Forgiveness, gratitude, loneliness, spiritual well-being and quality of life in palliative care patients

Forgiveness, gratitude, loneliness, spiritual well-being and quality of life in palliative care patients | 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 Forgiveness, gratitude, loneliness, spiritual well-being and quality of life in palliative care patients Fabio Ikedo, Luisa Castro, Francisca Rego, Rui Nunes This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6555812/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background The main goal of palliative care (PC) is to achieve the best possible quality of life for patients and families. Physical, emotional, social, and spiritual dimensions are intertwined and can contribute to the quality of life (QoL). The relief of physical symptoms, such as pain, with pharmacological approaches is very important. The non-pharmacological aspects are also essential, as part of the holistic care. We aimed to investigate the QoL, loneliness, forgiveness, gratitude and spiritual well-being in patients under PC, and to examine the correlation between QoL and these non-pharmacological aspects. Methods A cross-sectional study was conducted between April 2019 and May 2022 with a convenience sample of PC patients, hospitalized and outpatients in Porto, Portugal. Besides demographic and disease characteristics, the EORTC Quality of Life Questionnaire Core 15 for Palliative Care (QLQ-C15-PAL), Heartland Forgiveness Scale (HFS), Gratitude Questionnaire 6 (GQ-6), revised UCLA Loneliness Scale, and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp-12) were collected. The Spearman correlation coefficient assessed the correlation between quantitative variables. Univariate analysis and multiple regression analysis were performed. Results A total of 75 patients in PC, from 2 inpatient and 2 outpatient settings, were included. The median age was 73 years (range: 45–91 years); 57% were male; 58.7% were married, and 92% were Catholic. The majority (89%) had cancer. The multiple regression analysis revealed that regarding the prediction of overall QoL, meaning (p = 0.016), and emotional functioning (p = 0.001) were significant predictors of overall QoL. For the prediction of pain, peace (p = 0.013), fatigue (p = 0.023) and insomnia (p = 0.009) were predictors of pain. With regards to the prediction of emotional functioning, peace (p < 0.001), faith (p = 0.002), self-forgiveness (p = 0.029), forgiveness of situations (p = 0.032), and fatigue (p < 0.001) were significant predictors of emotional functioning. Conclusion PC patients may consider as relevant for QoL some factors that are not included in the majority of QoL questionnaires. The most commonly used QoL instruments do not include existential questions, but these factors may be important domains in QoL at end of life, particularly issues of meaning and peace. Introduction The central goal of palliative care (PC) is to preserve, to support, to enhance and to achieve the best possible quality of life (QoL) for both the patient and the family ( 1 ). PC goes beyond the relief of physical symptoms with pharmacological approaches. The non-pharmacological aspects are essential in QoL, providing whole-person care. All dimensions—physical, emotional, social, spiritual—are intertwined, and one dimension can affect other dimensions ( 2 ). Hence, all four aspects will contribute to the QoL. The World Health Organization stated that spirituality is an important dimension of QoL ( 3 ). A high level of spiritual well-being can enhance QoL and protect against end-of-life despair of cancer patients ( 4 ). Around half of cancer patients have a spiritual struggle that is positively associated with poorer emotional and QoL outcomes ( 5 ). Unaddressed spiritual needs are associated with worse QoL, while the spiritual care provision is associated with better end-of-life outcomes ( 6 ). Strengthening relationships with loved ones is an important factor related to quality end-of-life care, and may affect or interact with key aspects that can impact QoL, such as forgiveness ( 7 ) and loneliness ( 8 ). Existence has "boundary" or "limit" situations, which include finitude, death and loneliness. Death is beyond one's comprehension or control. The feeling of powerlessness when facing a life-threatening issue or an incurable disease may increase or activate feelings of loneliness ( 9 ). Persons may look back upon their lives, and trying to solve any unfinished business ( 10 ). Decreased QoL may be a consequence of loneliness. A study revealed that loneliness was significantly associated with lower QoL in older cancer patients ( 11 ). Forgiveness has also been associated with QoL. Regrets or feeling guilty increase the suffering and the need for forgiveness ( 12 ). Unresolved forgiveness may cause spiritual distress, while forgiveness may help ensure a more peaceful death ( 13 ). During a terminal disease, the patient may start losing the identity and sense of self due to the feeling that no one can imagine what it is to die. He/she may experience a lack of relatedness with others ( 14 ), and a need to forgive or be forgiven, to love and to be loved ( 15 ). In the end of life, “saying the four things that matter most: ‘Please forgive me. I forgive you. Thank you. I love you’” can be powerful ways for improving the relationships of dying patients and their families. According to Byock, relationships are complete when we feel whole, reconciled, and at peace ( 16 ). Therefore it is important to consider these non-pharmacological factors when thinking about the appropriate QoL and end of life care, as QoL questionnaires using only physical functioning evaluation produce different outcomes compared to the results obtained with assessment of psychological dimensions, spirituality, or religiousness ( 17 ). The aim of this study is to investigate the QoL, loneliness, forgiveness, gratitude and spiritual well-being in patients under PC, and to examine the association between QoL and non-pharmacological aspects of PC: forgiveness, loneliness, gratitude and spiritual well-being. Methods Study procedures The cross-sectional study was approved by the ethics committees of two hospitals that participated in the region of Porto, Portugal. This study was conducted from April 17, 2019, to May 31, 2022 with hospitalized patients from two palliative care units, one from an oncology hospital and other from a local health unit, and also from outpatient settings from the oncology hospital and another local health unit. The inclusion criteria for patients were ≥ 18 years old; chronic, progressive, incurable illness; read, write and understand Portuguese; mentally fit to understand the nature of the study and give informed consent. They were enrolled in the study using convenience sampling. Due to their health conditions, 85% answered (verbally) and the researcher (FI) filled out the questionnaires. It took around one hour to complete the questionnaires. Among the sociodemographic factors, age, gender, marital status and education were collected. The final records did not contain data that could identify the participants. Participants were excluded if they presented cognitive impairment that precluded understanding or answering the study questions, active delirium, or clinically recognized dementia. The following assessment tools for quality of life, forgiveness, gratitude, loneliness and spiritual well-being were used: Quality of life: The EORTC (European Organization for Research and Treatment of Cancer) Quality of Life Questionnaire Core 15 for Palliative Care (QLQ-C15-PAL), an abbreviated 15-item version of the Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), was developed as a simple and relevant tool to assess QoL in patients under palliative care ( 18 ). QLQ-C15-PAL consists of 15 questions: three-item physical functional scale, five single-item symptom scales (dyspnoea, insomnia, appetite loss, nausea/vomiting, and constipation), two-item symptom scales (fatigue and pain), two-item emotional functional scale, and one item referring to overall QoL. Patients responded to a four-point Likert scale from 1 (not at all) to 4 (very much), with the exception of overall QoL, which was rated from 1 (very poor) to 7 (excellent). Scores and scale scores were calculated according to the EORTC QLQ-C30 Scoring Manual ( 19 ) and its addendum ( 20 ). Scores ranged from 0–100, after standardization by linear transformation. Higher scores on overall QoL and the functioning scales represented higher QoL and higher levels of functioning. Higher symptom scores indicated more severe symptoms. Cronbach’s α in our study ranged between 0.567 and 0.857: pain (2 items, 0.846); fatigue (2 items, 0.758); emotional functioning (2 items, 0.567), and physical functioning (3 items, 0.857). Forgiveness: The 18-item Heartland Forgiveness Scale (HFS), European Portuguese version ( 21 ), was used to assess dispositional forgiveness. The HFS has 3 subscales that reflect a person’s tendency to forgive oneself, others, and situations. It is a seven-point Likert-type scale ranging from 1 (“almost always false of me”) to 7 (“almost always true of me”). Each response is given a numerical value and scale scores are calculated for the three subscales and the total scale. Higher scores on each scale reflect higher levels of forgivingness. Our Cronbach’s α was 0.695 (total), 0.317 (self), 0.696 (others), and 0.530 (situations). Gratitude: Gratitude was assessed using the Gratitude Questionnaire 6 (GQ-6), a six-item scale that was developed by McCullough et al. ( 22 ). It is a five-point Likert scale, ranging from 1 = “strongly disagree” to 5 =“strongly agree”. The Portuguese translation and validation was performed by Neto ( 23 ). The Cronbach’s α in our study was 0.608. Loneliness: Loneliness scores were assessed using the revised UCLA Loneliness Scale ( 24 ), that was translated, adapted, and validated to Portuguese ( 25 ). It is an 18-item questionnaire in which nine of the questions were reverse scored. The subject is asked to indicate how often she or he feels that way (never/rarely /sometimes/ often). This scale score ranges from 18 to 72. The Cronbach’s α in our sample was 0.834. Spiritual well-being (SWB): Spirituality (Spiritual well-being) was measured with the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp-12) ( 26 ). It has subscales that measure faith, meaning, and peace: an eight-item meaning (2,3,5,8th items)/peace (1,4,6,7th items) subscale, and the four-item faith (9,10,11,12th items) subscale. Responses are given on a five-point Likert scale, from 0 to 4, with higher scores indicating higher spiritual well-being. Besides the 2-factor (meaning/peace, faith), a 3-factor (meaning, peace, faith) structure has been reported in the literature ( 27 , 28 ). We did also evaluate the 3-factor (meaning, peace, faith) model. The Cronbach’s α was 0.876 (total), 0.806 (faith), 0.863 (meaning/peace), 0.801 (meaning), and 0.786 (peace). Statistical analysis The data were collected through a Google Forms survey and exported to an Excel spreadsheet, used for data organization, cleaning, and basic exploratory analysis. Then, the data were imported to IBM SPSS software (Statistical Package for the Social Sciences, IBM, version 28.0), for descriptive and inferential statistical analyses. Categorical variables were described using absolute frequencies (n) and relative frequencies (%). The majority of quantitative variables exhibited skewed distributions (visually assessed through histograms); therefore, they were described using the median, interquartile range [1st quartile; 3rd quartile], minimum and maximum values. For quantitative variables, mean and standard deviation were also reported for comparison with other studies. The correlation between quantitative variables was assessed using the Spearman correlation coefficient, which measures the rank correlation between variables. In all statistical tests, significance values lower than 0.05 were considered significant. Multiple regression analysis was performed to examine the extent to which demographic, QLQ-C15-PAL functioning domains (physical, emotional), symptom domains (fatigue, pain, nausea/vomiting, dyspnoea, sleep disturbances, appetite loss, constipation), FACIT-Sp, UCLA have a predictive power to QoL overall, pain and emotional functioning. Results of multiple regression analysis are presented using unstandardized regression coefficients (B) with 95% confidence intervals (CI) and p-values (p), F-statistics, and determination coefficients, R². Variables with a p-value ≤ 0.20 in the simple regressions were included in the initial multiple regression model, for each outcome variable. In the final model, only variables with significance at p ≤ 0.05 remained. Results During the study, 80 persons were recruited and gave their informed consent, but 5 dropped out because of their mental and/or physical conditions. The total study population consisted of 75 patients in palliative care. The median age was 73 years (range: 45–91 years); 57% were male; 58.7% were married; 92% were Catholic. The majority (89%) had cancer. The most common types of cancer were lung (12%), prostate and esophagus (11% each). Table 1 shows the demographic and disease characteristics of the participants. In this sample, 29 were hospitalized patients (14 from the oncology hospital, and 15 from a local health unit) and 46 were seen in the outpatient settings (39 from the oncology hospital – outpatient service, and 7 from a second local health unit). The questionnaires were filled out in the hospital (for the hospitalized patients), in the clinic waiting room (outpatient service) or at home (7 patients from the second local health unit). Table 1 Patient characteristics (N = 75) Variable n (%) Gender Male 43 (57.3) Female 32 (42.7) Family status Single 10 (13.3) Married 44 (58.7) Divorced or Separated 10 (13.3) Widowed 11 (14.7) Religion Catholic 69 (92) Christian non-Catholic 1 (1.3) Jehovah's Witnesses 1 (1.3) None 4 (5.3) Education Up to 4 years 43 (57.3) 5 years or more 32 (42.7) Diagnosis Cancer Site of primary cancer Lung 9 ( 12 ) Prostate 8 (10.7) Oesophagus 8 (10.7) Gastric 5 (6.7) Rectum 5 (6.7) Ovarian 5 (6.7) Breast 3 ( 4 ) Melanoma 2 (2.7) Liver 2 (2.7) Pancreatic 2 (2.7) Lymphoma 2 (2.7) Glioblastoma 2 (2.7) Other cancer site 14 (18.7) Non-malignant diseases Amyotrophic lateral sclerosis 4 (5.3) Heart Failure 2 (2.7) Others 2 (2.7) The participants’ EORTC QLQ-C15-PAL mean scores were 53.33 ± 26.42 for overall QoL, 67.34 ± 24.98 for emotional functioning (EF) and 28.8 ± 30.87 for physical functioning (PF), showing low PF and similar overall QoL and EF in comparison to a large study in 12 European countries ( 29 ). The mean FACIT-Sp-12 Total score was 28.65 ± 9.15. The meaning/peace subscale was 19.17 ± 6.75, and the faith subscore was 9.48 ± 3.67. Using the 3-factor model, the mean meaning subscore was 9.73 ± 3.91, while the mean peace subscore was 9.44 ± 3.5. Some articles also reported higher meaning scores than peace ( 28 , 30 – 32 ). The mean UCLA total score was 31.07 ± 8.94, comparable to a Portuguese study in 3,144 adults, where the mean score of loneliness was 34.56 ± 9.12 ( 33 ) The mean GQ-6 total score was 4.10 ± 0.57, and did not differ from the sample in the validation study in Portugal ( 23 ). The mean score of HFS, overall scale, was 98.47 ± 14.37. The mean self subscale was 32.6 ± 5.73, while the mean others subscale was 33.79 ± 7.37, and the mean situations subscale, 32.08 ± 6.54. One article of HFS in cancer patients receiving chemotherapy treatment in Turkey (43.8% with stage 4 cancer) had mean subscales from 29.45 to 30.59 (SD from 5.94 to 8.08) ( 34 ). According to our knowledge, no HFS data in Portuguese oncologic/palliative care patients has been published in the medical literature. Univariate analysis Associations between Health-related Quality of Life and socio-demographic variables Univariate analyses were used to compare the QoL and socio-demographic variables. Female scores for physical functioning were significantly worse than those for males: 13 [0; 26.7] vs 20 [6.7; 60]; p = 0.034. In comparison with low educational level (no more than primary education), those with educational level above primary education had a significant association with higher overall QoL (67 [50; 83.3] vs 50 [33.3; 66.7]; p = 0.045), higher emotional functioning (83 [50; 100] vs 67 [41.7; 83.3]; p = 0.036), and less fatigue (33 [11.1; 66.7] vs 56 [33.3; 66.7]; p = 0.024). Regarding marital status and QoL, married scores for emotional functioning were significantly worse than others (58 [50; 83.3] vs 83 [50; 100]; p = 0.040). Correlations between QLQ-C15-PAL overall quality of life and scores (functional and symptoms) (see Table 2 ): QLQ-C15-PAL overall QoL scores were significantly correlated with physical functioning (r = 0.243, p < 0.05), emotional functioning (r = 0.367, p < 0.01), and negatively associated with pain (r = -0.239, p < 0.05), fatigue (r = -0.256, p < 0.05), and dyspnoea (r = -0.244, p < 0.05). Correlations between Health-related Quality of Life, HFS, GQ-6, UCLA and SWB (see Table 2 for correlations that are not mentioned below): The correlation analyses revealed that QLQ-C15-PAL overall QoL scores were positively associated with FACIT-Sp total scores (r = 0.290, p < 0.05), FACIT-Sp meaning (r = 0.317, p < 0.01), FACIT-Sp peace (r = 0.305, p < 0.01), HFS total scores (r = 0.283, p < 0.05) and negatively associated with UCLA scores (r = -0.277, p < 0.05). QLQ-C15-PAL emotional functioning scores were positively associated with FACIT-Sp peace (r = 0.358, p < 0.01), HFS total scores (r = 0.312, p < 0.01), HFS situations (r = 0.327, p < 0.01), QLQ-C15‐PAL physical functioning (r = 0.273, p < 0.05), and negatively associated with UCLA scores (r = -0.354, p < 0.01). QLQ-C15-PAL physical functioning scores were negatively associated with GQ-6 scores (r = -0,305, p < 0.01). QLQ-C15-PAL pain scores were positively associated with fatigue (r = 0.329, p < 0.01), and negatively associated with FACIT-Sp total (r = -0.231, p < 0.05), FACIT-Sp peace (r = -0.290, p < 0.05), meaning (r = -0.285, p < 0.05), and emotional functioning (r = -0.261, p < 0.05). QLQ-C15-PAL fatigue scores were negatively associated with physical functioning (r = -0.321, p < 0.01), and emotional functioning (r = -0.436, p < 0.01). QLQ-C15-PAL insomnia scores were positively associated with fatigue (r = 0.302, p < 0.01), pain (r = 0.370, p < 0.01), and negatively associated with physical functioning (r = -0.247, p < 0.05), and emotional functioning (r = -0.356, p < 0.01). Correlations between SWB, HFS, GQ-6, and UCLA (see Table 2 for correlations that are not described below) FACIT-Sp total scores were negatively associated with UCLA scores (r = -0.385, p < 0.01) and positively associated with GQ-6 scores (r = 0.411, p < 0.01). FACIT-Sp peace scores were positively associated with HFS situations (r = 0.242, p < 0.05) and GQ-6 (r = 0.266, p < 0.05), and negatively associated with UCLA scores (r = -0.312, p < 0.01). FACIT-Sp meaning scores were positively associated with GQ-6 (r = 0.337, p < 0.01), and negatively associated with UCLA scores (r = -0.354, p < 0.01). FACIT-Sp faith scores