Portal de Periódicos da CAPES

Suffering and Spirituality: Analysis of Living Experiences

2011; Elsevier BV; Volume: 42; Issue: 3 Linguagem: Inglês

10.1016/j.jpainsymman.2011.04.003

1873-6513

Lodovico Balducci,

Grief, Bereavement, and Mental Health

"Considerate la vostra semenzaFatti non foste a viver come brutiMa per seguir virtute e canoscenza"[Be aware of the seed you are coming from!Your prime inclination is to understand your mission and to act accordingly, not to behave like aimless zombies.] —Dante Alighieri, The Divine Comedy1Alighieri D. Inferno.Google Scholar In Dante's Inferno, Ulysses exhorted his reluctant crew to continue their journey of discovery by reminding them of their human duty and aspiration to pursue more knowledge, and to overcome their fear of the unknown.1Alighieri D. Inferno.Google Scholar With the recitation of these verses, Primo Levi assuaged the pain of a friend dying of exhaustion, starvation, and abuse at Dachau.2Levi P. If this is a man. The Orion Press, New York1959Google Scholar Levi, an Italian Jewish engineer, also a Dachau prisoner, was himself exhausted, malnourished, and under ongoing threat of abuse and violent death at the whims of Nazi guards. At the same time, concealed in a Florence psychiatric hospital, as the German troops roamed the city, in permanent peril of being discovered and transported to a concentration camp or slaughtered on sight, Attilio Momigliano, a Jewish professor of Italian literature, wrote what is considered one of the most memorable comments to Dante's poem.3Momigliano A. Dante, Manzoni, Verga. G. D'Anna, Florence, Italy1965Google Scholar The daily contact with poetry relieved him of his existential anguish, as well as of the pain of witnessing the daily deterioration of his spouse's mind under stress. It is remarkable that the sufferings of Momigliano, an avowed atheist up to the time of his death in 1951, were soothed by a poem dealing with life after death and God's kingdom. "Remember that your humanity is stronger than the virus destroying your and your children's lives!" These simple words turned around the life of Gilda, a woman from Uganda, abandoned by her husband who was responsible for her and her youngest child's HIV infection. Shunned by her tribe and her own family, she had retired with her three children to a hut on the village outskirts, like a biblical leper. There she waited, with her family, to die of AIDS, starvation, or the bite of a scorpion or of a poisonous snake. The exhortation of a social worker visiting her from a nearby Christian health facility transformed this illiterate woman into an eloquent advocate for AIDS patients. Thanks to the missionary care, her youngest son is free from HIV 10 years later and is finishing high school. Music is the soothing background of Father Aldo Trento's medical compound that houses incurable patients rejected by their families, by the local hospitals, and even by the local prisons. The facility represents an oasis of neatness and hope in the most dilapidated slum of Asuncion, Paraguay. "Music reminds these individuals, rejected throughout their lives, that nobody can rob them of their humanity as long as they can appreciate and identify with beauty," stated Father Trento. "Music is the universal language that speaks to everybody and for everybody. It is the spirit that gives to each of us the awareness of being part of a universal family." "The last year of my life has been by far the most meaningful. The closeness with death allowed me to reap treasures of love and beauty whose seeds I had laid throughout my life. Though short, my life has been full and meaningful."4Balducci L. And a time to die.J Med Person. 2008; 6: 99-103Google Scholar It took a couple of minutes for the 17-year-old to pronounce this statement. Every three or four words, he had to stop and gasp for air. To an observer, this declaration looked like a match between the patient and his cancer, which tried to prevent the emergence of his persona; it felt like the cancer knew that if the young man had been allowed to finish his sentence, he, rather than the disease, would have won the final battle. Death would have been defeated. Two months earlier, this young man, who remained agnostic throughout his life, was all but desperate. His sarcoma had recurred, there was no treatment, and he would die in a matter of a few months. Under the guidance of the hospital chaplain who paid daily visits to him, he had been able to prepare a distillate of his own life, like one of those extracts of thousands of Bulgarian roses that fills a small bottle and where the perfume of the flowers survives centuries after the petals have withered. He became aware that he had been endowed with a unique talent, to be able to play the violin, and