid. There is growing evidence that spiritual care at the end of life is important to patients and that patients want healthcare professionals to provide this type of care [25]. Neglected assessment of spiritual well-being As shown by Murray and colleagues [26], spiritual well-being fluctuates and does not necessarily correlate with social, psychological, or physical well-being. This tends to indicate that spiritual well-being is a domain distinct from physical, social, and psychological well-being and should be addressed separately. According to our hypothesis, the assessment of the spiritual well-being and spiritual needs of people living with HF is marginal. Only 5% of cardiologists formally assess spiritual well-being. Thus, these needs are undervalued despite their importance to patients: failure to consider these aspects [spirituality in healthcare] may have potential adverse effects, including undermining person-centered care [20]. The rather low evaluation rate of spiritual well-being and needs is explained by a lack of time, a lack of trust, personal discomfort related to the topic, a lack of training and knowledge regarding spirituality and assessment tools, the fear of going beyond one's field of expertise and the presence or absence of intrinsic spirituality. Best and colleagues' study [21] mentioned other barriers, such as the fear of imposing one’s beliefs, concerns related to colleagues’ opinions, and differences between patients’ and physicians’ religious or cultural positions. The absence of psychosocial and spiritual care resources could also be an issue. It seems possible that the model of care used by cardiologists in the context of HF treatment, in addition to their conception of healing, can also play a role in spiritual well-being assessment failure. Considering the chronic and fatal nature of HF, one can be surprised by the definition of healing and the models of care used by cardiologists in the treatment of this disease. In an acute setting, a biomedical model of care might be an appropriate approach. However, in the context of chronic disease, another approach is needed: According to the Pan American Health Organization, the management of chronic disease should be patient‐centered, proactive, and prevention‐focused, as opposed to the disease‐centered, reactive, and treatment‐focused conventional biomedical approach; the model of care should also be collaborative and integrated. [27]. Over the years, many spiritual assessment tools have been developed: FICA [28], HOPE [29] and SPIRITual history [30] are examples, but others have been evaluated and validated [31]. However, it seems that such tools were largely ignored or neglected by the cardiologists who were interviewed. Discussions on the topic of spirituality with patients or assessing their spiritual needs imply the acquisition of certain knowledge (and certain skills) on this matter. However, this topic is rarely addressed in medical student training [32]. Educational initiatives regarding spirituality in medicine are emerging and are intended to fill this gap among new students and residents [33]. Additionally, it seems that openness to spirituality among medical students promotes empathy and reduces personal levels of depression, stress, and anxiety [34]. Concerning continuous education, a simple review of certain conferences, symposiums, or congresses on HF allows us to see that the vast majority address only biomedical issues. Little or no place is given to the psychological, social or spiritual support and accompaniment needed for HF patients [35]. From heart failure to spiritual failure To enhance the understanding of the significance of this spiritual assistance throughout the journey of care, we wish to draw an analogy between the evolution of HF and its symbolic “equivalence” on a spiritual level. Spirituality is considered the “heart” of a person [36] and is often defined as the personal quest for meaning and purpose in life [19-37]. In the context of HF, the physical inability of the heart to meet the body's oxygen needs can ultimately lead to insufficient spirituality, meaning the inability to generate meaning and purpose. One of the main symptoms of HF is dyspnea (hypervolemia). On an existential level, HF can cause "spiritual dyspnea", namely, spiritual distress that can be seen as an absence of hope and inner peace and a misunderstood or rather unfound purpose [38]. In this sense, spiritual accompaniment can be viewed as a way of freeing patients from this “existential overload”, in the same way diuretics treat pulmonary overload. The assessment of spiritual needs could therefore allow the prevention of spiritual distress. Recommendations and perspectives Cardiologists can play a central role in the screening of spiritual needs, followed by a formal assessment by spiritual care providers or other trained professionals. These professionals have not only the required skills but also the necessary time for assessment and accompaniment. Since referrals to spiritual care professionals are present (but marginal), we believe that it is something worth building upon. Cardiology residents could greatly benefit from workshops that emphasize a global approach to care, including their view of the concept of spirituality and the importance of considering its impact on patient outcomes. Spirituality is not an esoteric topic. When confronted with chronic or life-threatening disease, medical schools should (1) incorporate spiritual care into care for patients with serious illness; (2) incorporate spiritual care education into the 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 [20]. Conclusion There is unanimous agreement among cardiologists that the psychological and spiritual state of patients can influence the physical symptoms associated with HF. The relationship between spiritual well-being and medical disease has therefore not been questioned. Spirituality is a legitimate coping strategy. Since patients’ beliefs can influence their medical decisions, it is important to pay attention to this matter. In a broader