were negatively associated with UCLA scores (r = -0.265, p < 0.05), and positively associated with GQ-6 scores (r = 0.428, p < 0.01). Table 2 The Relationship Between QoL, FACIT-Sp, GQ-6, UCLA, and the HFS mean scores (N = 75) : FACIT_Faith FACIT_Total GQ-6_Total UCLA Total HFS Total HFS Self HFS Others HFS Situations QLQ-C15-PAL Overall QoL QLQ-C15-PAL Physical Functioning QLQ-C15-PAL Emotional Functioning QLQ-C15-PAL Fatigue QLQ-C15-PAL Nausea/ Vomiting QLQ-C15-PAL Pain QLQ-C15-PAL Dyspnoea QLQ-C15-PAL Insomnia QLQ-C15-PAL Appetite Loss QLQ-C15-PAL Constipation FACIT Meaning/Peace ,484 ** ,940 ** ,332 ** -,364 ** 0,127 0,093 0,022 0,185 ,316 ** 0,050 ,291 * -0,063 -0,019 -,319 ** -0,083 -0,095 -0,223 -0,087 FACIT Meaning .458** ,869** .337** − .354 ** 0.105 0.117 0.010 0.141 .317** 0.035 0.211 -0.011 0.035 − .285* -0.103 0.001 -0.124 -0.061 FACIT Peace .461** ,862** .266* − .312 ** 0.170 0.109 0.035 .242* .305** 0.073 .358** -0.087 -0.094 − .290* -0.074 -0.203 − .292* -0.101 FACIT Faith ,735 ** ,428 ** -,265 * 0,166 0,164 0,100 0,103 0,118 -0,217 -0,132 0,088 -0,033 0,014 -0,033 0,219 -0,012 -0,139 FACIT Total ,411 ** -,385 ** 0,163 0,141 0,047 0,189 ,290 * -0,015 0,180 -0,023 -0,019 -,231 * -0,108 0,007 -0,172 -0,087 GQ-6 Total -,264 * ,300 ** ,240 * ,295 * 0,193 0,131 -,305 ** -0,044 0,128 0,131 0,048 0,044 0,130 0,152 0,080 UCLA Total -,382 ** -,363 ** -0,219 -,312 ** -,277 * -0,057 -,354 ** 0,130 -0,008 0,071 ,256 * 0,157 -0,012 0,197 HFS Total ,648 ** ,798 ** ,751 ** ,283 * 0,134 ,312 ** -0,044 0,015 -0,050 0,084 -0,053 0,130 -0,045 HFS Self ,267 * ,336 ** 0,147 0,006 0,227 0,039 -0,025 0,111 -0,040 0,048 0,155 -0,037 HFS Others ,404 ** 0,221 0,028 0,170 -0,131 0,031 -0,009 0,173 -0,036 0,137 -0,097 HFS Situations 0,220 0,219 ,327 ** 0,014 0,044 -0,198 0,051 -0,147 0,011 0,060 QLQ-C15-PAL Overall Quality of Life ,243 * ,367 ** -,256 * -0,131 -,239 * -,244 * -0,122 -0,190 0,011 QLQ-C15-PAL Physical Functioning ,273 * -,321 ** -0,059 -0,223 -0,170 -,247 * -0,039 0,059 QLQ-C15-PAL Emotional Functioning -,436 ** -,310 ** -,261 * -,262 * -,356 ** -,330 ** -0,046 QLQ-C15-PAL Fatigue ,382 ** ,329 ** ,433 ** ,302 ** ,508 ** 0,207 QLQ-C15-PAL Nausea/ Vomiting 0,046 ,253 * 0,224 ,457 ** 0,174 QLQ-C15-PAL Pain 0,059 ,370 ** 0,187 0,044 QLQ-C15-PAL Dyspnoea 0,150 ,277 * ,293 * QLQ-C15-PAL Insomnia ,247 * 0,134 QLQ-C15-PAL Appetite Loss 0,226 **. p < 0.01 *. p < 0.05 Multiple regression A series of multiple regression analysis was conducted to evaluate the unique contribution of the demographic variables (years of education, gender, marital status), FACIT-Sp (3-factor model), UCLA, HFS, GQ-6 and QLQ-C15-PAL functioning domains (physical, emotional), symptom domains (fatigue, pain, nausea/vomiting, dyspnea, sleep disturbances, appetite loss, constipation) as a predictive power to QLQ-C15‐PAL Overall QoL scores. Multiple regression analysis was also performed with emotional functioning and pain as dependent variables. The results are shown in Tables 3 , 4 and 5 . The independent variables that were associated with the dependent variable at the p < 0.2 significance level entered into the initial multiple regression models. For the prediction of overall QoL, the final model, explained 22.6% of outcome’s variance (see Table 3 ). Meaning (p = 0.016), and emotional functioning (p = 0.001) were significant predictors of overall QoL. For the prediction of pain, the model explained 26.3% of variance (see Table 4 ). Peace (p = 0.013), fatigue (p = 0.023) and insomnia (p = 0.009) were predictors of pain. Regarding the prediction of emotional functioning, the model explained 46.8% of variance (see Table 5 ). Peace (p < 0.001), faith (p = 0.002), self-forgiveness (p = 0.029), forgiveness of situations (p = 0.032), and fatigue (p < 0.001) were significant predictors of Emotional Functioning. Table 3 Multiple regression results for the dependent variable QLQ-C15-PAL Overall quality of life (N = 75) Initial Model Final Model R 2 = 22.6% F( 2 , 72 ) = 10.5, p < 0.001 Variáveis Independentes B [95% CI] p-value B [95% CI] p-value Education (up to 4 years/5 years or more) Up to 4 years Reference 5 years or more 1.51 [-11.14; 14.15] 0.813 FACIT_peace -0.26 [-2.69; 2.17] 0.831 FACIT_meaning 1.8 [-0.38; 3.97] 0.104 1.76 [0.34; 3.19] 0.016 UCLA - Total -0.03 [-0.82; 0.76] 0.931 HFS self 0.35 [-0.79; 1.49] 0.543 HFS others 0.56 [-0.32; 1.45] 0.209 HFS situations 0.38 [-0.76; 1.53] 0.503 QLQ-C15-PAL physical functioning 0.03 [-0.18; 0.25] 0.774 QLQ-C15-PAL emotional functioning 0.21 [-0.09; 0.52] 0.170 0.37 [0.15; 0.59] 0.001 QLQ-C15-PAL fatigue 0.002 [-0.25; 0.26] 0.985 QLQ-C15-PAL pain -0.05 [-0.24; 0.14] 0.587 QLQ-C15-PAL appetite Loss -0.05 [-0.26; 0.16] 0.615 QLQ-C15-PAL insomnia -0.04 [-0.23; 0.15] 0.671 Table 4 Multiple regression results for the dependent variable QLQ-C15-PAL Pain (N = 75) Initial Model Final Model R 2 = 26.3% F( 3 , 71 ) = 8.46, p < 0.001 Independent Variables B [95% CI] p-value B [95% CI] p-value FACIT_peace -1.03 [-4.21; 2.16] 0.522 -2.46 [-4.39; -0.53] 0.013 FACIT_meaning -1.83 [-4.45; 0.8] 0.169 HFS situations -1.03 [-2.36; 0.3] 0.126 QLQ-C15-PAL physical functioning -0.12 [-0.4; 0.15] 0.378 QLQ-C15-PAL emotional functioning 0.13 [-0.26; 0.52] 0.508 QLQ-C15-PAL fatigue 0.3 [-0.01; 0.62] 0.061 0.29 [0.04; 0.55] 0.023 QLQ-C15-PAL appetite loss 0.01 [-0.26; 0.27] 0.97 QLQ-C15-PAL insomnia 0.25 [0.02; 0.49] 0.036 0.30 [0.08; 0.53] 0.009 Table 5 Multiple regression results for the dependent variable QLQ-C15-PAL Emotional Functioning (N = 75) Initial Model Final Model R 2 = 46.8% F( 5 , 69 ) = 12.1, p < 0.001 Independent Variables B [95% CI] p-value B [95% CI] p-value Family Status Married Reference Single/Widowed/Divorced or Separated 1.47 [-9.72; 12.65] 0.794 Education (up to 4 years/5 years or more) up to 4 years Reference 5 years or more 2.04 [-8.71; 12.79] 0.706 FACIT_peace 2.65 [0.51; 4.79] 0.016 3.03 [1.47; 4.57] < 0.001 FACIT_meaning 0.01 [-1.77; 1.8] 0.987 FACIT faith -2.15 [-3.77; -0.54] 0.01 -2.28 [-3.72; -0.84] 0.002 UCLA - Total -0.2 [-0.85; 0.44] 0.535 HFS self 0.82 [-0.11; 1.74] 0.081 0.91 [0.10; 1.73] 0.029 HFS others 0.23 [-0.58; 1.03] 0.574 HFS situations 0.69 [-0.26; 1.64] 0.15 0.80 [0.07; 1.54] 0.032 QLQ-C15-PAL physical functioning 0.01 [-0.18; 0.19] 0.945 QLQ-C15-PAL fatigue -0.19 [-0.41; 0.03] 0.084 -0.29 [-0.44; -0.15] < 0.001 QLQ-C15-PAL nausea/ vomiting -0.09 [-0.34; 0.17] 0.495 QLQ-C15-PAL pain 0.01 [-0.15; 0.16] 0.935 QLQ-C15-PAL dyspnoea -0.03 [-0.22; 0.16] 0.742 QLQ-C15-PAL appetite loss -0.11 [-0.31; 0.09] 0.274 QLQ-C15-PAL constipation 0.04 [-0.11; 0.19] 0.601 Discussion The World Health Organisation definition of palliative care was revised in 2002, with emphasis on QoL: "Palliative care is an approach that improves the QoL of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual” ( 35 ). When cure is no longer possible, QoL is the main concern ( 36 ), and should focus on the holistic approach for the body, mind and spirit ( 37 ), the “total care of patients whose disease is not responsive to curative treatment.” ( 1 ). How one is faring psychologically will affect one’s physical, spiritually, relationships, and vice-versa, contributing to the overall QoL ( 38 ). In cancer patients the spiritual well-being has been described as significant as the physical component ( 5 ). We’ve focused our study on non-pharmacological factors (forgiveness, loneliness, spirituality and gratitude) as these factors may have great influence and impact on QoL, being important components of the holistic care. In the midst of terminal diseases it is common to think about what really matters, and those factors are essentially non-pharmacological ones: having a sense of meaning, making a positive difference in the lives of those around us, sharing and saying important things to the family and loved ones ( 39 ). And questions of meaning, value, and relationship constitute the core definition of spirituality, according to Dr Sulmasy ( 40 ). Spirituality has been considered a predictive construct of QoL ( 41 ), as a way to maintain hope, and a coping mechanism during the journey of cancer to derive meaning from it ( 42 ). In one study, combined spirituality scores predicted 24% of the variance in global QoL ( 43 ). Among 29 QoL instruments for use in palliative care, a review identified that 15 included spirituality items, and most of them contained items related to ‘‘feeling at peace with life’’ and ‘‘purpose or meaning of life’’ ( 44 ). Persons in life-threatening situations, and their families, may define QoL differently from those not facing a terminal disease. QoL at the end of life may focus on comfort, peace, and spiritual matters more than in the past. Seeking resolution of conflicts and making peace with others could also contribute to the QoL ( 45 ), pointing to the role of forgiveness. In our study, meaning and peace as part of a 2-factor FACIT-Sp were significant predictors of overall QoL, pain, and emotional functioning, supporting the findings of Brady et al ( 46 ), where Meaning/Peace was the best predictor of ‘contentment with QoL’, compared to other domains. Faith evidenced a smaller relationship with QoL compared to Meaning/Peace, according to our findings and other studies ( 46 , 47 ). Our 3-factor FACIT-Sp multiple regression analysis showed that meaning was a significant predictor of overall QoL, and peace was a significant predictor of pain and emotional functioning. Using a Single-Item Quality of Life Scale–Numeric Rating Scale, a Swiss study found that meaning in life represented a significant predictor of QoL, explaining up to 22% of the QoL variance ( 48 ). As an essential aspect of spirituality, meaning is of special importance to QoL at the end of life ( 49 ). Overall QoL and measures of physical, psychological and existential well-being can improve during the first week following admission to a palliative care unit, suggesting the responsiveness of QoL and existential/spiritual domains even close to death ( 50 ). In an oncology population, meaning was most highly associated with total QoL (FACT-G scale), and showed a much stronger association with Social Wellbeing in comparison with Peace ( 47 ). Some questions in the Social Wellbeing domain may have an overlap with emotional functioning. Examples of those questions: I feel distant from my friends; I get emotional support from my family; I get support from my friends and neighbors; My family has accepted my illness; Family communication about my illness is poor. Similar to our findings, QLQ-C15-PAL emotional functioning was a significant predictive factor for worse overall (global) QoL in patients with advanced cancer from six countries. Worse emotional functioning was the most significant predictive factor for worse QoL, along with pain and appetite loss ( 51 ). In a cross-sectional sample of patients with advanced serious illness, peacefulness was strongly associated with the emotional and spiritual well-being subscales, and moderately significant relationships with other dimensions of QoL: functional well-being, physical well-being, and social well-being. The authors suggested that the concept of patients’ sense of being at peace may be a point with which to initiate a conversation about emotional and spiritual concerns in a nonthreatening, nonsectarian manner ( 52 ). Regarding pain and aspects of spirituality, the intensity of pain in advanced cancer patients was lower in those reporting a belief in a power greater than man, in the helpfulness of prayer, and in afterlife ( 53 ). The attempt to find peace of mind, and meaning, or getting a purpose from the experience of pain-induced limitations, may evoke more effective forms of emotional, cognitive and behavioral coping ( 54 ). Individuals who use positive forms of religious and spiritual coping are less likely to feel overwhelmed by chronic pain, with feelings of peace, calmness, spiritual support, spiritual connection, decreased anxiety and improvement of mood. ( 55 ). Interventions that facilitate reflection on meaning and purpose in life are related to increased pain tolerance, better health-related QoL and positive mood ( 56 , 57 ). A sense of peace that can reduce anxiety and depression may relieve pain, being a mechanism underlying the peace-pain association ( 58 ). A strong sense of peace and meaning during illness may impact the experience of chronic symptoms, including other domains of QoL such as physical and functional wellbeing ( 47 ). In a sample of patients with advanced serious illness, feeling at peace was strongly associated with the emotional and spiritual well-being subscales ( 52 ). These articles are aligned with our findings regarding peace as a significant predictor of pain and emotional functioning. Pain in cancer patients may create a sense of hopelessness due to the fear that if they live in pain their lives lose their meaning or are not worth continuing ( 59 ). Besides being associated with other core domains of QoL, meaning and peace may contribute to the prediction of a cancer patient's QoL, supporting the hypothesis that spiritual wellbeing should always be evaluated when determining QoL. Without assessing the level of meaning and peace, we could miscalculate the true burden of the disease. In other words, a patient with high meaning in life and/or a good sense of peace may have better QoL than a patient with lower scores on these factors ( 47 ). In our multiple regression, faith and peace were also predictors of emotional functioning. These findings were previously described. A study with adult advanced cancer inpatients who had been admitted to seven palliative care units showed that faith correlated weakly with emotional functioning ( 60 ). In a cross-sectional, multicenter study in adult patients with advanced cancer feeling at peace was correlated more with QoL and Emotional functioning (p < 0.001) than religiosity and spirituality ( 61 ). During illness, patients may find more meaning in their relationships, and more peace from good emotional stability. Hence peace is more associated with affective components ( 47 ). A Systematic Review included eighteen studies that examined the contribution of the Faith factor to QoL. Faith was positively associated with overall QoL, emotional, and functional dimensions of QoL, with one exception ( 62 ). Gratitude can have a profound spiritual grounding. Positive aspects of life, such as love and health, are seen as gifts with appreciation in several religious communities. This view motivates individuals to practice prosocial activities and self-care and to grow via meaning-making in the middle of adversity ( 63 ). Gratitude may also generate a sense of meaning and connectedness, which facilitates coping with changes. According to the socioemotional selective theory, people become increasingly aware that their lifetime is limited as they age. This awareness leads older adults to prioritize engagement in meaningful events and close relationships ( 63 ). A terminal disease may also lead to priorities related to meaning and relationships, and raise or strength spiritual matters ( 38 , 63 ). In agreement with this perspective, our study has found an association between gratitude and spiritual well-being, measured by faith, meaning/peace factors. Having a grateful attitude may help to become less fearful of death due to a sense that life has been well lived. Patients with palliative care needs have been appreciative about their accomplishments and important persons in their life, providing support to the idea that gratitude could be an important outcome in end of life ( 64 ). In a palliative care setting, a positive and significant association was found between gratitude (GQ-6 total score) and global QoL [McGill Quality of Life questionnaire revised (MQoL) total score], and with three MQoL subscales (psychological, physical, and existential). The strongest relationship occurred with the existential dimension of QoL, providing support to the hypothesis that gratitude may improve meaning in life and reinforce spirituality ( 65 ). Similarly, our data also revealed a significant correlation of gratitude with FACIT-Sp total scores, and also with the subscores: meaning of life, peace and faith. The strongest relationships were with meaning of life and faith. Our results did not demonstrate a positive association of gratitude with QoL. The only QoL significant finding (not confirmed by multiple linear regression analysis) had been of GQ-6 with physical functioning. We may not exclude the fact that patients with worse physical functioning may gain strength through spirituality and gratitude. Another point is that the ability to cope with the disease is not included in the GQ-6 questionnaire ( 65 ). Loneliness is considered an essential part of QoL. Increasing death anxiety, loneliness and hopelessness were all associated with poorer QoL ( 66 ). Our study has agreed with the link of increased loneliness and lower QoL as we´ve observed a negative correlation between overall QoL and loneliness, and also between emotional functioning and loneliness. Our data showed a significant negative relationship between UCLA total score and FACIT-Sp scores, in agreement with a cross-sectional study in 347 oncology inpatients ( 67 ). The association between forgiveness and emotional functioning in palliative care patients has not been previously described. In a study testing the provisional European Organisation for Research and Treatment of Cancer measure of spiritual well-being (EORTC QLQ-SWB), and that explored the relationship between SWB and QoL for palliative care patients in Iceland, the most frequent difficult to answer question was the item exploring self-forgiveness (30% of the participants) ( 68 ). Regarding situational forgiveness, it may allow coping with circumstances beyond one’s control, as an illness. As a result of forgiveness, the person will understand, and accept these situations, being able to let go of negative thoughts, reaching a state of peacefulness ( 69 ). In our analysis, peace was positively correlated with forgiveness of situations. Fatigue is the most frequently reported symptom in patients with cancer, and one of the most distressing symptoms ( 70 , 71 ). The prevalence of fatigue among patients with bone metastasis or advanced cancer patients is at least 75% ( 72 ). In a group of cancer patients undergoing radiotherapy, fatigue was associated with poor QoL ( 71 ). In a prospective cohort study, a linear regression model of advanced cancer patients, with fatigue as the dependent variable and EORTC QLQ-C15-PAL items as independent variables, emotional functioning ( P < 0.001) was found to be associated with fatigue ( 73 ). Our data showed that emotional functioning and fatigue were strongly negatively correlated, in agreement with Iwase et al ( 74 ). With regards to pain and fatigue, they are among the most debilitating and commonly reported symptoms in advanced cancer ( 29 ). One study of 1,957 breast cancer survivors revealed that fatigue was significantly associated with pain, depression and sleep disturbance ( 75 ). Our correlation between insomnia and pain was not unexpected, but it is not easy to state which primary factor affected the other. Lung cancer patients suffering from insomnia