that his music had left an inerasable track on this earth. He also realized that the isolation of his childhood, the result of rejection by his peers, for which he had suffered deeply, was the price he had to pay to develop his talent. His talent also had gained him the affection of a young woman, who went with him throughout his last months of life, during which they both learned to enjoy their sexuality as a mutual gift, even in the absence of sexual intercourse, made impossible by his deteriorating health. The proximity of death allowed him to come to terms with the sadness and humiliation that had haunted his full existence. These cases, and many others I had the privilege to witness and to hear of during my 33 years as an oncologist, contain a unifying theme. They reveal that each human being is endowed with a source of personal strength that allows her or him to overcome—even more than survive—the ultimate challenges of life, including suffering and death. Irrespective of the underlying physiologic mechanism, or lack thereof, this strength cannot be measured the same way we assess a hematocrit or a blood sugar or a blood pressure, and cannot be quantified the way one pretends to quantify pain or quality of life according to numerical scales. Whereas it may be temporarily turned off by interventions that suppress human cognition (brain trauma, anesthesia, and medications), this strength cannot be modulated by other types of medical interventions, the way one modulates glycemia with insulin, hemoglobin levels with erythropoietin, and bacterial growth with antibiotics. Everybody may identify the source of that strength in what is still considered a unique human characteristic, self-awareness, commonly referred to as consciousness. The personal strength that springs from consciousness is commonly known as spirit. Whether consciousness and spirit belong to a different dimension than bodily functions and dysfunctions is not the subject of the present discussion. Suffice it to say that the spirit and its domain, spirituality, are real and cannot be studied with the same instruments used to assess physical and emotional parameters. At the same time, our histories reveal that spirituality is a very valuable resource with which to face disease and, indeed, it is the only resource that is always available, even in extreme conditions such as imprisonment in a concentration camp or lonely death in the streets of a metropolitan slum. All health care providers, and especially those involved in palliative care, cannot ignore spirituality without jeopardizing their own effectiveness. In exploring the influence of spirituality on palliative care, this article will examine some manifestations of spirituality that, in addition to religion, include art and humanities, philosophy, and, more in general, that form of love referred to by the Greek word agape. Agape is the enshrining of each person including oneself, stemming from the recognition that each person is sacred, that is, reserved to a unique function or mission (from the Latin sacer, reserved), that each person is endowed with the ability to bring a unique and indispensable contribution to the universal human family. (Note that agape differs from three other Greek words that are translated into English as love: eros, sexual passion; filia, love of friends; and eusebeia, love of children and parents). As John Donne said, "Ask not for whom the bell tolls, it tolls for thee,"5Hemingway E. For whom the bell tolls. Charles Scribner's Sons, New York1940Google Scholar meaning that each human death is a death of the self. It was agape that allowed each and every character of the previous cases to survive either life or death. Palliation is derived from the Latin word pallium, which indicates, among other things, the vest of the ancient mendicants that protected them from injury of extreme weather and concealed their nakedness, and the shroud that covered the coffin during the Catholic funeral mass. Palliation may be intended then as "protection from the adverse effects of the disease and its treatment or as concealment of terminal symptoms." Fortunately, the first definition has prevailed in common use today. By embracing a wide gamut of symptoms and complications aside from terminal discomfort, this definition states that palliative care is a set of interventions from diagnosis onward involving the relief of all forms of suffering. This definition supports a robust discussion of the role of spirituality in palliative care. Central to the discussion is the distinction between pain and discomfort on one side and suffering on the other.6Sulmasy D.P. The rebirth of the clinic. Georgetown University Press, Washington, DC2006Google Scholar Suffering results from the awareness of