view, assessing CHF patients’ quality of life should be integrated into medical follow-up to identify patients who may face adverse effects such as depression and anxiety [39]. Although the cardiologists involved in our study did not formally assess spiritual needs, certain factors still seem to be indirectly taken into consideration. Among these, relational needs (impact of the illness on patients’ relationships with their loved ones) and inner peace (level of concern about their medical condition and the progression of the illness) seem to be the subjects of greater consideration. The need for meaning and purpose (impact of illness on the meaning of one’s personal existence), wholeness (need to be considered as a whole (complex individual) and not only as a patient, a “sick person”, or a “sick heart”) and identity (perception of oneself on the basis of their symptoms and the limitations they cause) are more often neglected. The need for hope remains limited. Abbreviations CHF: Chronic heart failure FACIT-SP: Functional assessment of chronic illness therapy–spiritual well-being SCC: Société Canadienne de Cardiologie SQIC: Société québécoise d’insuffisance cardiaque WHO: Worl health organization Declarations Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Competing interests: The authors declare that they have no competing interests. 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Damiano RF, DiLalla LF, Lucchetti G, Dorsey JK. Empathy in Medical Students Is Moderated by Openness to Spirituality. Teaching and Learning in Medicine. 2016 Dec 20;29(2):188–95. Park CL, Lim H, Newlon M, Suresh DP, Bliss DE. Dimensions of Religiousness and Spirituality as Predictors of Well-Being in Advanced Chronic Heart Failure Patients. Journal of Religion and Health. 2013 Apr 25;53(2):579–90. Nolan MT, Mock V. A conceptual framework for end-of-life care: a reconsideration of factors influencing the integrity of the human person. Journal of professional nursing : official journal of the American Association of Colleges of Nursing [Internet]. 2004 Nov [cited 2024 Oct 21];20(6):351–60. Frankl VE. The Doctor and the Soul. Vintage; 2010. Klimasiński M, Baum E, Praczyk J, Ziemkiewicz M, Springer D, Cofta S, et al. Spiritual Distress and Spiritual Needs of Chronically Ill Patients in Poland: A Cross-Sectional Study. International Journal of Environmental Research and Public Health. 2022 May 1;19(9):5512. Veskovic J, Dragoš Cvetković, Tahirović E, Marija Zdravković, Apostolović S, Dragana Kosevic, et al. Depression, anxiety, and quality of life as predictors of rehospitalization in patients with chronic heart failure. BMC Cardiovascular Disorders. 2023 Oct 27;23(1). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6596513","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":454214517,"identity":"26510b62-3ad3-445c-ba42-aab1b435222a","order_by":0,"name":"Stéphane Rivest","email":"data:image/png;base64,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","orcid":"","institution":"University of Sherbrooke. Sherbrooke. Quebec","correspondingAuthor":true,"prefix":"","firstName":"Stéphane","middleName":"","lastName":"Rivest","suffix":""},{"id":454214518,"identity":"bf12f78b-1669-4112-80c7-fda5437e1c57","order_by":1,"name":"Sylvie Lafrenaye","email":"","orcid":"","institution":"University of Sherbrooke. Sherbrooke. Quebec","correspondingAuthor":false,"prefix":"","firstName":"Sylvie","middleName":"","lastName":"Lafrenaye","suffix":""},{"id":454214519,"identity":"6dcc48f1-b47a-48fc-80b2-ca811743aa57","order_by":2,"name":"Serge Lepage","email":"","orcid":"","institution":"University of Sherbrooke. Sherbrooke. Quebec","correspondingAuthor":false,"prefix":"","firstName":"Serge","middleName":"","lastName":"Lepage","suffix":""}],"badges":[],"createdAt":"2025-05-05 17:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6596513/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6596513/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85756536,"identity":"854912f9-fa31-4cd7-b036-84b3622d79a9","added_by":"auto","created_at":"2025-07-01 10:50:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45357,"visible":true,"origin":"","legend":"\u003cp\u003ePhysical, social, psychological and spiritual well-being of patients with heart failure in the palliative phase of care.\u003c/p\u003e\n\u003cp\u003eMurray, S.A., Kendall, M., Grant, E., Boyd, K., Barclay, S., \u0026amp; Sheikh, A. (2007). “Patterns of social, psychological, and spiritual decline toward the end of life in lung cancer and heart failure.”\u003cem\u003e Journal of Pain and Symptom Management \u003c/em\u003e, 34(4) , p. 398\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6596513/v1/d2e832e9d067f7074018668b.jpg"},{"id":85757764,"identity":"ee4f4a0f-8a79-41f9-ae11-6d56cb679b00","added_by":"auto","created_at":"2025-07-01 10:58:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":819435,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6596513/v1/f27f57f6-8dda-474b-82a6-35b7c770d79c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Spiritual assessment in heart failure: The blind spot that shattered person-centered care","fulltext":[{"header":"Background","content":"\u003cp\u003eCardiovascular diseases represent the leading cause of mortality in all countries around the world [1]. Heart failure (HF) alone is a significant cause of death and places substantial strain on healthcare systems, both financially and in terms of resource allocation [2].\u0026nbsp;It affects up to 10% of people aged 70 and over [3] with a mortality rate that reaches 50% to 75% over a five-year period [4]. Patients hospitalized for HF frequently suffer from comorbidities and present significant functional disabilities.\u003c/p\u003e\n\u003cp\u003ePhysical impairments associated with HF are likely to negatively affect people's quality of life as they cause symptoms of depression and anxiety [5]. The prevalence of such comorbidities can reach 22% and 38% to 70%, respectively [6]. The emotional distress experienced by people living with HF has various causes, including the presence of physical symptoms, a loss of autonomy, the grief of lost abilities, and the acceptance of a limited life expectancy [7]. These psychological impacts compromise survival rates [8] and increase health care use [9].