Quality of life and religious-spiritual coping in palliative cancer care patients

ABSTRACT Objectives: to compare the quality of life and religious-spiritual coping of palliative cancer care patients with a group of healthy participants; assess whether the perceived quality of life is associated with the religious-spiritual coping strategies; identify the clinical and sociodemographic variables related to quality of life and religious-spiritual coping. Method: cross-sectional study involving 96 palliative outpatient care patient at a public hospital in the interior of the state of São Paulo and 96 healthy volunteers, using a sociodemographic questionnaire, the McGill Quality of Life Questionnaire and the Brief Religious-Spiritual Coping scale. Results: 192 participants were interviewed who presented good quality of life and high use of Religious-Spiritual Coping. Greater use of negative Religious-Spiritual Coping was found in Group A, as well as lesser physical and psychological wellbeing and quality of life. An association was observed between quality of life scores and Religious-Spiritual Coping (p<0.01) in both groups. Male sex, Catholic religion and the Brief Religious-Spiritual Coping score independently influenced the quality of life scores (p<0.01). Conclusion: both groups presented high quality of life and Religious-Spiritual Coping scores. Male participants who were active Catholics with higher Religious-Spiritual Coping scores presented a better perceived quality of life, suggesting that this coping strategy can be stimulated in palliative care patients.


Introduction
In Brazil, palliative care is an emerging end-oflife care modality that has gained emphasis in recent years due to the increased life expectancy of the population, the change in the epidemiological profile of chronic-degenerative diseases and the need to provide a dignified death to patients whose illness no longer responds to the curative treatment (1) . This fact has compelled the health professionals to rethink the way they take care of patients beyond possibilities of cure, in view of countless difficulties at home, contributing to the institutionalization of death.
Care in the palliative care context differs from curative care because it reaffirms life and faces death as a reality to be experienced together with the family members. Its purpose is to improve the patients and relatives' Quality of Life (QoL) in view of an advanced disease, through the prevention and relief of suffering, pain treatment and valuation of the culture, spirituality, customs and values, besides the desires and beliefs that permeate death (2)(3) .
Both cancer and its treatment can negatively influence the perceived QoL. Therefore, its assessment is The discussions about QoL among health professionals and patients are frequent but, often, the control of physical symptoms is emphasized, while little attention is paid to the psychological, social and spiritual aspects (4) .
Religion and spirituality are constructs adopted to cope with the stress the cancer causes as, for many patients, they can contribute to the relief of suffering and greater hope concerning the QoL (5) .
Although distinct, both are intertwined, as spirituality is considered to be the essence of a person, as if it were a search for meaning and purpose in life, while religiosity is the expression of spirituality itself, through rituals, dogmas and doctrines (6)(7) .
In that context, religious coping refers to the use of faith, religion or spirituality in coping with stressful situations or crisis moments, which happen in the course of life. Therefore, its study should be broad and based on a functional view of religion and the role it plays in coping (8) .
Although the religious coping concept has a positive bias, it can be both positive and negative, and the same is true for its strategies. The positive aspect combines measures that offer beneficial effects to individuals, while the negative aspect is related to the measures that entail harmful consequences, such as questioning their existence, delegating the solution of problems to God, defining stress as a punishment from God, among others (8)(9) .
The relations between religiosity and palliative care have been increasingly investigated and evidence appoints a relationship that is positive in most cases.
Studies demonstrate that religiosity and spirituality improve the Religious-Spiritual Coping (RSC) and QoL, besides contributing to reduce the remission time of depression (10)(11)(12)(13) . Nevertheless, the relation between QoL and RSC in palliative care has been hardly discussed in the literature, despite the importance of this theme.
The research hypothesis is that the perceived QoL and RSC are influenced by religion/spirituality, as well as by the patients' sociodemographic and clinical variables.
In view of the lack of studies, this research was proposed to answer the following questions.   To collect the data, four instruments were used.
The first consisted of sociodemographic data, collected during the application of the questionnaire, and the second was the Portuguese version of the McGill Quality of Life Questionnaire (MQOL ) (14) .
It should be clarified that few specific questionnaires exist to assess palliative care patients' quality of life. The CRE scale is a North-American tool that contains 92 items, originally called RCOPE (15) , whose short version has been validated for the Brazilian culture (16) . The CRE- very high (16) .
In this research, direct kinship was considered as the relationship in which people are blood-related, while indirect kinship is considered as marriagerelated. Each participant answered the questionnaire in a private room, individually and, if the questionnaire could not be answered, an appointment was made at each relative's convenience. In addition, it was informed that the refusal to participate in the study would imply no losses of any kind for the continuity of care.
As little knowledge exists on the QoL and RSC indicators in this population, for a 20% effect size and 95% reliability, the minimum sample size was estimated as 96 patients for each group.
Initially, all variables were analyzed descriptively.
The proportions between the groups were compared using Pearson's chi-squared or the chi-squared trend test, and quantitative data were compared by means