one's discomfort as well as the violation of one's intimacy. Though suffering and discomfort go together most of the time, there are situations in which suffering may be divorced from any physical symptoms. One may think of the grief elicited by death, abandonment, or personal failure or the inability of identifying one's role in this life. Likewise, discomfort may occur without suffering. A mountain climber who has just completed the difficult ascension of a summit may experience pain and fatigue accompanied by the joy of his achievements. Common forms of suffering in the course of illness include loss of independence, loss of ability to pursue one's previous goals, and, in general, the inability to understand the meaning of illness. This last form of suffering was very well known in the ancient world and was crystallized in some imperishable works of art. These starred characters such as the biblical Job, whose main cause of suffering involved the loss of his previous status, the incomprehension of his friends, but most of all, the inability to find a reason for his disease;7The book of Job. King James Bible.Google Scholar Philoctetes, compelled to escape the human consortium because of a disgusting gangrene;8Sophocles. Philoctetes. The Internet Classic Archives. Available from http://classics.mit.edu/Sophocles/philoct.html. Accessed June 21, 2011.Google Scholar or Sophocles's Oedipus, whose main cause of suffering was his combined incest and patricide rather than his self-inflicted blindness.9Sophocles. Oedipus the King. The Internet Classic Archives. Available from http://classics.mit.edu/Sophocles/oedipus.html. Accessed June 21, 2011.Google Scholar Unfortunately, modern medicine, founded on the Enlightment's delusion to try to solve all human problems through reason, has all but ignored the dimension of suffering in medical care. Were it not tragic, I would find it ironic that the promoters of "evidence-based medicine" consistently ignore the evidence that they cannot explain.10Malick S.M. Hadley J. Davis J. Khan K.S. Is evidence-based medicine teaching and learning directed at improving practice?.J R Soc Med. 2010; 103: 231-238Crossref PubMed Scopus (19) Google Scholar In medicine, suffering and discomfort are often interwoven. It goes without saying that the relief of pain, fatigue, or nausea also may relieve the suffering that may result from losing human contact because of those symptoms. Clearly, cure may lead to the relief of both symptoms and suffering caused by the disease. Likewise, suffering may influence all symptoms. Puchalski reported the case of a patient with pancreatic cancer, whose untreatable pain waned once he was reassured that he was still welcome in his Episcopal church despite being gay. Decades old indiscretions, such as abortion or adultery, may haunt the final days of a terminally ill person and exacerbate physical and emotional symptoms.11Balducci L. Healing and curing. In: Puchalski C, Cobb M, Rumsbold B, eds., Spirituality in health care. New York: Oxford University Press, in press.Google Scholar Seemingly, suffering belongs to the spiritual dimension, the dimension where spiritual interventions are more likely to provide effective palliative care. Successful management of suffering, through which suffering becomes bearable, is commonly referred to as healing.12Abbot N.C. Healing as a therapy for human disease: a systematic review.J Altern Complement Med. 2000; 6: 159-169Crossref PubMed Scopus (60) Google Scholar Healing refers to the personal experience of the disease, unlike cure, which refers to the objective manifestations of the disease.11Balducci L. Healing and curing. In: Puchalski C, Cobb M, Rumsbold B, eds., Spirituality in health care. New York: Oxford University Press, in press.Google Scholar Whereas cure is possible only occasionally, healing is always achievable, and spirituality may play a central role in this endeavor. In the following section, I will illustrate a practical approach to the management of suffering with interventions inspired by spirituality, art, and humanities, and in the process, I will review the pertinent literature. The patient's suffering is modulated by the disease, by his/her perception of the disease and by the attitude of the patient's home caregiver, as well as by the medical team. To some extent, palliative care needs to involve all of these actors. When I witnessed the open recriminations of a daughter blaming her mother's ovarian cancer for her own lack of human relations, I realized I could not provide effective care to the patient without convincing both the patient and the daughter that ovarian cancer had nothing to do with the daughter's loneliness; instead, it might have been an opportunity for her to meet more people through supports