\u003c/p\u003e\n\u003cp\u003eIn addition to their physical and psychological needs, people living with HF also experience spiritual needs [10]. Among these are the needs for love, joy, transcendence [11], and hope [12]. Of even greater importance are spiritual needs linked to the search for meaning and purpose\u003cem\u003e,\u0026nbsp;\u003c/em\u003eas well asthe search for a reason \u003cem\u003efor\u0026nbsp;\u003c/em\u003etheir illnes\u003cem\u003es\u0026nbsp;\u003c/em\u003e[13]. There is also an important need for inner peace, relationships, and wholeness. Meeting these needs can enhance spiritual well-being, quality of life, and the coping process and improve adherence to treatment [14].\u003c/p\u003e\n\u003cp\u003eAs stated by Clark and Hunter[15]\u003cem\u003e, the literature does show correlations between spirituality and several mental health and quality-of-life factors. These correlations provide evidence that spiritual well-being affects the suffering experienced by individuals with advanced heart failure\u003c/em\u003e (p.12).\u003c/p\u003e\n\u003cp\u003eSpiritual well-being is considered a state that can be clinically assessed via psychometric tools such as the FACIT-SP (\u003cem\u003eFunctional Assessment of Chronic Illness Therapy–Spiritual Well-Being Scale)\u0026nbsp;\u003c/em\u003e[16]. The ability to give/find meaning in life, the degree of peace concerning illness, and the propensity to maintain faith and hope can thus be evaluated.\u003c/p\u003e\n\u003cp\u003eFor many years, physicians have been advocating for the integration of spirituality in health care [17-18]. Although the World Health Organization [19] affirms that spiritual well-being is an integral part of health and quality of life, such integration seems limited in healthcare settings [20]. Our goal in this study was to explore the actuality and reasons behind this state of clinical nonintegration in cardiology with respect to HF patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis descriptive study focus on three main objectives that were to 1) describe the propensity of Quebec cardiologists to assess the spiritual well-being and spiritual needs of HF patients; 2) identify factors that limit or facilitate this assessment; and 3)\u0026nbsp;explore\u0026nbsp;cardiologists' understanding and perspective on fundamental issues pertaining to HF patient care: their conception of healing, the care model they use, and the significance they place on spirituality in HF.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCreation of the survey\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe survey, consisting of thirty questions, was developed on the basis of literature on the spiritual needs of HF patients and, more broadly, in patients facing a life-threatening disease. The survey includes questions related to cardiologists’ perspective on making tough discussions (if and when discussions on diagnosis and prognosis took place), the care models they adopt in clinical practice, their perception of healing, and\u0026nbsp;their view regarding their responsibility to mitigate the disease's impact on their patient's personal life. In this paper, we\u0026nbsp;discuss\u0026nbsp;only data related to the objectives described above.\u003c/p\u003e\n\u003cp\u003eTo avoid an unfavorable bias regarding the term \"spiritual needs\", the survey was developed in such a way that the questions did not explicitly mention this term. Rather, they implicitly referred to the existential reality that these needs represent. For example, rather than asking, \"How often do you assess the need for inner peace in patients with HF?\" \", we asked, \"How often do you evaluate a patient’s degree of serenity regarding their future? \". See Table 2 for more details.\u003c/p\u003e\n\u003cp\u003eWith respect to spiritual needs, the questions focused on the frequency of assessment of elements such as peace, meaning, hope, identity, wholeness, values, and relationships. The possible answers to these questions varied from “always” to “never”, with intermediate choices “often” and “occasionally”. We also used questions regarding the assessment of spiritual well-being (‘’How often do you assess HF patients’ spiritual well-being?’’), the understanding of spirituality versus religion, the recognition of spirituality as a coping mechanism, the influence that personal beliefs have on medical decisions and, finally, cardiologists’ perceptions of the influence that the spiritual state has on physical symptoms. We also asked what model of care they use in their clinical practice and what their interpretation of the healing concept is.\u003c/p\u003e\n\u003cp\u003eWe validated the questionnaire in two distinct phases. We began with a semi directed interview with a cardiologist, with the goal of verifying the relevance of the questionnaire. Second, a group of three cardiologists validated the questionnaire and its use on a digital platform (\u003cem\u003eSurveymonkey\u003c/em\u003e). We asked cardiologists to answer the online questionnaire via their mobile devices and obtained their comments regarding the user-friendliness of the process. We then discussed the content of the questionnaire and the issues raised by certain questions. Comments from cardiologists were considered, and modifications were made.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were recruited via emails sent to Quebec members of the Canadian Society of Cardiology (SCC) and the Société Québécoise d'Insuffisance Cardiaque (SQIC). A reminder was planned to be made after one month.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was performed via EXELSTAT software. We carried out a descriptive analysis using a flat sort to extract, for each of the questions, the percentages associated with each answer choice.