presented significantly higher levels of pain and lower QoL than those in the comparison group. It could be that insomnia may have contributed to increased pain or that pain may interfere with sleep ( 76 ). Our multiple regression analysis, among the non-pharmacological factors, has highlighted aspects of spirituality, particularly meaning of life and peace, showing relationships with QoL, emotional functioning and pain, which are main concerns in end-of-life care, with potential to affect patients and caregivers. The lack of spiritual support by health care professionals is associated with increased costs, dissatisfaction with care, more aggressive treatment, less hospice utilization, and poor QoL ( 77 ). The quality and satisfaction with care may be enhanced by asking not only about a patient’s religious affiliation or any important ritual/religious practice, but by taking a spiritual assessment, which contains purpose and meaning in life, forgiveness, love, hope, trust, and a sense of connection ( 42 ). In a study that examined end-of-life preferences for atheists, participants expressed a deep desire to find meaning in their own lives, to maintain connection with family, friends, and the natural world through the dying experience ( 78 ). The end of life is often a time where spiritual issues come to the fore and patients may wish to revise and reiterate their beliefs in order to die peacefully ( 79 ). By acknowledging the spiritual needs of palliative care patients and their caregivers, interdisciplinary healthcare professionals can support them in facing the losses associated with advanced disease and impending death, increasing QoL even as death approaches ( 42 ), when the value of life, the meaning of suffering, relationship with others and with God, need of forgiveness, reconciliation, and life after death become important questions ( 41 ). Limitations This study has a few limitations. First, a selection bias may have occurred because palliative care patients experiencing cognitive or physical impairment would be less likely to participate in the interviews. Our cross-sectional design precludes interpretation of causality and, thus, bidirectionality of associations is a possibility. Results concerning self-forgiveness should be interpreted with caution due to the low internal consistency coefficient of this subscale. Another limitation is related to the FACIT-Sp, as it is based on self-reported answers, and the scale does not cover every central aspect of spirituality (e.g., forgiveness, love, generosity), lacking elements such as “acceptance” or “connection” which are central to spirituality ( 28 ). It was not evaluated negative religious coping methods (example, anger at God) as they can be related to poorer overall QoL and lower scores on the psychological and existential domains of QoL (sense of meaning and control) ( 80 ). It was not included the evaluation of performance status (ECOG) of cancer patients. One study revealed that performance status was the strongest predictor of severe pain intensity, poor QoL, low satisfaction, and low quality of care. Decreases in performance status could identify candidates for intensive palliative care interventions ( 81 ). Conclusions QoL in terms of subjective well-being, includes physical symptoms and functioning, psychologic and social well-being, but other factors may also be important because QoL is influenced by all domains of our human experience, as a result of the interaction between disease, health care, and the individual’s experience ( 28 ). We´ve observed that palliative care patients may consider factors beyond those considered by most HR-QoL instruments. The most commonly used QoL questionnaires do not include existential or forgiveness questions, but these factors may be important domains in QoL at end of life, particularly issues of meaning and peace. Future studies can confirm the findings of our study and longitudinal studies should evaluate changes throughout the illness/palliative care period rather than just focusing on a specific moment. Declarations Ethics approval and consent to participate Participants gave verbal consent prior to their participation. The study was carefully explained and any questions or doubts were answered by the investigator. After the participants were clarified, those who agreed to participate gave their verbal consent before filling out the questionnaire. The project in which this study is included was submitted and approved by the Ethics Committees of the Portuguese Institute of Oncology – Porto and Pedro Hispano Hospital – ULSM Matosinhos. Consent for publication: Not applicable. Availability of data and materials: Not applicable Competing interests The authors declare that they have no competing interests. Funding: Not applicable Authors´ Contributions Concept and design (FI, LC, FR, RN); acquisition of data (FI, LC); statistical analysis and interpretation of data (FI, LC); manuscript writing (FI, LC); supervision (FR, RN). All authors reviewed the manuscript. Acknowledgements We thank Dr Paula Silva and all the palliative care teams members for the help with patient recruitment. The authors would like to thank all patients and family caregivers who participated in the survey. Our thanks to all palliative care service providers supporting the study recruitment, and managers of collaborating clinical sites who supported and permitted this study. References Chellaraj A. Dying a Good Death: End-of-Life Decision Making for Terminally Ill Christians. Honors Program Thesis, Baylor University, 2018. http://hdl.handle.net/2104/10277 . Puchalski CM. Spirituality and the care of patients at the end-of-life: an essential component of care. Omega (Westport). 2007;56:33-46. World Health Organization Quality of Life (WHOQOL) Group. The WHO quality of life assessment (WHOQOL) position paper from the World Health Organization. Social Science and Medicine. 1995;41:1403-1409. Bauereiß N, Obermaier S, Özünal SE, Baumeister H. Effects of existential interventions on spiritual, psychological, and physical well-being in adult patients with cancer: Systematic review and meta-analysis of randomized controlled trials. Psychooncology. 2018;27:2531-2545. Puchalski CM, King SDW, Ferrell BR. Spiritual Considerations. Hematol Oncol Clin North Am. 2018;32:505-517. Balboni TA, VanderWeele TJ, Doan-Soares SD, Long KNG, Ferrell BR, Fitchett G, Koenig HG, Bain PA, Puchalski C, Steinhauser KE, Sulmasy DP, Koh HK. Spirituality in Serious Illness and Health. JAMA. 2022;328:184-197. Erratum in: JAMA. 2022;328:780. Keeley MP. 'Turning toward death together': The functions of messages during final conversations in close relationships. Journal of Social and Personal Relationships. 2007;24:225–253. Singer PA, Martin DK, Kelner M. (1999). Quality end-of-life care: patients' perspectives. JAMA. 1999;281:163-168. McGraw JG. Loneliness, its nature and forms: an existential perspective. Man and World. 1995;28:43–64. Leget C. Forgiveness and reconciliation in palliative care: The gap between the psychological and moral approaches. Religions. 2020;11:440. Deckx L, Daniels L, Nelissen K, Van Abbema D, Visconti L, Stinissen P, et al. Quality of life and loneliness in older cancer patients. Preliminary results of KLIMOP, a cohort study on the wellbeing of older cancer patients in Belgium and the Netherlands. European Journal of General Practice. 2013;19:41. Best M, Aldridge L, Butow P, Olver I, Webster F. Conceptual analysis of suffering in cancer: a systematic review. Psychooncology. 2015;24:977-86. Renz M, Bueche D, Reichmuth O, Schuett Mao M, Renz U, Siebenrock R, Strasser F. Forgiveness and Reconciliation Processes in Dying Patients With Cancer. Am J Hosp Palliat Care. 2020;37:222-234. Erratum in: Am J Hosp Palliat Care. 2019; 1049909119884407. Rokach A. The Dying and Those Who Care for Them. Journal of Patient Care. 2015;1:1. Strang P, Bergström J, Martinsson L, Lundström S. Dying From COVID-19: Loneliness, End-of-Life Discussions, and Support for Patients and Their Families in Nursing Homes and Hospitals. A National Register Study. J Pain Symptom Manage. 2020;60:e2-e13. Byock I. The four things that matter most: A book about living. 1 st ed. New York: Atria Books; 2014. Panzini RG, Mosqueiro BP, Zimpel RR, Bandeira DR, Rocha NS, Fleck MP. Quality-of-life and spirituality, International Review of Psychiatry. 2017;29:263-282. Groenvold M, Petersen MA, Aaronson NK, Arraras JI, Blazeby JM, Bottomley A, et al. EORTC Quality of Life Group. The development of the EORTC QLQ-C15-PAL: a shortened questionnaire for cancer patients in palliative care. Eur J Cancer. 2006;42:55-64. Fayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran D, Bottomley A, on behalf of the EORTC Quality of Life Group. The EORTC QLQ-C30 scoring manual. 3rd ed. Brussels, Belgium: European Organisation for Research and Treatment of Cancer; 2001. Groenvold M, Petersen MA. Addendum to the EORTC QLQ-C30 Scoring Manual: Scoring of the EORTC QLQC15-PAL. Brussels, Belgium: EORTC Quality of Life Group; 2006. Ikedo F, Castro L, Fraguas S, Rego F, Nunes R. Cross-cultural adaptation and validation of the European Portuguese version of the heartland forgiveness scale. Health Qual Life Outcomes. 2020;18:289. McCullough ME, Emmons RA, Tsang JA. The grateful disposition: a conceptual and empirical topography. Journal of Personality and Social Psychology. 2002;82:112-127. Neto F. Forgiveness, personality and gratitude. Pers. Individ. Differ. 2007;43:2313–2323. Russell D, Peplau LA, Cutrona CE. The revised UCLA Loneliness Scale: Concurrent and discriminant validity evidence. Journal of Personality and Social Psychology. 1980;39:472–480. Neto F. Avaliação da solidão. Psicologia Clínica. 1989;2:65–79. Peterman A, Fitchett G, Brady M, Hernandez L. Measuring Spiritual Well-Being in People With Cancer: The Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being Scale (FACIT-Sp). Annals of Behavioral Medicine 2002;24:49–58. Canada AL, Murphy PE, Fitchett G, Peterman AH, Schover LR. A 3-factor model for the FACIT-Sp. Psychooncology. 2008;17:908-916. Ahmad N, Sinaii N, Panahi S, Bagereka P, Serna-Tamayo C, Shnayder S, Ameli R, Berger A. The FACIT-Sp spiritual wellbeing scale: a factor analysis in patients with severe and/or life-limiting medical illnesses. Ann Palliat Med. 2022;11:3663-3673. Verkissen MN, Hjermstad MJ, Van Belle S, Kaasa S, Deliens L, Pardon K. Quality of life and symptom intensity over time in people with cancer receiving palliative care: Results from the international European Palliative Care Cancer Symptom study. PLoS ONE. 2019;14: e0222988. Yoon SJ, Suh SY, Kim SH, Park J, Kim YJ, Kang B, et al. Spiritual Well-being Among Palliative Care Patients With Different Religious Affiliations: A Multicenter Korean Study. J Pain Symptom Manage. 2018;56:893-901. Damen A, Raijmakers NJH, van Roij J, Visser A, Beuken-Everdingen MVD, Kuip E, et al. Spiritual Well-Being and Associated Factors in Dutch Patients With Advanced Cancer. J Pain Symptom Manage. 2022;63:404-414. Munoz AR, Salsman JM, Stein KD, Cella D. Reference values of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being: a report from the American Cancer Society's studies of cancer survivors. Cancer. 2015;121:1838-44. Neto F. Socio-demographic predictors of loneliness across the adult life span in Portugal. Interpersona: An International Journal on Personal Relationships. 2014;8:222-230. Belen HM, Sarikoç G. Cancer Patients: Forgiveness, Discomfort Intolerance and Psychiatric Symptoms. J Palliat Care. 2024;39:227-237. World Health Organization. National cancer control programmes, policies and managerial guidelines. 2002 Cohen SR, Mount BM. Living with cancer: "good" days and "bad" days--what produces them? Can the McGill quality of life questionnaire distinguish between them? Cancer. 2000;89:1854-65. Haitt JF. Spirituality, medicine, and healing. Southern Medical Journal. 1986;79:736–743. Sulmasy DP. A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist. 2002;42 Spec No 3:24-33. Steinhauser KE, Bosworth HB, Clipp EC, McNeilly M, Christakis NA, Parker J, Tulsky JA. Initial assessment of a new instrument to measure quality of life at the end of life. J Palliat Med. 2002;5:829-41. Sulmasy DP. Physicians, Spirituality, and Compassionate Patient Care. N Engl J Med. 2024;390:1061-1063. Goyarrola R, Lipsanen J, Saarelainen SM, Suviranta R, Rahko E, Lamminmäki A, et al. Spiritual well-being correlates with quality of life of both cancer and non-cancer patients in palliative care - further validation of EORTC QLQ-SWB32 in Finnish. BMC Palliat Care. 2023;22:33. Sherman DW, Ye XY, McSherry C, Calabrese M, Parkas V, Gatto M. Spiritual well-being as a dimension of quality of life for patients with advanced cancer and AIDS and their family caregivers: results of a longitudinal study. Am J Hosp Palliat Care. 2005;22:349-62. Beery TA, Baas LS, Fowler C, Allen G. Spirituality in Persons with Heart Failure. Journal of Holistic Nursing. 2002;20:5-25. Albers G, Echteld MA, de Vet HC, Onwuteaka-Philipsen BD, van der Linden MH, Deliens L. Content and spiritual items of quality-of-life instruments appropriate for use in palliative care: a review. J Pain Symptom Manage. 2010;40:290-300. Mabenagha A. (2009). Nurses's perspectives of loneliness amongst terminally ill patients. Bachelor's thesis, Nursing Degree Program. Laurea University of Applied Sciences. Finland. 2009 https://www.theseus.fi/bitstream/handle/10024/2257/Mabenagha.Arlene.pdf?sequence=3&isAllowed=y Brady MJ, Peterman AH, Fitchett G, Mo M, Cella D. A case for including spirituality in quality of life measurement in oncology. Psychooncology. 1999;8:417-28. Whitford HS, Olver IN. The multidimensionality of spiritual wellbeing: peace, meaning, and faith and their association with quality of life and coping in oncology. Psychooncology. 2012;21:602-10. Bernard M, Berchtold A, Strasser F, Gamondi C, Borasio GD. Meaning in life and quality of life: palliative care patients versus the general population. BMJ Support Palliat Care. 2024;14:e2537-e2545. Mount BM, Boston PH, Cohen SR. Healing connections: on moving from suffering to a sense of well-being. J Pain Symptom Manage. 2007;33:372-88. Cohen SR, Boston P, Mount BM, Porterfield P. Changes in quality of life following admission to palliative care units. Palliative Medicine. 2001;15:363-371. Cramarossa G, Chow E, Zhang L, Bedard G, Zeng L, Sahgal A, et al. Predictive factors for overall quality of life in patients with advanced cancer. Support Care Cancer. 2013;21:1709-16. Steinhauser KE, Voils CI, Clipp EC, Bosworth HB, Christakis NA, Tulsky JA: ‘‘Are You at Peace?’’ One item to probe spiritual concerns at the end of life. Arch Int Med 2006;166:101–105. Yates JW, Chalmer BJ, St James P, Follansbee M, McKegney FP. Religion in patients with advanced cancer. Med Pediatr Oncol. 1981;9:121-8. Nsamenang SA, Hirsch JK, Topciu R, Goodman AD, Duberstein PR. The interrelations between spiritual well-being, pain interference and depressive symptoms in patients with multiple sclerosis. J Behav Med. 2016;39:355-63. Erratum in: J Behav Med. 2016;39:364. Wachholtz AB, Pearce MJ, Koenig H. Exploring the relationship between spirituality, coping, and pain. J Behav Med. 2007;30:311-8. Delaney C, Barrere C, Helming M. The influence of a spirituality-based intervention on quality of life, depression, and anxiety in community-dwelling adults with cardiovascular disease: a pilot study. J Holist Nurs. 2011;29:21-32. Wachholtz AB, Pargament KI. Is spirituality a critical ingredient of meditation? Comparing the effects of spiritual meditation, secular meditation, and relaxation on spiritual, psychological, cardiac, and pain outcomes. J Behav Med. 2005;28:369-84. Yang Y, Zhao X, Cui M, Wang Y. Dimensions of spiritual well-being in relation to physical and psychological symptoms: a cross-sectional study of advanced cancer patients admitted to a palliative care unit. BMC Palliat Care. 2023;22:137. Mystakidou K, Tsilika E, Parpa E, Pathiaki M, Patiraki E, Galanos A, Vlahos L. Exploring the relationships between depression, hopelessness, cognitive status, pain, and spirituality in patients with advanced cancer. Arch Psychiatr Nurs. 2007;21:150-61. Shin DW, Suh SY, Kim SH, Park J, Yoon SJ, Kim YJ, et al. Is spirituality related to survival in advanced cancer inpatients in Korea? Palliat Support Care. 2018;16:669-676. Park Y, Suh SY, Kim SH, Park J, Yoon SJ, Kim YJ, et al. Development of a One-item Screening Question to Assess Spiritual Well-Being for Advanced Cancer Inpatients in Korea. J Pain Symptom Manage. 2021;62:910-917. Bai M, Lazenby M. A systematic review of associations between spiritual well-being and quality of life at the scale and factor levels in studies among patients with cancer. J Palliat Med. 2015;18:286-98. Chen Y, Okereke OI, Kim ES, Tiemeier H, Kubzansky LD, VanderWeele TJ. Gratitude and Mortality Among Older US Female Nurses. JAMA Psychiatry. 2024;81:1030-1038. Söderman A, Östlund U, Werkander Harstäde C, Blomberg K. Dignity-conserving care for persons with palliative care needs - identifying outcomes studied in research: An integrative review. Palliat Support Care. 2020;18:722-740. Althaus B, Borasio GD, Bernard M. Gratitude at the End of Life: A Promising Lead for Palliative Care. J Palliat Med. 2018;21:1566-1572. Kaymak ZA, ÖZdamar ÜNal G, ÖZkan EE. The association of death anxiety, loneliness, and hopelessness with clinical features and quality of life in palliative radiotherapy patients. Turkish Journal of Oncology/Türk Onkoloji Dergisi. 2022;37:337–345. Erdoğan TK, Koç Z. Loneliness, Death Perception, and Spiritual Well-Being in Adult Oncology Patients. Cancer Nursing. 2021;44:E503-E512. Asgeirsdottir GH, Sigurdardottir V, Gunnarsdottir S, Sigurbjörnsson E, Traustadottir R, Kelly E, Young T, Vivat B. Spiritual well-being and quality of life among Icelanders receiving palliative care: data from Icelandic pilot-testing of a provisional measure of spiritual well-being from the European Organisation for Research and Treatment of Cancer. Eur J Cancer Care (Engl). 2017;26(2). Boleková V, Chlebcová V. Predictors of forgiveness in cancer patients after treatment. Health Psychol Rep. 2024;12:219-226. Gupta D, Lis CG, Grutsch JF. The relationship between cancer-related fatigue and patient satisfaction with quality of life in cancer. J Pain Symptom Manage. 2007;34:40-7. Visser MR, Smets EM. Fatigue, depression and quality of life in cancer patients: how are they related? Support Care Cancer. 1998;6:101-8. Stone P, Hardy J, Broadley K, Tookman AJ, Kurowska A, A'Hern R. Fatigue in advanced cancer: a prospective controlled cross-sectional study. Br J Cancer. 1999;79:1479-86. Ghoshal A, Salins N, Deodhar J, Damani A, Muckaden MA. Fatigue and Quality of Life Outcomes of Palliative Care Consultation: A Prospective, Observational Study in a Tertiary Cancer Center. Indian J Palliat Care. 2016;22:416-426. Iwase S, Kawaguchi T, Tokoro A, Yamada K, Kanai Y, Matsuda Y, Kashiwaya Y, Okuma K, Inada S, Ariyoshi K, Miyaji T, Azuma K, Ishiki H, Unezaki S, Yamaguchi T. Assessment of Cancer-Related Fatigue, Pain, and Quality of Life in Cancer Patients at Palliative Care Team Referral: A Multicenter Observational Study (JORTC PAL-09). PLoS One. 2015;10:e0134022. Bower JE, Ganz PA, Desmond KA, Rowland JH, Meyerowitz BE, Belin TR. Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin Oncol. 2000;18:743-53. Rumble ME, Keefe FJ, Edinger JD, Porter LS, Garst JL. A pilot study investigating the utility of the cognitive-behavioral model of insomnia in early-stage lung cancer patients. J Pain Symptom Manage. 2005;30:160-9. Gijsberts MHE, Liefbroer AI, Otten R, Olsman E. Spiritual Care in Palliative Care: A Systematic Review of the Recent European Literature. Med Sci (Basel). 20197:25. Smith-Stoner M. End-of-life preferences for atheists. J Palliat Med. 2007;10:923-8. Choudry M, Latif A, Warburton KG. An overview of the spiritual importances of end-of-life care among the five major faiths of the United Kingdom. Clin Med (Lond). 2018;18:23-31. Tarakeshwar N, Vanderwerker LC, Paulk E, Pearce MJ, Kasl SV, Prigerson HG. Religious coping is associated with the quality of life of patients with advanced cancer. J Palliat Med. 2006;9:646-57. Yamagishi A, Morita T, Miyashita M, Igarashi A, Akiyama M, Akizuki N, Shirahige Y, Eguchi K. Pain intensity, quality of life, quality of palliative care, and satisfaction in outpatients with metastatic or recurrent cancer: a Japanese, nationwide, region-based, multicenter survey. J Pain Symptom Manage. 2012;43:503-14. Additional Declarations No competing interests reported. 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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-6555812","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":463397594,"identity":"6c2244e7-8d76-4a0f-a5ca-f51acd3f6548","order_by":0,"name":"Fabio Ikedo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBAC9mY2BgYeBpsEMC+hgAgtPIfBWtISGNhAWgyI0XIArOUwRAsDUVrY2RIfvKk4n8cv35344YEBgzy/2AECWpjZDhvOOXO7WLKNd7ME0GGGM2cn4Ndiz8zeJs3bdjtxwzHeDSAtCQa3CWjhYWZv/83bdg6kZfMPIrWwHWPmbTsA0rKNWFvYkiXnnElOnNmWu80iwUCCsF94+I8ZfnhTYZfYz3x2880fFTby/NIEtKADCdKUj4JRMApGwSjADgCWHj6iDifZQQAAAABJRU5ErkJggg==","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":true,"prefix":"","firstName":"Fabio","middleName":"","lastName":"Ikedo","suffix":""},{"id":463397595,"identity":"6564a897-3dd0-4aa6-a2c5-877a7dfef500","order_by":1,"name":"Luisa Castro","email":"","orcid":"","institution":"University of Porto","correspondingAuthor":false,"prefix":"","firstName":"Luisa","middleName":"","lastName":"Castro","suffix":""},{"id":463397596,"identity":"529a20ac-fbf4-46f3-9044-3953f7e997b3","order_by":2,"name":"Francisca Rego","email":"","orcid":"","institution":"University of Porto","correspondingAuthor":false,"prefix":"","firstName":"Francisca","middleName":"","lastName":"Rego","suffix":""},{"id":463397597,"identity":"c952ae50-aae2-4f5f-9d42-90ce35f1c2b0","order_by":3,"name":"Rui Nunes","email":"","orcid":"","institution":"University of Porto","correspondingAuthor":false,"prefix":"","firstName":"Rui","middleName":"","lastName":"Nunes","suffix":""}],"badges":[],"createdAt":"2025-04-29 11:08:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6555812/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6555812/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83659679,"identity":"a8f84485-cace-43e4-8e99-dbeaa6358430","added_by":"auto","created_at":"2025-05-30 09:38:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":937261,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6555812/v1/6c6cd97d-6c8f-45ed-856e-399b9f96d019.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Forgiveness, gratitude, loneliness, spiritual well-being and quality of life in palliative care patients ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe central goal of palliative care (PC) is to preserve, to support, to enhance and to achieve the best possible quality of life (QoL) for both the patient and the family (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePC goes beyond the relief of physical symptoms with pharmacological approaches. The non-pharmacological aspects are essential in QoL, providing whole-person care. All dimensions\u0026mdash;physical, emotional, social, spiritual\u0026mdash;are intertwined, and one dimension can affect other dimensions (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Hence, all four aspects will contribute to the QoL.\u003c/p\u003e \u003cp\u003eThe World Health Organization stated that spirituality is an important dimension of QoL (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A high level of spiritual well-being can enhance QoL and protect against end-of-life despair of cancer patients (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Around half of cancer patients have a spiritual struggle that is positively associated with poorer emotional and QoL outcomes (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Unaddressed spiritual needs are associated with worse QoL, while the spiritual care provision is associated with better end-of-life outcomes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStrengthening relationships with loved ones is an important factor related to quality end-of-life care, and may affect or interact with key aspects that can impact QoL, such as forgiveness (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and loneliness (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExistence has \"boundary\" or \"limit\" situations, which include finitude, death and loneliness. Death is beyond one's comprehension or control. The feeling of powerlessness when facing a life-threatening issue or an incurable disease may increase or activate feelings of loneliness (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Persons may look back upon their lives, and trying to solve any unfinished business (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Decreased QoL may be a consequence of loneliness. A study revealed that loneliness was significantly associated with lower QoL in older cancer patients (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eForgiveness has also been associated with QoL. Regrets or feeling guilty increase the suffering and the need for forgiveness (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Unresolved forgiveness may cause spiritual distress, while forgiveness may help ensure a more peaceful death (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDuring a terminal disease, the patient may start losing the identity and sense of self due to the feeling that no one can imagine what it is to die. He/she may experience a lack of relatedness with others (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), and a need to forgive or be forgiven, to love and to be loved (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In the end of life, \u0026ldquo;saying the four things that matter most: \u0026lsquo;Please forgive me. I forgive you. Thank you. I love you\u0026rsquo;\u0026rdquo; can be powerful ways for improving the relationships of dying patients and their families. According to Byock, relationships are complete when we feel whole, reconciled, and at peace (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore it is important to consider these non-pharmacological factors when thinking about the appropriate QoL and end of life care, as QoL questionnaires using only physical functioning evaluation produce different outcomes compared to the results obtained with assessment of psychological dimensions, spirituality, or religiousness (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe aim of this study is to investigate the QoL, loneliness, forgiveness, gratitude and spiritual well-being in patients under PC, and to examine the association between QoL and non-pharmacological aspects of PC: forgiveness, loneliness, gratitude and spiritual well-being.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy procedures\u003c/p\u003e \u003cp\u003e The cross-sectional study was approved by the ethics committees of two hospitals that participated in the region of Porto, Portugal. This study was conducted from April 17, 2019, to May 31, 2022 with hospitalized patients from two palliative care units, one from an oncology hospital and other from a local health unit, and also from outpatient settings from the oncology hospital and another local health unit.\u003c/p\u003e \u003cp\u003eThe inclusion criteria for patients were \u0026ge;\u0026thinsp;18 years old; chronic, progressive, incurable illness; read, write and understand Portuguese; mentally fit to understand the nature of the study and give informed consent. They were enrolled in the study using convenience sampling. Due to their health conditions, 85% answered (verbally) and the researcher (FI) filled out the questionnaires. It took around one hour to complete the questionnaires. Among the sociodemographic factors, age, gender, marital status and education were collected. The final records did not contain data that could identify the participants.\u003c/p\u003e \u003cp\u003eParticipants were excluded if they presented cognitive impairment that precluded understanding or answering the study questions, active delirium, or clinically recognized dementia.\u003c/p\u003e \u003cp\u003eThe following assessment tools for quality of life, forgiveness, gratitude, loneliness and spiritual well-being were used:\u003c/p\u003e \u003cp\u003eQuality of life:\u003c/p\u003e \u003cp\u003eThe EORTC (European Organization for Research and Treatment of Cancer) Quality of Life Questionnaire Core 15 for Palliative Care (QLQ-C15-PAL), an abbreviated 15-item version of the Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), was developed as a simple and relevant tool to assess QoL in patients under palliative care (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). QLQ-C15-PAL consists of 15 questions: three-item physical functional scale, five single-item symptom scales (dyspnoea, insomnia, appetite loss, nausea/vomiting, and constipation), two-item symptom scales (fatigue and pain), two-item emotional functional scale, and one item referring to overall QoL. Patients responded to a four-point Likert scale from 1 (not at all) to 4 (very much), with the exception of overall QoL, which was rated from 1 (very poor) to 7 (excellent). Scores and scale scores were calculated according to the EORTC QLQ-C30 Scoring Manual (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and its addendum (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Scores ranged from 0\u0026ndash;100, after standardization by linear transformation. Higher scores on overall QoL and the functioning scales represented higher QoL and higher levels of functioning. Higher symptom scores indicated more severe symptoms. Cronbach\u0026rsquo;s α in our study ranged between 0.567 and 0.857: pain (2 items, 0.846); fatigue (2 items, 0.758); emotional functioning (2 items, 0.567), and physical functioning (3 items, 0.857).\u003c/p\u003e \u003cp\u003eForgiveness:\u003c/p\u003e \u003cp\u003eThe 18-item Heartland Forgiveness Scale (HFS), European Portuguese version (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), was used to assess dispositional forgiveness. The HFS has 3 subscales that reflect a person\u0026rsquo;s tendency to forgive oneself, others, and situations. It is a seven-point Likert-type scale ranging from 1 (\u0026ldquo;almost always false of me\u0026rdquo;) to 7 (\u0026ldquo;almost always true of me\u0026rdquo;). Each response is given a numerical value and scale scores are calculated for the three subscales and the total scale. Higher scores on each scale reflect higher levels of forgivingness. Our Cronbach\u0026rsquo;s α was 0.695 (total), 0.317 (self), 0.696 (others), and 0.530 (situations).\u003c/p\u003e \u003cp\u003eGratitude:\u003c/p\u003e \u003cp\u003eGratitude was assessed using the Gratitude Questionnaire 6 (GQ-6), a six-item scale that was developed by McCullough et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). It is a five-point Likert scale, ranging from 1 = \u0026ldquo;strongly disagree\u0026rdquo; to 5 =\u0026ldquo;strongly agree\u0026rdquo;. The Portuguese translation and validation was performed by Neto (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The Cronbach\u0026rsquo;s α in our study was 0.608.\u003c/p\u003e \u003cp\u003eLoneliness:\u003c/p\u003e \u003cp\u003eLoneliness scores were assessed using the revised UCLA Loneliness Scale (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), that was translated, adapted, and validated to Portuguese (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). It is an 18-item questionnaire in which nine of the questions were reverse scored. The subject is asked to indicate how often she or he feels that way (never/rarely /sometimes/ often). This scale score ranges from 18 to 72. The Cronbach\u0026rsquo;s α in our sample was 0.834.\u003c/p\u003e \u003cp\u003eSpiritual well-being (SWB):\u003c/p\u003e \u003cp\u003eSpirituality (Spiritual well-being) was measured with the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp-12) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). It has subscales that measure faith, meaning, and peace: an eight-item meaning (2,3,5,8th items)/peace (1,4,6,7th items) subscale, and the four-item faith (9,10,11,12th items) subscale. Responses are given on a five-point Likert scale, from 0 to 4, with higher scores indicating higher spiritual well-being. Besides the 2-factor (meaning/peace, faith), a 3-factor (meaning, peace, faith) structure has been reported in the literature (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). We did also evaluate the 3-factor (meaning, peace, faith) model. The Cronbach\u0026rsquo;s α was 0.876 (total), 0.806 (faith), 0.863 (meaning/peace), 0.801 (meaning), and 0.786 (peace).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data were collected through a Google Forms survey and exported to an Excel spreadsheet, used for data organization, cleaning, and basic exploratory analysis. Then, the data were imported to IBM SPSS software (Statistical Package for the Social Sciences, IBM, version 28.0), for descriptive and inferential statistical analyses.\u003c/p\u003e \u003cp\u003eCategorical variables were described using absolute frequencies (n) and relative frequencies (%). The majority of quantitative variables exhibited skewed distributions (visually assessed through histograms); therefore, they were described using the median, interquartile range [1st quartile; 3rd quartile], minimum and maximum values. For quantitative variables, mean and standard deviation were also reported for comparison with other studies. The correlation between quantitative variables was assessed using the Spearman correlation coefficient, which measures the rank correlation between variables. In all statistical tests, significance values lower than 0.05 were considered significant.\u003c/p\u003e \u003cp\u003eMultiple regression analysis was performed to examine the extent to which demographic, QLQ-C15-PAL functioning domains (physical, emotional), symptom domains (fatigue, pain, nausea/vomiting, dyspnoea, sleep disturbances, appetite loss, constipation), FACIT-Sp, UCLA have a predictive power to QoL overall, pain and emotional functioning. Results of multiple regression analysis are presented using unstandardized regression coefficients (B) with 95% confidence intervals (CI) and p-values (p), F-statistics, and determination coefficients, R\u0026sup2;. Variables with a p-value\u0026thinsp;\u0026le;\u0026thinsp;0.20 in the simple regressions were included in the initial multiple regression model, for each outcome variable. In the final model, only variables with significance at p\u0026thinsp;\u0026le;\u0026thinsp;0.05 remained.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e During the study, 80 persons were recruited and gave their informed consent, but 5 dropped out because of their mental and/or physical conditions. The total study population consisted of 75 patients in palliative care. The median age was 73 years (range: 45\u0026ndash;91 years); 57% were male; 58.7% were married; 92% were Catholic. The majority (89%) had cancer. The most common types of cancer were lung (12%), prostate and esophagus (11% each). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the demographic and disease characteristics of the participants. In this sample, 29 were hospitalized patients (14 from the oncology hospital, and 15 from a local health unit) and 46 were seen in the outpatient settings (39 from the oncology hospital \u0026ndash; outpatient service, and 7 from a second local health unit). The questionnaires were filled out in the hospital (for the hospitalized patients), in the clinic waiting room (outpatient service) or at home (7 patients from the second local health unit).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics (N\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (57.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (42.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSingle\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMarried\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (58.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDivorced or Separated\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWidowed\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCatholic\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eChristian non-Catholic\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eJehovah's Witnesses\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEducation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eUp to 4 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (57.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e5 years or more\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (42.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDiagnosis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite of primary cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (10.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOesophagus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (10.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMelanoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlioblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther cancer site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (18.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-malignant diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmyotrophic lateral sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart Failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe participants\u0026rsquo; EORTC QLQ-C15-PAL mean scores were 53.33\u0026thinsp;\u0026plusmn;\u0026thinsp;26.42 for overall QoL, 67.34\u0026thinsp;\u0026plusmn;\u0026thinsp;24.98 for emotional functioning (EF) and 28.8\u0026thinsp;\u0026plusmn;\u0026thinsp;30.87 for physical functioning (PF), showing low PF and similar overall QoL and EF in comparison to a large study in 12 European countries (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe mean FACIT-Sp-12 Total score was 28.65\u0026thinsp;\u0026plusmn;\u0026thinsp;9.15. The meaning/peace subscale was 19.17\u0026thinsp;\u0026plusmn;\u0026thinsp;6.75, and the faith subscore was 9.48\u0026thinsp;\u0026plusmn;\u0026thinsp;3.67. Using the 3-factor model, the mean meaning subscore was 9.73\u0026thinsp;\u0026plusmn;\u0026thinsp;3.91, while the mean peace subscore was 9.44\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5. Some articles also reported higher meaning scores than peace (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe mean UCLA total score was 31.07\u0026thinsp;\u0026plusmn;\u0026thinsp;8.94, comparable to a Portuguese study in 3,144 adults, where the mean score of loneliness was 34.56\u0026thinsp;\u0026plusmn;\u0026thinsp;9.12 (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe mean GQ-6 total score was 4.