groups and overcome her own emotional difficulties. When I witnessed the ongoing conflict of a nurse with a patient, who reminded her of her former abusive husband, I realized I could not provide palliative care to the patient until he was assigned to a different nurse. I also recommended to the nurse that she should seek counseling. Occasionally, I myself have had to refer a patient to a different provider because personal conflicts interfered with medical care. The provision of personalized care is further complicated by the fact that each person is multifaceted and ever changing so that the object of care is, to some extent, always a moving target. As Oliver Wendell Holmes discovered almost 200 years ago, in a dialogue between Thomas and John, there are at least six individual dialogues: the real Thomas and the real John, the persons that Thomas and John think they are, and the persons each one of them thinks that the other person is.13Holmes O.W. The autocrat of the breakfast table III. The Atlantic Monthly, Boston, MA1857Google Scholar With the addition of each person, the number of real interlocutors increases by the power of three. With such an abundance of personalities, the provider should be ready to face discontent and incomprehension when he/she ventures into the maze of human suffering. In the meantime, this very complexity may fill the provider with the sense of a mission that is always unfinished, whose scope goes well beyond the boundaries of a defined disease, and whose effects may encompass individuals that the provider does not know; it may extend beyond his/her comprehension and even his or her lifetime. The management of human suffering may be possible only when the provider is aware of his/her own spirituality, that is, of being endowed with a unique power that makes him/her an active participant in a unique mission of human rescue. Despite the diversity of the human environment, some basic rules, aimed to gain the confidence of patients, family, and friends, help to set the best atmosphere for a spiritual intervention. These include:•To acknowledge that it is a unique privilege to be trusted with a human life. I always thank the patients for their trust when I enter the room for the first visit, and I apologize for any conditions that may interfere with the success of the encounter (in my case, one of these conditions is my heavy Italian accent).•To acknowledge that one plans to take care of a person, not just to manage a disease. Whenever possible, I like to make some personal comments regarding the patient before discussing the disease. This may involve the patient's background, the profession, the beliefs, or even the clothes and jewelry. Professing admiration for the patient's taste in clothing means respect for the patient's self-perception.•To try to understand what the patient wishes as an outcome of his/her disease. This is another statement privileging the person over the disease. For some, the main desire is to attempt every available means to be kept alive; for others, it is to reach a preestablished landmark (e.g., I took care of the chief of a disbanded tribe of American Indians whose main goal was to finish writing the history of his tribe, which otherwise might have been forever lost with his death. When he learned that chemotherapy might impede his writing, he decided to forgo chemotherapy to achieve his main goal). Virtually everybody wishes to be reassured that he/she will not be abandoned when death draws near and will not be allowed to suffer. Whenever possible, I try to obtain both a value and a religious history.•Being truthful and compassionate. Truthfulness is the base of mutual confidence in any relationship. In a patient-provider relationship, truthfulness also manifests as respect for the patient's autonomy, for his/her supreme right to decide how to manage his/her life disrupted by the disease. When it relates to a human experience, truth is fluid rather than ironclad. Failure to recognize such fluidity in communication with the patient is far from being truthful. Indeed, it is the statement of a terrible lie under the appearance of truth. As Miguel De Unamuno stated in his second novel Amor y Pedagogia, when referring to the human experience, "the truth is the worst of all lies." For example, the median survival of patients with stage IV nonsmall cell lung cancer is nine months. To tell the patient "You have more or less nine months to live" may be correct from a statistical standpoint, but it is a lie from a human one. A more truthful statement would be "Approximately 50% of patients in your condition die within nine months, but 5% of them may still be alive at five years. Right now, I have no means to predict how long you personally will live. In part, it will