\u003c/p\u003e\n\u003cp\u003eThe initial data analysis was then presented to two committees, consisting of HF specialists and spirituality specialists. Explanatory discussions and an exploration of the results took place. The first committee consisted of three senior cardiologists working with HF patients. The second was a theologian, a physician-researcher, a physician-ethicist and a spiritual care worker with a Ph.D. The informal nature of the analysis facilitated the identification of underlying issues and recurrent themes, allowing for the determination of factors that limit or favor the assessment of spiritual needs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received approval by the University of Sherbrooke ethical committee (Ref. 2018-1616). Before filling the online survey, all participants agreed to a consent form stating that their participation was voluntary and anonymous. They were also assured that all data would be securely stored. This study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographic data (target population)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of \u003cem\u003en\u003c/em\u003e=320 emails were sent. A limited number of questionnaires (n=47) were completed. A total of 21 questionnaires were excluded because the respondents were not cardiologists. Our final sample included \u003cem\u003en\u003c/em\u003e=26 Quebec cardiologists, composed of men (\u003cem\u003en\u003c/em\u003e=20) and women (\u003cem\u003en\u003c/em\u003e=6) belonging to various age groups: between 25 and 35 years (\u003cem\u003en\u003c/em\u003e=4), between 36 and 45 years (\u003cem\u003en\u0026nbsp;\u003c/em\u003e=9), between 46 and 54 years (\u003cem\u003en\u003c/em\u003e=5), between 55 and 65 years (\u003cem\u003en\u003c/em\u003e=6) and 65 years and over (\u003cem\u003en\u003c/em\u003e=2). Among these 26 cardiologists, the majority described themselves as Caucasian (\u003cem\u003en\u003c/em\u003e=21). The others described their ethnicity as Asian (\u003cem\u003en\u003c/em\u003e=2), Hispanic (\u003cem\u003en\u003c/em\u003e =1), North African (\u003cem\u003en\u003c/em\u003e=1), or African American (\u003cem\u003en\u003c/em\u003e=1). The 26 respondents essentially belong to three geographic regions: the National Capital Region (\u003cem\u003en\u0026nbsp;\u003c/em\u003e=8), the Eastern Township Region (\u003cem\u003en\u003c/em\u003e=8), the Montreal Region (\u003cem\u003en\u003c/em\u003e=9), and Mauricie (\u003cem\u003en=1\u003c/em\u003e). The full demographic data of the respondents are shown in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1. | Demographic variables of the study sample\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"522\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u0026nbsp;\u003c/em\u003e=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u0026nbsp;\u003c/em\u003e=6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u0026nbsp;\u003c/em\u003e=26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge groups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e25-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e36-45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e46-54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e19%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e55-65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e23%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e65 and over\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003eCaucasian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e81%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003eHispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003eAfro-American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003eNorth African\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdministrative Region\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003eMontreal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003eNational capital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e31%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003eEstrie\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e31%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003eMauricie\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42.7203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7088%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e77%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6015%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e23%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9847%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eClinical environment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCardiologists meet patients in three distinct settings: the hospital (\u003cem\u003en\u003c/em\u003e=2), an outpatient clinic (heart failure clinic and private office) (\u003cem\u003en\u003c/em\u003e=12), or both (outpatient clinic and hospital environments) (\u003cem\u003en\u003c/em\u003e=5). Therefore, the majority of encounters take place in an office or a specialized HF clinic.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe average time allocated to encounters with patients is approximately\u0026nbsp;15 minutes. Some meetings last longer (\u003cem\u003en\u003c/em\u003e=19),\u0026nbsp;and others are shorter (\u003cem\u003en\u003c/em\u003e=7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of spiritual needs and spiritual well-being\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 shows the distribution of responses to questions regarding the assessment of spiritual needs. The most valued are inner peace and the need for personal relationships. Regarding the need for inner peace, most cardiologists (\u003cem\u003en\u003c/em\u003e=24) always (\u003cem\u003en\u003c/em\u003e=7) or often (\u003cem\u003en\u003c/em\u003e=17) address patients\u0026rsquo; concerns regarding their medical condition (\u0026ldquo;Do you ask patients if they are concerned about their medical condition, the evolution of the disease and the success of the treatment? \u0026raquo;). On the other hand, there is a greater disregard for the evaluation of patients\u0026apos; peace of mind concerning their