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57, and did not differ from the sample in the validation study in Portugal (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe mean score of HFS, overall scale, was 98.47\u0026thinsp;\u0026plusmn;\u0026thinsp;14.37. The mean self subscale was 32.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.73, while the mean others subscale was 33.79\u0026thinsp;\u0026plusmn;\u0026thinsp;7.37, and the mean situations subscale, 32.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.54. One article of HFS in cancer patients receiving chemotherapy treatment in Turkey (43.8% with stage 4 cancer) had mean subscales from 29.45 to 30.59 (SD from 5.94 to 8.08) (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). According to our knowledge, no HFS data in Portuguese oncologic/palliative care patients has been published in the medical literature.\u003c/p\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003cp\u003eAssociations between Health-related Quality of Life and socio-demographic variables\u003c/p\u003e \u003cp\u003eUnivariate analyses were used to compare the QoL and socio-demographic variables. Female scores for physical functioning were significantly worse than those for males: 13 [0; 26.7] vs 20 [6.7; 60]; p\u0026thinsp;=\u0026thinsp;0.034. In comparison with low educational level (no more than primary education), those with educational level above primary education had a significant association with higher overall QoL (67 [50; 83.3] vs 50 [33.3; 66.7]; p\u0026thinsp;=\u0026thinsp;0.045), higher emotional functioning (83 [50; 100] vs 67 [41.7; 83.3]; p\u0026thinsp;=\u0026thinsp;0.036), and less fatigue (33 [11.1; 66.7] vs 56 [33.3; 66.7]; p\u0026thinsp;=\u0026thinsp;0.024). Regarding marital status and QoL, married scores for emotional functioning were significantly worse than others (58 [50; 83.3] vs 83 [50; 100]; p\u0026thinsp;=\u0026thinsp;0.040).\u003c/p\u003e \u003cp\u003eCorrelations between QLQ-C15-PAL overall quality of life and scores (functional and symptoms) (see Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/p\u003e \u003cp\u003eQLQ-C15-PAL overall QoL scores were significantly correlated with physical functioning (r\u0026thinsp;=\u0026thinsp;0.243, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), emotional functioning (r\u0026thinsp;=\u0026thinsp;0.367, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and negatively associated with pain (r = -0.239, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), fatigue (r = -0.256, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and dyspnoea (r = -0.244, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eCorrelations between Health-related Quality of Life, HFS, GQ-6, UCLA and SWB (see Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for correlations that are not mentioned below):\u003c/p\u003e \u003cp\u003eThe correlation analyses revealed that QLQ-C15-PAL overall QoL scores were positively associated with FACIT-Sp total scores (r\u0026thinsp;=\u0026thinsp;0.290, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), FACIT-Sp meaning (r\u0026thinsp;=\u0026thinsp;0.317, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), FACIT-Sp peace (r\u0026thinsp;=\u0026thinsp;0.305, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), HFS total scores (r\u0026thinsp;=\u0026thinsp;0.283, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and negatively associated with UCLA scores (r = -0.277, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eQLQ-C15-PAL emotional functioning scores were positively associated with FACIT-Sp peace (r\u0026thinsp;=\u0026thinsp;0.358, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), HFS total scores (r\u0026thinsp;=\u0026thinsp;0.312, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), HFS situations (r\u0026thinsp;=\u0026thinsp;0.327, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), QLQ-C15‐PAL physical functioning (r\u0026thinsp;=\u0026thinsp;0.273, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and negatively associated with UCLA scores (r = -0.354, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eQLQ-C15-PAL physical functioning scores were negatively associated with GQ-6 scores (r = -0,305, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eQLQ-C15-PAL pain scores were positively associated with fatigue (r\u0026thinsp;=\u0026thinsp;0.329, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and negatively associated with FACIT-Sp total (r = -0.231, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), FACIT-Sp peace (r = -0.290, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), meaning (r = -0.285, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and emotional functioning (r = -0.261, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eQLQ-C15-PAL fatigue scores were negatively associated with physical functioning (r = -0.321, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and emotional functioning (r = -0.436, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eQLQ-C15-PAL insomnia scores were positively associated with fatigue (r\u0026thinsp;=\u0026thinsp;0.302, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), pain (r\u0026thinsp;=\u0026thinsp;0.370, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and negatively associated with physical functioning (r = -0.247, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and emotional functioning (r = -0.356, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eCorrelations between SWB, HFS, GQ-6, and UCLA (see Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for correlations that are not described below)\u003c/p\u003e \u003cp\u003eFACIT-Sp total scores were negatively associated with UCLA scores (r = -0.385, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and positively associated with GQ-6 scores (r\u0026thinsp;=\u0026thinsp;0.411, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eFACIT-Sp peace scores were positively associated with HFS situations (r\u0026thinsp;=\u0026thinsp;0.242, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and GQ-6 (r\u0026thinsp;=\u0026thinsp;0.266, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and negatively associated with UCLA scores (r = -0.312, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eFACIT-Sp meaning scores were positively associated with GQ-6 (r\u0026thinsp;=\u0026thinsp;0.337, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and negatively associated with UCLA scores (r = -0.354, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eFACIT-Sp faith scores were negatively associated with UCLA scores (r = -0.265, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and positively associated with GQ-6 scores (r\u0026thinsp;=\u0026thinsp;0.428, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eThe Relationship Between QoL, FACIT-Sp, GQ-6, UCLA, and the HFS mean scores (N\u0026thinsp;=\u0026thinsp;75)\u003c/em\u003e:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"28\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c21\" colnum=\"21\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c22\" colnum=\"22\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c23\" colnum=\"23\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c24\" colnum=\"24\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c25\" colnum=\"25\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c26\" colnum=\"26\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c27\" colnum=\"27\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c28\" colnum=\"28\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFACIT_Faith\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eFACIT_Total\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eGQ-6_Total\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003eUCLA Total\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eHFS Total\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c15\"\u003e \u003cp\u003eHFS Self\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c16\"\u003e \u003cp\u003eHFS Others\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c17\"\u003e \u003cp\u003eHFS Situations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c18\"\u003e \u003cp\u003eQLQ-C15-PAL Overall QoL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003eQLQ-C15-PAL Physical Functioning\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c21\"\u003e \u003cp\u003eQLQ-C15-PAL Emotional Functioning\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c22\"\u003e \u003cp\u003eQLQ-C15-PAL Fatigue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c23\"\u003e \u003cp\u003eQLQ-C15-PAL Nausea/ Vomiting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c24\"\u003e \u003cp\u003eQLQ-C15-PAL Pain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c25\"\u003e \u003cp\u003eQLQ-C15-PAL Dyspnoea\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c26\"\u003e \u003cp\u003eQLQ-C15-PAL Insomnia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c27\"\u003e \u003cp\u003eQLQ-C15-PAL Appetite Loss\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c28\"\u003e \u003cp\u003eQLQ-C15-PAL Constipation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eFACIT Meaning/Peace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e,484\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e,940\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e,332\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e-,364\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0,127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0,093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0,022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0,185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e,316\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e0,050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e,291\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e-0,063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e-0,019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e-,319\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e-0,083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e-0,095\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e-0,223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e-0,087\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eFACIT Meaning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.458**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e,869**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e.337**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.354\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e.317**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e-0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.285*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e-0.103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e-0.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e-0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eFACIT Peace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.461**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e,862**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e.266*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.312\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e.242*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e.305**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e.358**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e-0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e-0.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.290*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e-0.074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e-0.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.292*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e-0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eFACIT Faith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e,735\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e,428\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e-,265\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0,166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0,164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0,100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0,103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0,118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e-0,217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e-0,132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e0,088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e-0,033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e0,014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e-0,033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e0,219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e-0,012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e-0,139\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eFACIT Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e,411\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e-,385\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0,163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0,141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0,047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0,189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e,290\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e-0,015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0,180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e-0,023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e-0,019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e-,231\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e-0,108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e0,007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e-0,172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e-0,087\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eGQ-6 Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e-,264\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e,300\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e,240\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e,295\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0,193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0,131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e-,305\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e-0,044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e0,128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e0,131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e0,048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e0,044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e0,130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e0,152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e0,080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eUCLA Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e-,382\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e-,363\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e-0,219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e-,312\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e-,277\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e-0,057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e-,354\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e0,130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e-0,008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e0,071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e,256\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e0,157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e-0,012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e0,197\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHFS Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e,648\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e,798\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e,751\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e,283\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e0,134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e,312\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e-0,044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e0,015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e-0,050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e0,084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e-0,053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e0,130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e-0,045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHFS Self\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e,267\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e,336\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0,147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e0,006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0,227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e0,039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e-0,025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e0,111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e-0,040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e0,048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e0,155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e-0,037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHFS Others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e,404\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0,221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e0,028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0,170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e-0,131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e0,031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e-0,009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e0,173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e-0,036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e0,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e-0,097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHFS Situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0,220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e0,219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e,327\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e0,014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e0,044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e-0,198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e0,051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e-0,147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e0,011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e0,060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL Overall Quality of