depend on the treatment you take and on the evolution of the cancer. If you have any unfinished business, I would recommend that you take care of it now, while you are in a condition to do so. In the meantime, I encourage you to be cautiously hopeful, as we have some effective treatments to take care of you, new medications may be developed, and a miracle is always possible." Likewise, when it is time to enter a hospice program, I find it generally very helpful to emphasize that death is a unique human experience, one that the patient and his or her loved ones should treasure as all human experiences. I would say something like this: "I really doubt that you will be alive three months from now. It is an appropriate reaction to be fearful of death. I can assure you that you will not be in pain, thanks to hospice care. I also would like to encourage you and your family to treasure this moment. The proximity of death allows you to prepare a distillate of the most meaningful times of your life. If you have just one day to visit Rome, you may decide to cram as many monuments as you can into one day and then find yourself at the train station at the end of the day, exhausted and only with confused memories. Or you can go to the Gianicolo Hill, have a general view of the city, decide which monument you really care to see, and have a memorable visit. The proximity of death is your Gianicolo Hill, which allows you a global vision of your life and the selection of the experiences that were most meaningful. In other words, truth is really truth only when it is modulated by compassion, when it maintains hope when hope is reasonable, and when it holds that all human experiences, including suffering and death, represent human opportunities. If death is the ultimate enemy, we are all doomed to failure, because ultimately we all are going to die. Healing is achieved only when we are able to come to terms with our own death.•To acknowledge the role of the home caregiver. After addressing the patient, I always thank the other people in the room for taking the patient to the clinic, for supporting, and loving the patient. I also try to warn the caregivers of the problems ahead and remind them that help is available. I explain that their role is essential to the successful treatment of the patient, and I feel privileged and duty bound to assist the caregivers in their struggles. With this introduction, the setting for spiritual interventions, when appropriate, is laid down. Perhaps the most common form of intervention for me has been prayer, including prayer with the patients, with the family, and even with the hospital staff. On Mondays at noon, a room is reserved in our hospital for the staff to gather and pray for personal as well as patient-related issues. As already mentioned, I obtain a religious history from all patients aimed to find out whether the patient has religious beliefs and what importance those beliefs hold in the patient's life.11Balducci L. Healing and curing. In: Puchalski C, Cobb M, Rumsbold B, eds., Spirituality in health care. New York: Oxford University Press, in press.Google Scholar, 14Borneman T. Ferrell B. Puchalski C.M. Evaluation of the FICA tool for religious assessment.J Pain Symptom Manage. 2010; 40: 163-173Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar When religious beliefs are central to a person's life, I am not shy about suggesting prayer at times of critical decisions, such as change in treatment, hospice referral, or some particular crisis in the patient's own life. I always agree to pray with patients and family when requested to do so. Although I am a church-going Roman Catholic, I have prayed to all types of deities and even no deity. More than once, I have been asked by avowed agnostics to pray with them and for them. Prayer with the family, in the absence of the patient, occurs more often when the patient is hospitalized or when family members or significant others ask to see me, to express their concerns and their stress. The most common form of prayer I share with patient and family is conversational or meditative prayer.15Jantos M. Kiat H. Prayer as medicine: how much have we learned?.Med J Aust. 2007; 186: S51-S53PubMed Google Scholar, 16Roberts L. Ahmed I. Hall S. et al.Intercessory prayer for the alleviation of ill health.Cochrane Database Syst Rev. 2009; (CD000368)Google Scholar In it, people trust themselves to the deity they worship and come to terms with events they cannot understand, such as death and suffering. Irrespective of their specific beliefs, prayer allows these individuals to feel embraced by unconditional love, to the point that some of them may state, "No matter what, everything is grace," in reference to disease and death, as the country priest of Bernanos