future, as only 62% of cardiologists occasionally evaluate this need (\u003cem\u003en\u003c/em\u003e=16). Next, the majority of cardiologists always (\u003cem\u003en\u003c/em\u003e=2) or often (\u003cem\u003en\u003c/em\u003e=13) discuss the disease\u0026rsquo;s impact on the patient\u0026rsquo;s personal relationships. The rest occasionally (\u003cem\u003en\u003c/em\u003e=10) or never (\u003cem\u003en\u003c/em\u003e=1) evaluate it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. | Spiritual needs assessment by cardiologists\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSpiritual needs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eQuestions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponses (\u003cem\u003en\u0026nbsp;\u003c/em\u003e=26)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eOften\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eOccasionally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eWholeness\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eDo you evaluate the impact of the illness on the perception of the sense of their integrity (the fact of feeling like a \u0026ldquo;subject\u0026rdquo; to be treated, that is to say a person, rather than an \u0026ldquo;object\u0026rdquo; of care? , that is to say a sick body)?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e(12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e(4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e(38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e(46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMeaning\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eDo you assess the impact of the illness on the meaning that patients give to their existence?\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e(19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e(31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ePurpose\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eDo you evaluate the reasons and motivations that encourage them to live despite the symptoms associated with the worsening of the disease?\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0)\u003c/p\u003e\n \u003cp\u003e(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e(31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e(62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e(8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePeace\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eDo you ask patients if they are concerned about their medical condition (symptoms, treatments, disease progression, etc.)?\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e(27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e(65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e(8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ePeace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eDo you assess their level of serenity about the future?\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e(35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e(62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e(4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIdentify\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eDo you assess the impact of the illness on their identity (their perception of themselves)?\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e(15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e(46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e(39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRelationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eDo you assess the impact of the illness on the nature of the relationships that the patient maintains with his family, his friends, and his loved ones?\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e(8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e(38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e(4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eDo you assess the level of hope that the patient has regarding a better quality of life, an absence of symptoms or suffering?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e(12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSpiritual needs related to maintaining identity and personal integrity are much less frequently assessed.\u0026nbsp;Eighty-five percent\u0026nbsp;of cardiologists (\u003cem\u003en\u003c/em\u003e=22)\u0026nbsp;said that\u0026nbsp;they occasionally (\u003cem\u003en\u003c/em\u003e=12) or never (\u003cem\u003en\u003c/em\u003e=10)\u0026nbsp;assessed\u0026nbsp;the impact of the disease on their patient\u0026rsquo;s identity (self-esteem and self-perception). The same percentage\u0026nbsp;of patients occasionally (\u003cem\u003en\u003c/em\u003e=10) or never (\u003cem\u003en\u003c/em\u003e=22)\u0026nbsp;evaluated\u0026nbsp;the impact of the illness on their patients\u0026rsquo; sense of integrity (\u003cem\u003ewholeness\u003c/em\u003e). Thus, only 15% (\u003cem\u003en\u003c/em\u003e=4) of respondents always or often evaluate the impact of illness on patient identity and integrity.\u003c/p\u003e\n\u003cp\u003eNineteen percent (n=5) of respondents frequently assess how the illness impacts patients\u0026rsquo; search for their life\u0026rsquo;s meaning, as opposed to the 81% who never evaluate it (\u003cem\u003en\u003c/em\u003e=8) or who occasionally (\u003cem\u003en\u0026nbsp;\u003c/em\u003e=13) evaluate it. In addition, the quest for existential significance is the reason for living despite symptoms associated with the disease. Seventy percent of the respondents occasionally (\u003cem\u003en\u003c/em\u003e=16) or never (\u003cem\u003en\u003c/em\u003e=2) evaluated this need, whereas 31% (\u003cem\u003en\u003c/em\u003e=8) often evaluated it. None of the respondents claimed to always evaluate the need for meaning \u003cem\u003eor\u0026nbsp;\u003c/em\u003ethe reason for \u003cem\u003eliving\u003c/em\u003e. Finally, the need for hope was often evaluated by 42% of the respondents (\u003cem\u003en\u003c/em\u003e=11), whereas 58% evaluated hope only occasionally (\u003cem\u003en\u003c/em\u003e=12) or never (\u003cem\u003en\u003c/em\u003e=3).