Life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e,243\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e,367\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e-,256\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e-0,131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e-,239\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e-,244\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e-0,122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e-0,190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e0,011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL Physical Functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e,273\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e-,321\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e-0,059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e-0,223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e-0,170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e-,247\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e-0,039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e0,059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL Emotional Functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e-,436\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e-,310\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e-,261\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e-,262\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e-,356\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e-,330\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e-0,046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL Fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e,382\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e,329\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e,433\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e,302\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e,508\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e0,207\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL Nausea/ Vomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e \u003cp\u003e0,046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e,253\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e0,224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e,457\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e0,174\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e \u003cp\u003e0,059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e,370\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e0,187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e0,044\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL Dyspnoea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e \u003cp\u003e0,150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e,277\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e,293\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL Insomnia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e \u003cp\u003e,247\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e0,134\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL Appetite Loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c24\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c25\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c26\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c27\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c28\"\u003e \u003cp\u003e0,226\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e**. p\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003cp\u003e*. p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003cp\u003eMultiple regression\u003c/p\u003e \u003cp\u003eA series of multiple regression analysis was conducted to evaluate the unique contribution of the demographic variables (years of education, gender, marital status), FACIT-Sp (3-factor model), UCLA, HFS, GQ-6 and QLQ-C15-PAL functioning domains (physical, emotional), symptom domains (fatigue, pain, nausea/vomiting, dyspnea, sleep disturbances, appetite loss, constipation) as a predictive power to QLQ-C15‐PAL Overall QoL scores. Multiple regression analysis was also performed with emotional functioning and pain as dependent variables. The results are shown in Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. The independent variables that were associated with the dependent variable at the p\u0026thinsp;\u0026lt;\u0026thinsp;0.2 significance level entered into the initial multiple regression models.\u003c/p\u003e \u003cp\u003eFor the prediction of overall QoL, the final model, explained 22.6% of outcome\u0026rsquo;s variance (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Meaning (p\u0026thinsp;=\u0026thinsp;0.016), and emotional functioning (p\u0026thinsp;=\u0026thinsp;0.001) were significant predictors of overall QoL. For the prediction of pain, the model explained 26.3% of variance (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Peace (p\u0026thinsp;=\u0026thinsp;0.013), fatigue (p\u0026thinsp;=\u0026thinsp;0.023) and insomnia (p\u0026thinsp;=\u0026thinsp;0.009) were predictors of pain. Regarding the prediction of emotional functioning, the model explained 46.8% of variance (see Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Peace (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), faith (p\u0026thinsp;=\u0026thinsp;0.002), self-forgiveness (p\u0026thinsp;=\u0026thinsp;0.029), forgiveness of situations (p\u0026thinsp;=\u0026thinsp;0.032), and fatigue (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significant predictors of Emotional Functioning.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultiple regression results for the dependent variable QLQ-C15-PAL Overall quality of life (N\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eInitial Model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFinal Model\u003c/p\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;22.6%\u003c/p\u003e \u003cp\u003eF(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;10.5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVari\u0026aacute;veis Independentes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB [95% CI]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB [95% CI]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (up to 4 years/5 years or more)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUp to 4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 years or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.51 [-11.14; 14.15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFACIT_peace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.26 [-2.69; 2.17]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.831\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFACIT_meaning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8 [-0.38; 3.97]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.76 [0.34; 3.19]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUCLA - Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.03 [-0.82; 0.76]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.931\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHFS self\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.35 [-0.79; 1.49]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHFS others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.56 [-0.32; 1.45]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHFS situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.38 [-0.76; 1.53]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL physical functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.03 [-0.18; 0.25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.774\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL emotional functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.21 [-0.09; 0.52]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37 [0.15; 0.59]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.002 [-0.25; 0.26]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.05 [-0.24; 0.14]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.587\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL appetite Loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.05 [-0.26; 0.16]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.615\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL insomnia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.04 [-0.23; 0.15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultiple regression results for the dependent variable QLQ-C15-PAL Pain (N\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eInitial Model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFinal Model\u003c/p\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;26.3%\u003c/p\u003e \u003cp\u003eF(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;8.46, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndependent Variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB [95% CI]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB [95% CI]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFACIT_peace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.03 [-4.21; 2.16]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.522\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.46 [-4.39; -0.53]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFACIT_meaning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.83 [-4.45; 0.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHFS situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.03 [-2.36; 0.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL physical functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.12 [-0.4; 0.15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL emotional functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.13 [-0.26; 0.52]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3 [-0.01; 0.62]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29 [0.04; 0.55]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL appetite loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.01 [-0.26; 0.27]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL insomnia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.25 [0.02; 0.49]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.30 [0.08; 0.53]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultiple regression results for the dependent variable QLQ-C15-PAL Emotional Functioning (N\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eInitial Model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFinal Model\u003c/p\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;46.8%\u003c/p\u003e \u003cp\u003eF(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;12.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndependent Variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB [95% CI]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB [95% CI]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle/Widowed/Divorced or Separated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.47 [-9.72; 12.65]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.794\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (up to 4 years/5 years or more)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eup to 4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 years or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.04 [-8.71; 12.79]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFACIT_peace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.65 [0.51; 4.79]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.03 [1.47; 4.57]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFACIT_meaning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.01 [-1.77; 1.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFACIT faith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2.15 [-3.77; -0.54]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.28 [-3.72; -0.84]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUCLA - Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.2 [-0.85; 0.44]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHFS self\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.82 [-0.11; 1.74]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.91 [0.10; 1.73]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHFS others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.23 [-0.58; 1.03]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.574\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHFS situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.69 [-0.26; 1.64]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.80 [0.07; 1.54]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL physical functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.01 [-0.18; 0.19]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.19 [-0.41; 0.03]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.29 [-0.44; -0.15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL nausea/ vomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.09 [-0.34; 0.17]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.495\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.01 [-0.15; 0.16]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.935\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL dyspnoea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.03 [-0.22; 0.16]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.742\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL appetite loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.11 [-0.31; 0.09]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQLQ-C15-PAL constipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.04 [-0.11; 0.19]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe World Health Organisation definition of palliative care was revised in 2002, with emphasis on QoL: \"Palliative care is an approach that improves the QoL of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual\u0026rdquo; (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen cure is no longer possible, QoL is the main concern (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), and should focus on the holistic approach for the body, mind and spirit (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), the \u0026ldquo;total care of patients whose disease is not responsive to curative treatment.\u0026rdquo; (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). How one is faring psychologically will affect one\u0026rsquo;s physical, spiritually, relationships, and vice-versa, contributing to the overall QoL (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn cancer patients the spiritual well-being has been described as significant as the physical component (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe\u0026rsquo;ve focused our study on non-pharmacological factors (forgiveness, loneliness, spirituality and gratitude) as these factors may have great influence and impact on QoL, being important components of the holistic care. In the midst of terminal diseases it is common to think about what really matters, and those factors are essentially non-pharmacological ones: having a sense of meaning, making a positive difference in the lives of those around us, sharing and saying important things to the family and loved ones (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). And questions of meaning, value, and relationship constitute the core definition of spirituality, according to Dr Sulmasy (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSpirituality has been considered a predictive construct of QoL (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), as a way to maintain hope, and a coping mechanism during the journey of cancer to derive meaning from it (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). In one study, combined spirituality scores predicted 24% of the variance in global QoL (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong 29 QoL instruments for use in palliative care, a review identified that 15 included spirituality items, and most of them contained items related to \u0026lsquo;\u0026lsquo;feeling at peace with life\u0026rsquo;\u0026rsquo; and \u0026lsquo;\u0026lsquo;purpose or meaning of life\u0026rsquo;\u0026rsquo; (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePersons in life-threatening situations, and their families, may define QoL differently from those not facing a terminal disease. QoL at the end of life may focus on comfort, peace, and spiritual matters more than in the past. Seeking resolution of conflicts and making peace with others could also contribute to the QoL (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), pointing to the role of forgiveness.\u003c/p\u003e \u003cp\u003eIn our study, meaning and peace as part of a 2-factor FACIT-Sp were significant predictors of overall QoL, pain, and emotional functioning, supporting the findings of Brady et al (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), where Meaning/Peace was the best predictor of \u0026lsquo;contentment with QoL\u0026rsquo;, compared to other domains. Faith evidenced a smaller relationship with QoL compared to Meaning/Peace, according to our findings and other studies (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur 3-factor FACIT-Sp multiple regression analysis showed that meaning was a significant predictor of overall QoL, and peace was a significant predictor of pain and emotional functioning. Using a Single-Item Quality of Life Scale\u0026ndash;Numeric Rating Scale, a Swiss study found that meaning in life represented a significant predictor of QoL, explaining up to 22% of the QoL variance (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). As an essential aspect of spirituality, meaning is of special importance to QoL at the end of life (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Overall QoL and measures of physical, psychological and existential well-being can improve during the first week following admission to a palliative care unit, suggesting the responsiveness of QoL and existential/spiritual domains even close to death (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn an oncology population, meaning was most highly associated with total QoL (FACT-G scale), and showed a much stronger association with Social Wellbeing in comparison with Peace (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Some questions in the Social Wellbeing domain may have an overlap with emotional functioning. Examples of those questions: I feel distant from my friends; I get emotional support from my family; I get support from my friends and neighbors; My family has accepted my illness; Family communication about my illness is poor.