stated when he was drowning in hematemesis from stomach cancer.17Bernanos G. Journal d'un curé de campagne. Libraire Plon, Paris, France1974Google Scholar Especially at the beginning of the disease, intercessory prayer is also common.16Roberts L. Ahmed I. Hall S. et al.Intercessory prayer for the alleviation of ill health.Cochrane Database Syst Rev. 2009; (CD000368)Google Scholar The palliative value of intercessory prayer consists also of the feeling of trusting one's destiny to a loving deity, and the perceived outcome is a product of love. Well aware of the fact that the benefits of intercessory prayer as a form of alternative treatment is controversial,16Roberts L. Ahmed I. Hall S. et al.Intercessory prayer for the alleviation of ill health.Cochrane Database Syst Rev. 2009; (CD000368)Google Scholar, 18Koenig H.G. George L.K. Titus P. Religion, spirituality, and health in medically ill hospitalized older patients.J Am Geriatr Soc. 2004; 52: 554-562Crossref PubMed Scopus (306) Google Scholar I always try to emphasize the fact that we may ask for but we cannot expect a miracle. In the meantime, I do not discourage intercessory prayer, as its benefits in terms of symptom management are well established.17Bernanos G. Journal d'un curé de campagne. Libraire Plon, Paris, France1974Google Scholar, 19Wachholtz A.B. Pearce M.J. Koenig H. Exploring the relationship between spirituality, coping, and pain.J Behav Med. 2007; 30: 311-318Crossref PubMed Scopus (113) Google Scholar, 20Rippentrop E.A. Altmaier E.M. Chen J.J. et al.The relationship between religion/spirituality and physical health, mental health, and pain in a chronic pain population.Pain. 2005; 116: 311-321Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar, 21Hollywell C. Walker J. Private prayer as a suitable intervention for hospitalised patients: a critical review of the literature.J Clin Nurs. 2009; 18: 637-651PubMed Google Scholar In intercessory prayer, patients feel they have explored all available healing methods and have become more prepared to accept the disease's final outcome. These benefits of prayer in terms of symptom management and relief of the anguish related to outcome have been established in a number of studies.18Koenig H.G. George L.K. Titus P. Religion, spirituality, and health in medically ill hospitalized older patients.J Am Geriatr Soc. 2004; 52: 554-562Crossref PubMed Scopus (306) Google Scholar, 19Wachholtz A.B. Pearce M.J. Koenig H. Exploring the relationship between spirituality, coping, and pain.J Behav Med. 2007; 30: 311-318Crossref PubMed Scopus (113) Google Scholar, 20Rippentrop E.A. Altmaier E.M. Chen J.J. et al.The relationship between religion/spirituality and physical health, mental health, and pain in a chronic pain population.Pain. 2005; 116: 311-321Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar, 21Hollywell C. Walker J. Private prayer as a suitable intervention for hospitalised patients: a critical review of the literature.J Clin Nurs. 2009; 18: 637-651PubMed Google Scholar, 22Arias A.J. Steinberg K. Banga A. et al.Systematic review of the efficacy of meditation techniques as treatments for medical illness.J Altern Complement Med. 2006; 12: 817-832Crossref PubMed Scopus (150) Google Scholar In addition to prayer, I might mention poetry, philosophy, and art in the course of an encounter. The thousands of "Pietás" that fill Western religious imagery represent an unsurpassed opportunity to remind caregivers that their function is sacred. I find this approach particularly rewarding when the patient is literate and has previous knowledge of these issues. I distinctly remember discussing the philosophy of Epictetus with a Greek physician facing treatment for lymphoma. In addition, I do encourage patients to participate in art therapy, which is provided in different forms at our institution, including drawing, painting, listening to and playing music, and creative writing. Like prayer, sensorial arts and poetry are means to a more complete expression of oneself.23Lipson E.J. Art in oncology: how patients add life to their days.J Clin Oncol. 2011; 29: 1392-1393Crossref PubMed Scopus (5) Google Scholar Few would argue that paintings like "The Scream" by Edvard Munch or "Guernica" by Pablo Picasso reflect universal feelings toward the 20th century, better than all history books. The drama of the modern caregiver was identified by Ligia Dominguez Barbagallo in the painting of Aeneas fleeing the burning Troy with his older father on his back and his little son held by the hand.24Dominguez L.J. Medicine and the arts: l'incendio di borgo.Acad Med. 2009; 84: 1260-1261Crossref PubMed Google Scholar Clary reported how his own and other authors' poetry informed his life and his profession at different times.25Clary P.L. Poetry and healing at the end of life.J Pain Symptom Manage. 