\u003c/p\u003e\n\u003cp\u003eThe majority of cardiologists (\u003cem\u003en\u003c/em\u003e=17) never assess the spiritual well-being of patients. A small number (\u003cem\u003en\u003c/em\u003e=8) evaluate it \u0026ldquo;occasionally\u0026rdquo;,\u0026nbsp;and only one (\u003cem\u003en\u003c/em\u003e=1) said that he evaluates it often.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCardiologists\u0026rsquo; conception of healing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCardiologists were asked to choose their definition of healing. They had several options to choose from: physical and psychological well-being, the relief of suffering, the recovery of biological functions and, finally, the ability to conquer the disease. Half of them (n=13) chose physical and psychological well-being. Two (n=2) chose the relief of suffering. Seven (n=7) chose conquering the disease, two (n=2) chose recovering biological functions, and two (n=2) affirmed that none of the definitions offered represented their view of healing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReference model of care use in\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ethe\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eclinical context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCardiologists were asked to choose between biomedical, biopsychosocial, biopsychosocial and spiritual, and integrative medicine to describe the model of care that characterizes their clinical practice. Thirty-one percent of cardiologists (n=8) affirmed that they do not know which model of care best characterizes their clinical practice. Twenty-six percent (n=7) stated that the biopsychosocial model of care was the most accurate. Five cardiologists (19%) affirm that they adopt a biopsychosocial and spiritual model of care. The biomedical model (n=3) and the integrative medicine model of care (n=3) were both chosen by three cardiologists.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerception of spirituality and referral to spiritual care professionals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConcerning the understanding and perception of spirituality and its relationship with HF, the data demonstrate\u0026nbsp;that only three (\u003cem\u003en\u003c/em\u003e=3) cardiologists believe that spirituality and religion are the same. The vast majority (\u003cem\u003en\u003c/em\u003e=20) affirm that these are two distinct realities.\u003c/p\u003e\n\u003cp\u003eAll the cardiologists affirm (\u003cem\u003en\u003c/em\u003e=26) that patients\u0026apos; beliefs can influence their medical decisions. Almost all of them, 92% (\u003cem\u003en\u003c/em\u003e=24), believed that the psychological and spiritual state of patients can influence their HF-associated physical symptoms. The majority of cardiologists believe that spirituality can \u0026ldquo;often\u0026rdquo; (\u003cem\u003en\u003c/em\u003e=10), \u0026ldquo;always\u0026rdquo; (\u003cem\u003en\u003c/em\u003e=4), or \u0026ldquo;sometimes\u0026rdquo; (\u003cem\u003en\u003c/em\u003e=11) help patients cope with their disease. Among the information collected on the cardiologists\u0026rsquo; profiles, we deliberately omitted asking about personal spiritual or religious allegiances. We wished to respect the intimate nature of the doctor\u0026rsquo;s spiritual beliefs, which, in our opinion, relate more to their personal lives than to their professional lives, the latter being our main research interest. Other studies have demonstrated the link between the religiousness or intrinsic spirituality of physicians and their positive inclination to address this topic in the context of medical care [21-22].\u003c/p\u003e\n\u003cp\u003eApproximately half of the cardiologists (\u003cem\u003en\u003c/em\u003e=14) affirm that they \u003cem\u003eoccasionally\u003c/em\u003e refer patients to spiritual care professionals. Thirty-five percent (\u003cem\u003en\u003c/em\u003e=9) said that they \u003cem\u003enever\u003c/em\u003e did. Only three of them (12%) \u003cem\u003eoften\u003c/em\u003e refer patients to spiritual care professionals. None said that they \u003cem\u003ealways\u003c/em\u003e do.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers to Spiritual Assessment in HF\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur expert committees identified several barriers to explaining why the formal assessment of spiritual well-being was limited. Some are closely linked to the clinical context: lack of time, the absence of psychosocial and spiritual resources to whom patients can be referred, and the absence of a more personal therapeutic relationship. Overall, it seems that the primary focus of care in HF is largely biomedical. Similar research should be conducted to determine whether this is the case in other chronic conditions and medical specialties or if cardiology and HF are unique cases.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe correlation between spiritual well-being and quality of life in people who suffer from HF appears to be proven [23]. Similarly, since spiritual well-being and depression are inversely correlated[15], it is in the patient's best interest to assess and meet their spiritual needs. \u003cem\u003eAs efforts are made to relieve suffering for individuals with advanced heart failure, the inverse correlation between depression (mental suffering) and spiritual well-being lends support to increased efforts to address spiritual needs (p.9)\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eIt is essential to combine biomedical treatments with screening for spiritual needs, with the goal of evaluating the need for spiritual care and intervention [24]. This allows proper referral of patients to spiritual care professionals. In the more advanced stages of the disease, where death anticipation becomes more acute, such interventions are even more relevant, as spiritual needs become more vivid. \u003cem\u003eThere is growing evidence that spiritual care at the end of life is important to patients and that patients want healthcare professionals to provide this type of care\u0026nbsp;\u003c/em\u003e[25].