\u003c/p\u003e \u003cp\u003eSimilar to our findings, QLQ-C15-PAL emotional functioning was a significant predictive factor for worse overall (global) QoL in patients with advanced cancer from six countries. Worse emotional functioning was the most significant predictive factor for worse QoL, along with pain and appetite loss (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn a cross-sectional sample of patients with advanced serious illness, peacefulness was strongly associated with the emotional and spiritual well-being subscales, and moderately significant relationships with other dimensions of QoL: functional well-being, physical well-being, and social well-being. The authors suggested that the concept of patients\u0026rsquo; sense of being at peace may be a point with which to initiate a conversation about emotional and spiritual concerns in a nonthreatening, nonsectarian manner (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding pain and aspects of spirituality, the intensity of pain in advanced cancer patients was lower in those reporting a belief in a power greater than man, in the helpfulness of prayer, and in afterlife (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). The attempt to find peace of mind, and meaning, or getting a purpose from the experience of pain-induced limitations, may evoke more effective forms of emotional, cognitive and behavioral coping (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Individuals who use positive forms of religious and spiritual coping are less likely to feel overwhelmed by chronic pain, with feelings of peace, calmness, spiritual support, spiritual connection, decreased anxiety and improvement of mood. (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Interventions that facilitate reflection on meaning and purpose in life are related to increased pain tolerance, better health-related QoL and positive mood (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). A sense of peace that can reduce anxiety and depression may relieve pain, being a mechanism underlying the peace-pain association (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). A strong sense of peace and meaning during illness may impact the experience of chronic symptoms, including other domains of QoL such as physical and functional wellbeing (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). In a sample of patients with advanced serious illness, feeling at peace was strongly associated with the emotional and spiritual well-being subscales (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). These articles are aligned with our findings regarding peace as a significant predictor of pain and emotional functioning.\u003c/p\u003e \u003cp\u003ePain in cancer patients may create a sense of hopelessness due to the fear that if they live in pain their lives lose their meaning or are not worth continuing (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBesides being associated with other core domains of QoL, meaning and peace may contribute to the prediction of a cancer patient's QoL, supporting the hypothesis that spiritual wellbeing should always be evaluated when determining QoL. Without assessing the level of meaning and peace, we could miscalculate the true burden of the disease. In other words, a patient with high meaning in life and/or a good sense of peace may have better QoL than a patient with lower scores on these factors (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our multiple regression, faith and peace were also predictors of emotional functioning. These findings were previously described. A study with adult advanced cancer inpatients who had been admitted to seven palliative care units showed that faith correlated weakly with emotional functioning (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). In a cross-sectional, multicenter study in adult patients with advanced cancer feeling at peace was correlated more with QoL and Emotional functioning (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than religiosity and spirituality (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). During illness, patients may find more meaning in their relationships, and more peace from good emotional stability. Hence peace is more associated with affective components (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). A Systematic Review included eighteen studies that examined the contribution of the Faith factor to QoL. Faith was positively associated with overall QoL, emotional, and functional dimensions of QoL, with one exception (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGratitude can have a profound spiritual grounding. Positive aspects of life, such as love and health, are seen as gifts with appreciation in several religious communities. This view motivates individuals to practice prosocial activities and self-care and to grow via meaning-making in the middle of adversity (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). Gratitude may also generate a sense of meaning and connectedness, which facilitates coping with changes. According to the socioemotional selective theory, people become increasingly aware that their lifetime is limited as they age. This awareness leads older adults to prioritize engagement in meaningful events and close relationships (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). A terminal disease may also lead to priorities related to meaning and relationships, and raise or strength spiritual matters (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). In agreement with this perspective, our study has found an association between gratitude and spiritual well-being, measured by faith, meaning/peace factors.\u003c/p\u003e \u003cp\u003eHaving a grateful attitude may help to become less fearful of death due to a sense that life has been well lived. Patients with palliative care needs have been appreciative about their accomplishments and important persons in their life, providing support to the idea that gratitude could be an important outcome in end of life (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn a palliative care setting, a positive and significant association was found between gratitude (GQ-6 total score) and global QoL [McGill Quality of Life questionnaire revised (MQoL) total score], and with three MQoL subscales (psychological, physical, and existential). The strongest relationship occurred with the existential dimension of QoL, providing support to the hypothesis that gratitude may improve meaning in life and reinforce spirituality (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). Similarly, our data also revealed a significant correlation of gratitude with FACIT-Sp total scores, and also with the subscores: meaning of life, peace and faith. The strongest relationships were with meaning of life and faith. Our results did not demonstrate a positive association of gratitude with QoL. The only QoL significant finding (not confirmed by multiple linear regression analysis) had been of GQ-6 with physical functioning. We may not exclude the fact that patients with worse physical functioning may gain strength through spirituality and gratitude. Another point is that the ability to cope with the disease is not included in the GQ-6 questionnaire (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLoneliness is considered an essential part of QoL. Increasing death anxiety, loneliness and hopelessness were all associated with poorer QoL (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Our study has agreed with the link of increased loneliness and lower QoL as we\u0026acute;ve observed a negative correlation between overall QoL and loneliness, and also between emotional functioning and loneliness. Our data showed a significant negative relationship between UCLA total score and FACIT-Sp scores, in agreement with a cross-sectional study in 347 oncology inpatients (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe association between forgiveness and emotional functioning in palliative care patients has not been previously described. In a study testing the provisional European Organisation for Research and Treatment of Cancer measure of spiritual well-being (EORTC QLQ-SWB), and that explored the relationship between SWB and QoL for palliative care patients in Iceland, the most frequent difficult to answer question was the item exploring self-forgiveness (30% of the participants) (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). Regarding situational forgiveness, it may allow coping with circumstances beyond one\u0026rsquo;s control, as an illness. As a result of forgiveness, the person will understand, and accept these situations, being able to let go of negative thoughts, reaching a state of peacefulness (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e). In our analysis, peace was positively correlated with forgiveness of situations.\u003c/p\u003e \u003cp\u003eFatigue is the most frequently reported symptom in patients with cancer, and one of the most distressing symptoms (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e). The prevalence of fatigue among patients with bone metastasis or advanced cancer patients is at least 75% (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e). In a group of cancer patients undergoing radiotherapy, fatigue was associated with poor QoL (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn a prospective cohort study, a linear regression model of advanced cancer patients, with fatigue as the dependent variable and EORTC QLQ-C15-PAL items as independent variables, emotional functioning (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was found to be associated with fatigue (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e). Our data showed that emotional functioning and fatigue were strongly negatively correlated, in agreement with Iwase et al (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). With regards to pain and fatigue, they are among the most debilitating and commonly reported symptoms in advanced cancer (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). One study of 1,957 breast cancer survivors revealed that fatigue was significantly associated with pain, depression and sleep disturbance (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur correlation between insomnia and pain was not unexpected, but it is not easy to state which primary factor affected the other. Lung cancer patients suffering from insomnia presented significantly higher levels of pain and lower QoL than those in the comparison group. It could be that insomnia may have contributed to increased pain or that pain may interfere with sleep (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur multiple regression analysis, among the non-pharmacological factors, has highlighted aspects of spirituality, particularly meaning of life and peace, showing relationships with QoL, emotional functioning and pain, which are main concerns in end-of-life care, with potential to affect patients and caregivers.\u003c/p\u003e \u003cp\u003eThe lack of spiritual support by health care professionals is associated with increased costs, dissatisfaction with care, more aggressive treatment, less hospice utilization, and poor QoL (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe quality and satisfaction with care may be enhanced by asking not only about a patient\u0026rsquo;s religious affiliation or any important ritual/religious practice, but by taking a spiritual assessment, which contains purpose and meaning in life, forgiveness, love, hope, trust, and a sense of connection (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn a study that examined end-of-life preferences for atheists, participants expressed a deep desire to find meaning in their own lives, to maintain connection with family, friends, and the natural world through the dying experience (\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe end of life is often a time where spiritual issues come to the fore and patients may wish to revise and reiterate their beliefs in order to die peacefully (\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBy acknowledging the spiritual needs of palliative care patients and their caregivers, interdisciplinary healthcare professionals can support them in facing the losses associated with advanced disease and impending death, increasing QoL even as death approaches (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), when the value of life, the meaning of suffering, relationship with others and with God, need of forgiveness, reconciliation, and life after death become important questions (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eThis study has a few limitations. First, a selection bias may have occurred because palliative care patients experiencing cognitive or physical impairment would be less likely to participate in the interviews. Our cross-sectional design precludes interpretation of causality and, thus, bidirectionality of associations is a possibility. Results concerning self-forgiveness should be interpreted with caution due to the low internal consistency coefficient of this subscale. Another limitation is related to the FACIT-Sp, as it is based on self-reported answers, and the scale does not cover every central aspect of spirituality (e.g., forgiveness, love, generosity), lacking elements such as \u0026ldquo;acceptance\u0026rdquo; or \u0026ldquo;connection\u0026rdquo; which are central to spirituality (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt was not evaluated negative religious coping methods (example, anger at God) as they can be related to poorer overall QoL and lower scores on the psychological and existential domains of QoL (sense of meaning and control) (\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e). It was not included the evaluation of performance status (ECOG) of cancer patients. One study revealed that performance status was the strongest predictor of severe pain intensity, poor QoL, low satisfaction, and low quality of care. Decreases in performance status could identify candidates for intensive palliative care interventions (\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eQoL in terms of subjective well-being, includes physical symptoms and functioning, psychologic and social well-being, but other factors may also be important because QoL is influenced by all domains of our human experience, as a result of the interaction between disease, health care, and the individual\u0026rsquo;s experience (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). We\u0026acute;ve observed that palliative care patients may consider factors beyond those considered by most HR-QoL instruments. The most commonly used QoL questionnaires do not include existential or forgiveness questions, but these factors may be important domains in QoL at end of life, particularly issues of meaning and peace. Future studies can confirm the findings of our study and longitudinal studies should evaluate changes throughout the illness/palliative care period rather than just focusing on a specific moment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eParticipants gave verbal consent prior to their participation. The study was carefully explained and any questions or doubts were answered by the investigator. After the participants were clarified, those who agreed to participate gave their verbal consent before filling out the questionnaire.\u003c/p\u003e\n\u003cp\u003eThe project in which this study is included was submitted and approved by the Ethics Committees of the Portuguese Institute of Oncology – Porto and Pedro Hispano Hospital – ULSM Matosinhos.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: Not applicable\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: Not applicable\u003c/p\u003e\n\u003cp\u003eAuthors´ Contributions\u003c/p\u003e\n\u003cp\u003eConcept and design (FI, LC, FR, RN); acquisition of data (FI, LC); statistical analysis and interpretation of data (FI, LC); manuscript writing (FI, LC); supervision (FR, RN). All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe thank Dr Paula Silva and all the palliative care teams members for the help with patient recruitment. The authors would like to thank all patients and family caregivers who participated in the survey. Our thanks to all palliative care service providers supporting the study recruitment, and managers of collaborating clinical sites who supported and permitted this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChellaraj A. Dying a Good Death: End-of-Life Decision Making for Terminally Ill Christians. Honors Program Thesis, Baylor University, 2018. http://hdl.handle.net/2104/10277 .\u003c/li\u003e\n\u003cli\u003ePuchalski CM. Spirituality and the care of patients at the end-of-life: an essential component of care. Omega (Westport). 2007;56:33-46.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization Quality of Life (WHOQOL) Group. The WHO quality of life assessment (WHOQOL) position paper from the World Health Organization. Social Science and Medicine. 1995;41:1403-1409. \u003c/li\u003e\n\u003cli\u003eBauerei\u0026szlig; N, Obermaier S, \u0026Ouml;z\u0026uuml;nal SE, Baumeister H. Effects of existential interventions on spiritual, psychological, and physical well-being in adult patients with cancer: Systematic review and meta-analysis of randomized controlled trials. Psychooncology. 2018;27:2531-2545. \u003c/li\u003e\n\u003cli\u003ePuchalski CM, King SDW, Ferrell BR. Spiritual Considerations. Hematol Oncol Clin North Am. 2018;32:505-517. \u003c/li\u003e\n\u003cli\u003eBalboni TA, VanderWeele TJ, Doan-Soares SD, Long KNG, Ferrell BR, Fitchett G, Koenig HG, Bain PA, Puchalski C, Steinhauser KE, Sulmasy DP, Koh HK. Spirituality in Serious Illness and Health. JAMA. 2022;328:184-197. Erratum in: JAMA. 2022;328:780. \u003c/li\u003e\n\u003cli\u003eKeeley MP. \u0026apos;Turning toward death together\u0026apos;: The functions of messages during final conversations in close relationships. Journal of Social and Personal Relationships. 2007;24:225\u0026ndash;253.\u003c/li\u003e\n\u003cli\u003eSinger PA, Martin DK, Kelner M. (1999). Quality end-of-life care: patients\u0026apos; perspectives. JAMA. 1999;281:163-168. \u003c/li\u003e\n\u003cli\u003eMcGraw JG. Loneliness, its nature and forms: an existential perspective. Man and World. 1995;28:43\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eLeget C. Forgiveness and reconciliation in palliative care: The gap between the psychological and moral approaches. Religions. 2020;11:440.\u003c/li\u003e\n\u003cli\u003eDeckx L, Daniels L, Nelissen K, Van Abbema D, Visconti L, Stinissen P, et al. Quality of life and loneliness in older cancer patients. Preliminary results of KLIMOP, a cohort study on the wellbeing of older cancer patients in Belgium and the Netherlands. European Journal of General Practice. 2013;19:41. \u003c/li\u003e\n\u003cli\u003eBest M, Aldridge L, Butow P, Olver I, Webster F. Conceptual analysis of suffering in cancer: a systematic review. Psychooncology. 2015;24:977-86. \u003c/li\u003e\n\u003cli\u003eRenz M, Bueche D, Reichmuth O, Schuett Mao M, Renz U, Siebenrock R, Strasser F. Forgiveness and Reconciliation Processes in Dying Patients With Cancer. Am J Hosp Palliat Care. 2020;37:222-234. Erratum in: Am J Hosp Palliat Care. 2019; 1049909119884407. \u003c/li\u003e\n\u003cli\u003eRokach A. The Dying and Those Who Care for Them. Journal of Patient Care. 2015;1:1.\u003c/li\u003e\n\u003cli\u003eStrang P, Bergstr\u0026ouml;m J, Martinsson L, Lundstr\u0026ouml;m S. Dying From COVID-19: Loneliness, End-of-Life Discussions, and Support for Patients and Their Families in Nursing Homes and Hospitals. A National Register Study. J Pain Symptom Manage. 2020;60:e2-e13. \u003c/li\u003e\n\u003cli\u003eByock I. The four things that matter most: A book about living. 