Results
Based on the inclusion criteria, 192 subjects were selected for the study sample, being 96 in each group. In Table 1 In Table 2 In Table 3, the multivariate analyses applied are displayed, using the generalized linear model for quality of life and CRE-Breve. The variables male sex, Catholic religion and total CRE-Breve presented a significant association to explain the variation in the QoL scores.
What the RSC is concerned, a positive association was identified between the participants in Group A (p=0.005) and the total quality of life (p=0.000).
In Table 4, the factors are presented that interfered in the perceived quality of life in the past two days. As observed, the disease symptoms and fear of death stand out among the factors that most strongly influenced the perception of the construct.      *The results add up to more than 100% because more than one category was identified in the answers to this question.

Discussion
The limits of the study results refer to its crosssectional design, as holding interviews at a single moment may not be enough to picture the magnitude of changes that can occur in the palliative care phase.
On the other hand, quality of life assessment has been used as an indicator to guide care practices and support the definition of public health policy strategies.
Nevertheless, there is a lack of studies that assess In addition, it should be kept in mind that this inter-relation exists within a certain cultural context, within the context of a value system, which individuals live in, and in relation to their objectives, concerns, expectations and standards. Therefore, any quality of life measure needs to reach exactly this set of elements within an index or score that reflects the perception of different individuals in different circumstances of life (18) .
In fact, in a prospective study, in which the quality of life of 105 cancer patients attended at a tertiary hospital outpatient clinic was assessed, impaired global wellbeing and a low general quality of life were revealed (19) .  (20) . In addition, it is known that the determining factors of cancer patients' quality of life often are not well understood (21) .
In this research, a statistically significant difference was observed in relation to the domains physical wellbeing, psychological wellbeing and support when the groups were compared. This finding is supported by a study involving lung cancer patients, in which the quality of life was lower than in the general population, being affected by the severity of the disease and the number of symptoms. In that study, fatigue and respiratory problems contributed to reduce the psychological dimension of quality of life (22) .
In a study involving 158 advanced cancer patients, it was shown that high levels of hopelessness, impaired body image and emotional suffering were the main factors associated with psychological stress (23) .
To reach the second specific objective in this study, In another study, involving 350 terminal patients, mostly married women with lung cancer, it was shown that the patients use a range of coping strategies. The use of emotional support and acceptance strategies was correlated with a better quality of life in that research (24) .
The limits of the research results initially refer to the application of the questionnaire at a single moment, which may not be enough to picture the range of interferences and difficulties the patient experiences in that period. In addition, the lack of studies on quality of life and RSC of palliative cancer care patients made it difficult to compare the results, but also showed that other studies are needed in the area. Hence, future studies with longitudinal designs are proposed to guide nursing actions for these clients, in view of associations between sex, religion and the use of RSC.

Conclusion
These study results indicate that the participants' quality of life was relatively good, and that the psychological domain was the most affected in Group A. When associated with sociodemographic and clinical variables, male participants who were actively religious and obtained higher RSC scores revealed a better perception of this construct.
The use of RSC was high and the use of positive coping prevailed. Nevertheless, when the groups were compared, the palliative care patients made greater use of the negative factor. In this research, healthy participants with better quality of life scores showed better religious-spiritual coping.