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeglected assessment of spiritual well-being\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown by Murray and colleagues [26], spiritual well-being fluctuates and does not necessarily correlate with social, psychological, or physical well-being. This tends to indicate that spiritual well-being is a domain distinct from physical, social, and psychological well-being and should be addressed separately.\u003c/p\u003e\n\u003cp\u003eAccording to our hypothesis, the assessment of the spiritual well-being and spiritual needs of people living with HF is marginal. Only 5% of cardiologists formally assess spiritual well-being.\u0026nbsp;Thus, these needs are\u0026nbsp;undervalued despite their importance to patients: \u003cem\u003efailure to consider these aspects [spirituality in healthcare] may have potential adverse effects, including undermining person-centered care\u003c/em\u003e [20].\u003c/p\u003e\n\u003cp\u003eThe rather low evaluation rate of spiritual well-being and needs is explained by a lack of time, a lack of trust, personal discomfort related to the topic, a lack of training and knowledge regarding spirituality and assessment tools, the fear of going beyond one's field of expertise and the presence or absence of intrinsic spirituality. Best and colleagues' study [21] mentioned other barriers, such as the fear of imposing one’s beliefs, concerns related to colleagues’ opinions, and differences between patients’ and physicians’ religious or cultural positions. The absence of psychosocial and spiritual care resources could also be an issue.\u003c/p\u003e\n\u003cp\u003eIt seems possible that the model of care used by cardiologists in the context of HF treatment, in addition to their conception of healing, can also play a role in spiritual well-being assessment failure. Considering the chronic and fatal nature of HF, one can be surprised by the definition of healing and the models of care used by cardiologists in the treatment of this disease. In an acute setting, a biomedical model of care might be an appropriate approach. However, in the context of chronic disease, another approach is needed:\u0026nbsp;\u003cem\u003eAccording to the Pan American Health Organization, the management of chronic disease should be patient‐centered, proactive, and prevention‐focused, as opposed to the disease‐centered, reactive, and treatment‐focused conventional biomedical approach; the model of care should also be collaborative and integrated.\u003c/em\u003e[27].\u003c/p\u003e\n\u003cp\u003eOver the years, many spiritual assessment tools have been developed: FICA [28], HOPE [29] and SPIRITual history [30] are examples, but others have been evaluated and validated [31]. However, it seems that such tools were largely ignored or neglected by the cardiologists who were interviewed. Discussions on the topic of spirituality with patients or assessing their spiritual needs imply the acquisition of certain knowledge (and certain skills) on this matter. However, this topic is rarely addressed in medical student training [32]. Educational initiatives regarding spirituality in medicine are emerging and are intended to fill this gap among new students and residents [33]. Additionally, it seems that openness to spirituality among medical students promotes empathy and reduces personal levels of depression, stress, and anxiety [34].\u003c/p\u003e\n\u003cp\u003eConcerning continuous education, a simple review of certain conferences, symposiums, or congresses on HF allows us to see that the vast majority address only biomedical issues. Little or no place is given to the psychological, social or spiritual support and accompaniment needed for HF patients [35].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFrom heart failure to spiritual failure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo enhance the understanding of the significance of this spiritual assistance throughout the journey of care, we wish to draw an analogy between the evolution of HF and its symbolic “equivalence” on a spiritual level. Spirituality is considered the “heart” of a person [36] and is often defined as the personal quest for meaning and purpose in life [19-37]. In the context of HF, the physical inability of the heart to meet the body's oxygen needs can ultimately lead to insufficient spirituality, meaning the inability to generate meaning and purpose. One of the main symptoms of HF is dyspnea (hypervolemia). On an existential level, HF can cause \"spiritual dyspnea\", namely, spiritual distress that can be seen as an absence of hope and inner peace and a misunderstood or rather unfound purpose [38]. In this sense, spiritual accompaniment can be viewed as a way of freeing patients from this “existential overload”, in the same way diuretics treat pulmonary overload. The assessment of spiritual needs could therefore allow the prevention of spiritual distress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations and perspectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCardiologists can play a central role in the screening of spiritual needs, followed by a formal assessment by spiritual care providers or other trained professionals. These professionals have not only the required skills but also the necessary time for assessment and accompaniment. Since referrals to spiritual care professionals are present (but marginal), we believe that it is something worth building upon.\u003c/p\u003e\n\u003cp\u003eCardiology residents could greatly benefit from workshops that emphasize a global approach to care, including their view of the concept of spirituality and the importance of considering its impact on patient outcomes. Spirituality is not an esoteric topic. When confronted with chronic or life-threatening disease, medical schools should\u003cem\u003e\u0026nbsp;(1) incorporate spiritual care into care for patients with serious illness; (2) incorporate spiritual care education into\u0026nbsp;\u003c/em\u003e\u003cem\u003ethe\u0026nbsp;\u003c/em\u003e\u003cem\u003etraining of interdisciplinary teams caring for persons with serious illness; and (3) include specialty practitioners of spiritual care in care of patients with serious illness\u0026nbsp;\u003c/em\u003e[20].