1\u003csup\u003est\u003c/sup\u003e ed. New York: Atria Books; 2014.\u003c/li\u003e\n\u003cli\u003ePanzini RG, Mosqueiro BP, Zimpel RR, Bandeira DR, Rocha NS, Fleck MP. Quality-of-life and spirituality, International Review of Psychiatry. 2017;29:263-282. \u003c/li\u003e\n\u003cli\u003eGroenvold M, Petersen MA, Aaronson NK, Arraras JI, Blazeby JM, Bottomley A, et al. EORTC Quality of Life Group. The development of the EORTC QLQ-C15-PAL: a shortened questionnaire for cancer patients in palliative care. Eur J Cancer. 2006;42:55-64. \u003c/li\u003e\n\u003cli\u003eFayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran D, Bottomley A, on behalf of the EORTC Quality of Life Group. The EORTC QLQ-C30 scoring manual. 3rd ed. Brussels, Belgium: European Organisation for Research and Treatment of Cancer; 2001.\u003c/li\u003e\n\u003cli\u003eGroenvold M, Petersen MA. Addendum to the EORTC QLQ-C30 Scoring Manual: Scoring of the EORTC QLQC15-PAL. Brussels, Belgium: EORTC Quality of Life Group; 2006.\u003c/li\u003e\n\u003cli\u003eIkedo F, Castro L, Fraguas S, Rego F, Nunes R. Cross-cultural adaptation and validation of the European Portuguese version of the heartland forgiveness scale. Health Qual Life Outcomes. 2020;18:289. \u003c/li\u003e\n\u003cli\u003eMcCullough ME, Emmons RA, Tsang JA. The grateful disposition: a conceptual and empirical topography. Journal of Personality and Social Psychology. 2002;82:112-127.\u003c/li\u003e\n\u003cli\u003eNeto F. Forgiveness, personality and gratitude. Pers. Individ. Differ. 2007;43:2313\u0026ndash;2323.\u003c/li\u003e\n\u003cli\u003eRussell D, Peplau LA, Cutrona CE. The revised UCLA Loneliness Scale: Concurrent and discriminant validity evidence. Journal of Personality and Social Psychology. 1980;39:472\u0026ndash;480. \u003c/li\u003e\n\u003cli\u003eNeto F. Avalia\u0026ccedil;\u0026atilde;o da solid\u0026atilde;o. Psicologia Cl\u0026iacute;nica. 1989;2:65\u0026ndash;79. \u003c/li\u003e\n\u003cli\u003ePeterman A, Fitchett G, Brady M, Hernandez L. Measuring Spiritual Well-Being in People With Cancer: The Functional Assessment of Chronic Illness Therapy\u0026mdash;Spiritual Well-Being Scale (FACIT-Sp). Annals of Behavioral Medicine 2002;24:49\u0026ndash;58.\u003c/li\u003e\n\u003cli\u003eCanada AL, Murphy PE, Fitchett G, Peterman AH, Schover LR. A 3-factor model for the FACIT-Sp. Psychooncology. 2008;17:908-916.\u003c/li\u003e\n\u003cli\u003eAhmad N, Sinaii N, Panahi S, Bagereka P, Serna-Tamayo C, Shnayder S, Ameli R, Berger A. The FACIT-Sp spiritual wellbeing scale: a factor analysis in patients with severe and/or life-limiting medical illnesses. Ann Palliat Med. 2022;11:3663-3673. \u003c/li\u003e\n\u003cli\u003eVerkissen MN, Hjermstad MJ, Van Belle S, Kaasa S, Deliens L, Pardon K. Quality of life and symptom intensity over time in people with cancer receiving palliative care: Results from the international European Palliative Care Cancer Symptom study. PLoS ONE. 2019;14: e0222988. \u003c/li\u003e\n\u003cli\u003eYoon SJ, Suh SY, Kim SH, Park J, Kim YJ, Kang B, et al. Spiritual Well-being Among Palliative Care Patients With Different Religious Affiliations: A Multicenter Korean Study. J Pain Symptom Manage. 2018;56:893-901. \u003c/li\u003e\n\u003cli\u003eDamen A, Raijmakers NJH, van Roij J, Visser A, Beuken-Everdingen MVD, Kuip E, et al. Spiritual Well-Being and Associated Factors in Dutch Patients With Advanced Cancer. J Pain Symptom Manage. 2022;63:404-414. \u003c/li\u003e\n\u003cli\u003eMunoz AR, Salsman JM, Stein KD, Cella D. Reference values of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being: a report from the American Cancer Society\u0026apos;s studies of cancer survivors. Cancer. 2015;121:1838-44. \u003c/li\u003e\n\u003cli\u003eNeto F. Socio-demographic predictors of loneliness across the adult life span in Portugal. Interpersona: An International Journal on Personal Relationships. 2014;8:222-230.\u003c/li\u003e\n\u003cli\u003eBelen HM, Sariko\u0026ccedil; G. Cancer Patients: Forgiveness, Discomfort Intolerance and Psychiatric Symptoms. J Palliat Care. 2024;39:227-237. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. National cancer control programmes, policies and managerial guidelines. 2002\u003c/li\u003e\n\u003cli\u003eCohen SR, Mount BM. Living with cancer: \u0026quot;good\u0026quot; days and \u0026quot;bad\u0026quot; days--what produces them? Can the McGill quality of life questionnaire distinguish between them? Cancer. 2000;89:1854-65. \u003c/li\u003e\n\u003cli\u003eHaitt JF. Spirituality, medicine, and healing. Southern Medical Journal. 1986;79:736\u0026ndash;743.\u003c/li\u003e\n\u003cli\u003eSulmasy DP. A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist. 2002;42 Spec No 3:24-33. \u003c/li\u003e\n\u003cli\u003eSteinhauser KE, Bosworth HB, Clipp EC, McNeilly M, Christakis NA, Parker J, Tulsky JA. Initial assessment of a new instrument to measure quality of life at the end of life. J Palliat Med. 2002;5:829-41.\u003c/li\u003e\n\u003cli\u003eSulmasy DP. Physicians, Spirituality, and Compassionate Patient Care. N Engl J Med. 2024;390:1061-1063.\u003c/li\u003e\n\u003cli\u003eGoyarrola R, Lipsanen J, Saarelainen SM, Suviranta R, Rahko E, Lamminm\u0026auml;ki A, et al. Spiritual well-being correlates with quality of life of both cancer and non-cancer patients in palliative care - further validation of EORTC QLQ-SWB32 in Finnish. BMC Palliat Care. 2023;22:33. \u003c/li\u003e\n\u003cli\u003eSherman DW, Ye XY, McSherry C, Calabrese M, Parkas V, Gatto M. Spiritual well-being as a dimension of quality of life for patients with advanced cancer and AIDS and their family caregivers: results of a longitudinal study. Am J Hosp Palliat Care. 2005;22:349-62. \u003c/li\u003e\n\u003cli\u003eBeery TA, Baas LS, Fowler C, Allen G. Spirituality in Persons with Heart Failure. Journal of Holistic Nursing. 2002;20:5-25. \u003c/li\u003e\n\u003cli\u003eAlbers G, Echteld MA, de Vet HC, Onwuteaka-Philipsen BD, van der Linden MH, Deliens L. Content and spiritual items of quality-of-life instruments appropriate for use in palliative care: a review. J Pain Symptom Manage. 2010;40:290-300. \u003c/li\u003e\n\u003cli\u003eMabenagha A. (2009). Nurses\u0026apos;s perspectives of loneliness amongst terminally ill patients. Bachelor\u0026apos;s thesis, Nursing Degree Program. Laurea University of Applied Sciences. Finland. 2009 https://www.theseus.fi/bitstream/handle/10024/2257/Mabenagha.Arlene.pdf?sequence=3\u0026amp;isAllowed=y \u003c/li\u003e\n\u003cli\u003eBrady MJ, Peterman AH, Fitchett G, Mo M, Cella D. A case for including spirituality in quality of life measurement in oncology. Psychooncology. 1999;8:417-28. \u003c/li\u003e\n\u003cli\u003eWhitford HS, Olver IN. The multidimensionality of spiritual wellbeing: peace, meaning, and faith and their association with quality of life and coping in oncology. Psychooncology. 2012;21:602-10. \u003c/li\u003e\n\u003cli\u003eBernard M, Berchtold A, Strasser F, Gamondi C, Borasio GD. Meaning in life and quality of life: palliative care patients versus the general population. BMJ Support Palliat Care. 2024;14:e2537-e2545.\u003c/li\u003e\n\u003cli\u003eMount BM, Boston PH, Cohen SR. Healing connections: on moving from suffering to a sense of well-being. J Pain Symptom Manage. 2007;33:372-88. \u003c/li\u003e\n\u003cli\u003eCohen SR, Boston P, Mount BM, Porterfield P. Changes in quality of life following admission to palliative care units. Palliative Medicine. 2001;15:363-371. \u003c/li\u003e\n\u003cli\u003eCramarossa G, Chow E, Zhang L, Bedard G, Zeng L, Sahgal A, et al. Predictive factors for overall quality of life in patients with advanced cancer. Support Care Cancer. 2013;21:1709-16. \u003c/li\u003e\n\u003cli\u003eSteinhauser KE, Voils CI, Clipp EC, Bosworth HB, Christakis NA, Tulsky JA: \u0026lsquo;\u0026lsquo;Are You at Peace?\u0026rsquo;\u0026rsquo; One item to probe spiritual concerns at the end of life. Arch Int Med 2006;166:101\u0026ndash;105.\u003c/li\u003e\n\u003cli\u003eYates JW, Chalmer BJ, St James P, Follansbee M, McKegney FP. Religion in patients with advanced cancer. Med Pediatr Oncol. 1981;9:121-8. \u003c/li\u003e\n\u003cli\u003eNsamenang SA, Hirsch JK, Topciu R, Goodman AD, Duberstein PR. The interrelations between spiritual well-being, pain interference and depressive symptoms in patients with multiple sclerosis. J Behav Med. 2016;39:355-63. Erratum in: J Behav Med. 2016;39:364. \u003c/li\u003e\n\u003cli\u003eWachholtz AB, Pearce MJ, Koenig H. Exploring the relationship between spirituality, coping, and pain. J Behav Med. 2007;30:311-8. \u003c/li\u003e\n\u003cli\u003eDelaney C, Barrere C, Helming M. The influence of a spirituality-based intervention on quality of life, depression, and anxiety in community-dwelling adults with cardiovascular disease: a pilot study. J Holist Nurs. 2011;29:21-32. \u003c/li\u003e\n\u003cli\u003eWachholtz AB, Pargament KI. Is spirituality a critical ingredient of meditation? Comparing the effects of spiritual meditation, secular meditation, and relaxation on spiritual, psychological, cardiac, and pain outcomes. J Behav Med. 2005;28:369-84. \u003c/li\u003e\n\u003cli\u003eYang Y, Zhao X, Cui M, Wang Y. Dimensions of spiritual well-being in relation to physical and psychological symptoms: a cross-sectional study of advanced cancer patients admitted to a palliative care unit. BMC Palliat Care. 2023;22:137. \u003c/li\u003e\n\u003cli\u003eMystakidou K, Tsilika E, Parpa E, Pathiaki M, Patiraki E, Galanos A, Vlahos L. Exploring the relationships between depression, hopelessness, cognitive status, pain, and spirituality in patients with advanced cancer. Arch Psychiatr Nurs. 2007;21:150-61. \u003c/li\u003e\n\u003cli\u003eShin DW, Suh SY, Kim SH, Park J, Yoon SJ, Kim YJ, et al. Is spirituality related to survival in advanced cancer inpatients in Korea? Palliat Support Care. 2018;16:669-676. \u003c/li\u003e\n\u003cli\u003ePark Y, Suh SY, Kim SH, Park J, Yoon SJ, Kim YJ, et al. Development of a One-item Screening Question to Assess Spiritual Well-Being for Advanced Cancer Inpatients in Korea. J Pain Symptom Manage. 2021;62:910-917. \u003c/li\u003e\n\u003cli\u003eBai M, Lazenby M. A systematic review of associations between spiritual well-being and quality of life at the scale and factor levels in studies among patients with cancer. J Palliat Med. 2015;18:286-98. \u003c/li\u003e\n\u003cli\u003eChen Y, Okereke OI, Kim ES, Tiemeier H, Kubzansky LD, VanderWeele TJ. Gratitude and Mortality Among Older US Female Nurses. JAMA Psychiatry. 2024;81:1030-1038. \u003c/li\u003e\n\u003cli\u003eS\u0026ouml;derman A, \u0026Ouml;stlund U, Werkander Harst\u0026auml;de C, Blomberg K. Dignity-conserving care for persons with palliative care needs - identifying outcomes studied in research: An integrative review. Palliat Support Care. 2020;18:722-740. \u003c/li\u003e\n\u003cli\u003eAlthaus B, Borasio GD, Bernard M. Gratitude at the End of Life: A Promising Lead for Palliative Care. J Palliat Med. 2018;21:1566-1572. \u003c/li\u003e\n\u003cli\u003eKaymak ZA, \u0026Ouml;Zdamar \u0026Uuml;Nal G, \u0026Ouml;Zkan EE. The association of death anxiety, loneliness, and hopelessness with clinical features and quality of life in palliative radiotherapy patients. Turkish Journal of Oncology/T\u0026uuml;rk Onkoloji Dergisi. 2022;37:337\u0026ndash;345.\u003c/li\u003e\n\u003cli\u003eErdoğan TK, Ko\u0026ccedil; Z. Loneliness, Death Perception, and Spiritual Well-Being in Adult Oncology Patients. Cancer Nursing. 2021;44:E503-E512.\u003c/li\u003e\n\u003cli\u003eAsgeirsdottir GH, Sigurdardottir V, Gunnarsdottir S, Sigurbj\u0026ouml;rnsson E, Traustadottir R, Kelly E, Young T, Vivat B. Spiritual well-being and quality of life among Icelanders receiving palliative care: data from Icelandic pilot-testing of a provisional measure of spiritual well-being from the European Organisation for Research and Treatment of Cancer. Eur J Cancer Care (Engl). 2017;26(2). \u003c/li\u003e\n\u003cli\u003eBolekov\u0026aacute; V, Chlebcov\u0026aacute; V. Predictors of forgiveness in cancer patients after treatment. Health Psychol Rep. 2024;12:219-226. \u003c/li\u003e\n\u003cli\u003eGupta D, Lis CG, Grutsch JF. The relationship between cancer-related fatigue and patient satisfaction with quality of life in cancer. J Pain Symptom Manage. 2007;34:40-7. \u003c/li\u003e\n\u003cli\u003eVisser MR, Smets EM. Fatigue, depression and quality of life in cancer patients: how are they related? Support Care Cancer. 1998;6:101-8. \u003c/li\u003e\n\u003cli\u003eStone P, Hardy J, Broadley K, Tookman AJ, Kurowska A, A\u0026apos;Hern R. Fatigue in advanced cancer: a prospective controlled cross-sectional study. Br J Cancer. 1999;79:1479-86. \u003c/li\u003e\n\u003cli\u003eGhoshal A, Salins N, Deodhar J, Damani A, Muckaden MA. Fatigue and Quality of Life Outcomes of Palliative Care Consultation: A Prospective, Observational Study in a Tertiary Cancer Center. Indian J Palliat Care. 2016;22:416-426. \u003c/li\u003e\n\u003cli\u003eIwase S, Kawaguchi T, Tokoro A, Yamada K, Kanai Y, Matsuda Y, Kashiwaya Y, Okuma K, Inada S, Ariyoshi K, Miyaji T, Azuma K, Ishiki H, Unezaki S, Yamaguchi T. Assessment of Cancer-Related Fatigue, Pain, and Quality of Life in Cancer Patients at Palliative Care Team Referral: A Multicenter Observational Study (JORTC PAL-09). PLoS One. 2015;10:e0134022. \u003c/li\u003e\n\u003cli\u003eBower JE, Ganz PA, Desmond KA, Rowland JH, Meyerowitz BE, Belin TR. Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin Oncol. 2000;18:743-53. \u003c/li\u003e\n\u003cli\u003eRumble ME, Keefe FJ, Edinger JD, Porter LS, Garst JL. A pilot study investigating the utility of the cognitive-behavioral model of insomnia in early-stage lung cancer patients. J Pain Symptom Manage. 2005;30:160-9. \u003c/li\u003e\n\u003cli\u003eGijsberts MHE, Liefbroer AI, Otten R, Olsman E. Spiritual Care in Palliative Care: A Systematic Review of the Recent European Literature. Med Sci (Basel). 20197:25. \u003c/li\u003e\n\u003cli\u003eSmith-Stoner M. End-of-life preferences for atheists. J Palliat Med. 2007;10:923-8. \u003c/li\u003e\n\u003cli\u003eChoudry M, Latif A, Warburton KG. An overview of the spiritual importances of end-of-life care among the five major faiths of the United Kingdom. Clin Med (Lond). 2018;18:23-31. \u003c/li\u003e\n\u003cli\u003eTarakeshwar N, Vanderwerker LC, Paulk E, Pearce MJ, Kasl SV, Prigerson HG. Religious coping is associated with the quality of life of patients with advanced cancer. J Palliat Med. 2006;9:646-57. \u003c/li\u003e\n\u003cli\u003eYamagishi A, Morita T, Miyashita M, Igarashi A, Akiyama M, Akizuki N, Shirahige Y, Eguchi K. Pain intensity, quality of life, quality of palliative care, and satisfaction in outpatients with metastatic or recurrent cancer: a Japanese, nationwide, region-based, multicenter survey. J Pain Symptom Manage. 2012;43:503-14. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6555812/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6555812/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe main goal of palliative care (PC) is to achieve the best possible quality of life for patients and families. Physical, emotional, social, and spiritual dimensions are intertwined and can contribute to the quality of life (QoL). The relief of physical symptoms, such as pain, with pharmacological approaches is very important. The non-pharmacological aspects are also essential, as part of the holistic care. We aimed to investigate the QoL, loneliness, forgiveness, gratitude and spiritual well-being in patients under PC, and to examine the correlation between QoL and these non-pharmacological aspects.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted between April 2019 and May 2022 with a convenience sample of PC patients, hospitalized and outpatients in Porto, Portugal. Besides demographic and disease characteristics, the EORTC Quality of Life Questionnaire Core 15 for Palliative Care (QLQ-C15-PAL), Heartland Forgiveness Scale (HFS), Gratitude Questionnaire 6 (GQ-6), revised UCLA Loneliness Scale, and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp-12) were collected. The Spearman correlation coefficient assessed the correlation between quantitative variables. Univariate analysis and multiple regression analysis were performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 75 patients in PC, from 2 inpatient and 2 outpatient settings, were included. The median age was 73 years (range: 45\u0026ndash;91 years); 57% were male; 58.7% were married, and 92% were Catholic. The majority (89%) had cancer. The multiple regression analysis revealed that regarding the prediction of overall QoL, meaning (p\u0026thinsp;=\u0026thinsp;0.016), and emotional functioning (p\u0026thinsp;=\u0026thinsp;0.001) were significant predictors of overall QoL. For the prediction of pain, peace (p\u0026thinsp;=\u0026thinsp;0.013), fatigue (p\u0026thinsp;=\u0026thinsp;0.023) and insomnia (p\u0026thinsp;=\u0026thinsp;0.009) were predictors of pain. With regards to the prediction of emotional functioning, peace (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), faith (p\u0026thinsp;=\u0026thinsp;0.002), self-forgiveness (p\u0026thinsp;=\u0026thinsp;0.029), forgiveness of situations (p\u0026thinsp;=\u0026thinsp;0.032), and fatigue (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significant predictors of emotional functioning.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePC patients may consider as relevant for QoL some factors that are not included in the majority of QoL questionnaires. The most commonly used QoL instruments do not include existential questions, but these factors may be important domains in QoL at end of life, particularly issues of meaning and peace.\u003c/p\u003e","manuscriptTitle":"Forgiveness, gratitude, loneliness, spiritual well-being and quality of life in palliative care patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-30 09:30:39","doi":"10.21203/rs.3.rs-6555812/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-22T13:21:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T22:50:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-11T15:13:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7566519373215138378951047072146514070","date":"2025-06-09T11:26:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-09T09:54:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70725212725751385867630841299219594308","date":"2025-06-03T13:06:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231922069817862984274948561784192554812","date":"2025-05-31T19:11:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-28T09:01:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-06T08:56:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-06T08:50:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-02T05:04:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-04-29T11:06:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"84a2d5e4-36f1-4de6-861a-9e1bc318ee94","owner":[],"postedDate":"May 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T10:17:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-30 09:30:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6555812","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6555812","identity":"rs-6555812","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}