2010; 40: 796-800Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In addition to healing his relationship with his father, it helped him to identify the unspoken words of his patients and grant him a better understanding of their emotions and fears. Last but not least, poetry worked as a path of wordless communication, both with his patients and their caregivers. With these examples, it is easy to speculate about the benefits of art and literature in the management of suffering: they allow a vision of oneself deeper and more comprehensive than any spoken words, and in doing so, they may both grant a sense of self-accomplishment and lead to a more comprehensive appreciation of the effects as well as the opportunities implicit in one's disease. A number of studies, including randomized controlled trials (RCTs),26Stacey G. Stickely T. The meaning of art to people that use mental health services.Perspect Public Health. 2010; 130: 70-77Crossref PubMed Scopus (41) Google Scholar, 27Visser A. Op't Hoog M. Education of creative art therapy to cancer patients: evaluation of effects.J Cancer Educ. 2008; 23: 80-84Crossref PubMed Scopus (31) Google Scholar, 28Oster I. Svensk A.C. Magnusson E. et al.Art therapy improves coping resources: a randomized controlled study among women with breast cancer.Palliat Support Care. 2006; 4: 57-64Crossref PubMed Google Scholar, 29Monti D.A. Peterson C. Kunkel E.J. et al.A randomized, controlled trial of mindfulness-based art therapy (MBAT) for women with cancer.Psychooncology. 2006; 15: 363-373Crossref PubMed Scopus (201) Google Scholar, 30Svensk A.C. Oster I. Thyme K.E. et al.Art therapy improves experiences quality of life among women undergoing treatment for breast cancer: a randomized controlled study.Eur J Cancer Care (Engl). 2009; 18: 69-77Crossref PubMed Scopus (97) Google Scholar, 31Geue K. Goetze H. Buttstaedt M. et al.An overview of art therapy interventions for cancer patients and the results of research.Complement Ther Med. 2010; 18: 160-170Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 32Walsh S.M. Weiss S. An intervention with family caregivers and patients with cancer.Oncol Nurs Forum. 2003; 30: e115-e120Crossref PubMed Google Scholar have demonstrated the ability of some forms of art therapy to relieve the symptoms of cancer in patients undergoing treatment and their caregivers,32Walsh S.M. Weiss S. An intervention with family caregivers and patients with cancer.Oncol Nurs Forum. 2003; 30: e115-e120Crossref PubMed Google Scholar as well as some symptoms in psychiatric patients. Interventions included asking subjects to draw or paint, as well as exposing them to poetry, music, and works of visual art. It is impossible at this point, to state whether all interventions have the same efficacy, or to try to identify the intervention more appropriate for each individual patient. Although no adverse effects of art therapy were reported, it is reasonable to assume that exposure to situations reminding the patient of his or her own condition may be associated with unwanted reactions such as anger, depression, or desperation. Of the studies cited, two deserve special emphasis. Clary25Clary P.L. Poetry and healing at the end of life.J Pain Symptom Manage. 2010; 40: 796-800Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar demonstrated how poetry helped the provider in addition to the patient, and Walsh and Weiss showed how an "art infusion intervention" assuaged the depression, grief, and anxiety of family caregivers.32Walsh S.M. Weiss S. An intervention with family caregivers and patients with cancer.Oncol Nurs Forum. 2003; 30: e115-e120Crossref PubMed Google Scholar These reports emphasize the interchange of suffering in the triad of patient, caregiver, and provider. Although focused on the patients, the symptom management cannot be divorced from the other members of the triad. This brief review reports the benefit of "spiritual interventions" in the form of religious practice, sensory arts, and poetry in the management of symptoms of patients affected by severe disease. In Western culture, these interventions are seen mainly as a complement to accepted medical therapy. In the most impoverished parts of the world, however, they may represent the only form of palliative care. In the hospices of Mother Theresa in Calcutta, sometimes human touch was the only available form of symptom management. Through the Middle Eastern Cancer Consortium, I was made aware of how spousal and family closeness might represent the only form of palliation for dying cancer patients in war-torn Palestine.33Silbermann M. Dweib Khleif A. Balducci L. Healing by cancer.J Clin Oncol. 2010; 28: 1436-1437Crossref PubMed Scopus (14) Google Scholar