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThere is unanimous agreement among cardiologists that the psychological and spiritual state of patients can influence the physical symptoms associated with HF. The relationship between spiritual well-being and medical disease has therefore not been questioned. Spirituality is a legitimate coping strategy. Since patients’ beliefs can influence their medical decisions, it is important to pay attention to this matter. In a broader view, assessing CHF patients’ quality of life should be integrated into medical follow-up to identify patients who may face adverse effects such as depression and anxiety [39].\u003c/p\u003e\n\u003cp\u003eAlthough the cardiologists involved in our study did not formally assess spiritual needs, certain factors still seem to be indirectly taken into consideration. Among these, relational needs (impact of the illness on patients’ relationships with their loved ones) and inner peace (level of concern about their medical condition and the progression of the illness) seem to be the subjects of greater consideration. The need for meaning and purpose (impact of illness on the meaning of one’s personal existence), wholeness (need to be considered as a whole (complex individual) and not only as a patient, a “sick person”, or a “sick heart”) and identity (perception of oneself on the basis of their symptoms and the limitations they cause) are more often neglected. The need for hope remains limited.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHF: Chronic heart failure\u003c/p\u003e\n\u003cp\u003eFACIT-SP: Functional assessment of chronic illness therapy–spiritual well-being\u003c/p\u003e\n\u003cp\u003eSCC: Société Canadienne de Cardiologie\u003c/p\u003e\n\u003cp\u003eSQIC: Société québécoise d’insuffisance cardiaque\u003c/p\u003e\n\u003cp\u003eWHO: Worl health organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate: The study was submitted and approved by the Ethics and Research Committee of the University of Sherbrooke. Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003eConsent for publication: All the authors provided full consent for the publication of this article.\u003c/p\u003e\n\u003cp\u003eThe datasets and material used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: Each author has made substantial contributions to this article. The main author conducted the research and wrote the article. As for the two co-authors, they were actively involved in the study design and the interpretation of data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization (WHO). The top 10 causes of death [Internet]. World Health Organization. 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death\u003c/li\u003e\n\u003cli\u003eNorouzi S, Hajizadeh E, Jafarabadi MA, Mazloomzadeh S. 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BMC Cardiovascular Disorders. 2023 Oct 27;23(1).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"heart failure, spirituality, cardiologists, spiritual assessment, spiritual needs.","lastPublishedDoi":"10.21203/rs.3.rs-6596513/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6596513/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Heart failure is a chronic syndrome with serious physical, psychosocial, and spiritual burdens. The symptoms and life-threatening nature of the disease may give rise to spiritual needs and lead to spiritual distress. Caregivers should address spiritual issues with the goal of enhancing quality of life and spiritual well-being. Spiritual needs should therefore be included in person-centered care approaches, especially in more advanced stages of the disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: The aim of this study was to describe the propensity of Quebec cardiologists to assess the spiritual well-being and spiritual needs of heart failure patients and identify factors that limit or facilitate this assessment. A descriptive exploratory study was carried out with\u003cem\u003e \u003c/em\u003e26 cardiologists working in three main cities of the province of Quebec in Canada. The data collected through online surveys were statistically analyzed and discussed by expert committees.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The assessment of spiritual well-being is weak. Spiritual needs assessment is more common. Overall, the needs for inner peace and relationality are more frequently assessed than those related to meaning, purpose and wholeness. Cardiologists affirm that spirituality is different than religion and can be a valid coping mechanism for patients. The vast majority also think that the patient’s spiritual state can influence HF physical symptoms. Among other factors, the clinical context, lack of time and lack of training are barriers to spiritual evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Despite HF patients’ desire to discuss spiritual issues related to their disease, spiritual assessment is not well addressed in the context of a primarily biomedical model of health. Education on spiritual needs and spiritual assessment tools should be offered to cardiologists, as well as to any health professional taking care of seriously ill patients.\u003c/p\u003e","manuscriptTitle":"Spiritual assessment in heart failure: The blind spot that shattered person-centered care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 10:49:56","doi":"10.21203/rs.3.rs-6596513/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"625c3c81-fd43-4e75-9364-0ecd4de517df","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-01T10:49:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-01 10:49:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6596513","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6596513","identity":"rs-6596513","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}