Impact of Spiritual Support Interventions on the Quality of Life of Patients Who Receive Palliative Care: A Systematic Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Detailed review of ‘Impact of spiritual support interventions on the quality of life of patients who receive palliative care: A systematic review.

 

This manuscript presents a summary of the authors’ systematic review of published research articles that explicitly examined the quality-of-life impact of the use of spiritual support interventions with patients in palliative care. Specifically, this article summarizes and synthesizes published findings of twenty-four separate studies that involved patients and/or family care givers in thirteen countries living with a variety of life-shortening or potentially life-shortening illnesses. The authors state that this review article is guided by the PRISMA statement and note their protocol was registered in the Prospective International Register of Systematic Reviews.

The methodology used in this study appears to be sound as the authors identify six previously established inclusion criteria and three previously established exclusion criteria for this review article. The authors began their study with an extensive search for potentially significant articles published between 2012 and 2023 held within the PubMed, SCOPUS, and Web of Science databases which identified a total of 1305 articles (search criteria is provided in Table 1). The authors further identify that two independent reviewers were involved in the screening process that was assisted by Rayyan, a large-language processing model. This process yielded 24 papers as meeting the criteria for inclusion in this study (decision tree illustrated in Figure 1). Figure 2 reports the result of their test for Risk of Bias in the 24 selected articles. A summary of their qualitative analysis of these articles is included (Table 2) as well as the identification of four approaches or themes present in the literature. Thus, suggesting that the process of extracting meaning from the data coheres with best practice in qualitative research.

Taken as a whole, it is this reviewer’s assessment that, when assessed by the NIH quality assessment tool for systematic reviews and metanalyses, this systematic review merits a good quality rating (Study Quality Assessment Tools | NHLBI, NIH).

While this paper gives evidence of methodological soundness, at least some of the following minor issues merit attention or additional comment.

First, it is unclear to this reason why Figure 2 precedes Figure 1 in the type-set copy that was forwarded for review.

Next, although the scope of the initial search was extensive there is the possibility, as the authors acknowledge, that some potential sources may have been overlooked in the initial search.

Third, as noted by the authors, researcher inexperience may have affected the selection process. Not stated by the authors is the fact that inexperience may have either included sources that another researcher may have excluded or vice-vera.

Lastly, and of potentially greater significance, is the fact that one of the inclusion criteria was that the article needed to be in either English or Spanish. Admittedly, this was likely a pragmatic decision based on the languages the researchers are most fluent in. Nevertheless, it is an unknown as to how articles published in other languages would contribute to the findings of this study.

Author Response

Comment 1: First, it is unclear to this reason why Figure 2 precedes Figure 1 in the type-set copy that was forwarded for review.

Response 1: Apologies, there must have been an error. Figure 1 corresponds to the PRISMA diagram, while Figure 2 pertains to the risk of bias assessment using RoB2. Their appearance in the main text is consecutive. We have modified it to ensure consistency.

 

Comment 2: Next, although the scope of the initial search was extensive there is the possibility, as the authors acknowledge, that some potential sources may have been overlooked in the initial search. 

Response 2: We have expanded the search with a new database and updated the search in the previous ones, obtaining a total of 217 new references. However, none of these were selected for inclusion in our review as they did not meet the inclusion criteria or did not provide relevant and new information.

 

Comment 3: Third, as noted by the authors, researcher inexperience may have affected the selection process. Not stated by the authors is the fact that inexperience may have either included sources that another researcher may have excluded or vice-vera. 

Response 3: The lead author, Virginia Prieto, is inexperienced in conducting this type of article; however, Pedro Arevalo and Pablo Jesús López, both of whom have extensive experience in this type of publication, have guided and advised her at all times.

 

Comment 4: Lastly, and of potentially greater significance, is the fact that one of the inclusion criteria was that the article needed to be in either English or Spanish. Admittedly, this was likely a pragmatic decision based on the languages the researchers are most fluent in. Nevertheless, it is an unknown as to how articles published in other languages would contribute to the findings of this study. 

Response 4: Indeed, it is a pragmatic decision agreed upon by the team. While we may have some knowledge of other languages, conducting a critical reading of those articles would not be sufficient. Therefore, it would be best for our review to limit it to English and Spanish, given that most of the evidence is available in these two languages, and acknowledging that we might miss some information.

Reviewer 2 Report

Comments and Suggestions for Authors

How clever to use Rayyan to do a SR! The following recommendations would improve this manuscript:

* Re-think the inclusion criteria: Presently, any article about counseling for PC patients is included (according to the inclusion criteria listed). So that would include studies about psychotherapy etc that are not necessarily about addressing spiritual needs. So a very imprecise criteria that undermines the quality of this substantially. Likewise, the inclusion criteria state that only articles with an outcome of quality of life were included, yet when looking at Table 2, most studies measured other variables (eg, depression, ego integrity). Because these inclusion criteria were so loose, it is hard to see the findings as credible. And why not reports from prior to 2012?

* Yes, only 3 databases as recognized in the Limitations. I believe SRs are expected to have at least 4.

* Table 2 has a column for "Quality" yet nothing about how these scores were generated is given. 

* Know that there is already SRs of Dignity Therapy. Perhaps it is time for a meta-synthesis for DT?

* The Results do not offer much synthesis; rather, it is more summarizing of single or a couple studies. It also often conveys confirmation was found for existing theories, rather than the authors generating their own observations from the SR.

* The section on the impact of music shows the lack of precision with the inclusion criteria. Eg some studies summarized refer to music (but not as a spiritual tx) and to outcomes that are not overtly spiritual. 

* Check the numbering on the references as they are not in sync (between Table 2 and narrative).

* Whereas synthesis is missing in the analysis of the data, even the summarization is sometimes limp. Worst example may be at the end of the section where it is stated that "benefit" was demonstrated, but what benefit is never described.

* Often there are 1-sentence paragraphs. Please reconsider paragraph structure.

* Discussion section is basically another lit review, with summarization of single studies. 

* How the limitations of working with AI/Rayyan were addressed is never discussed in the Methods. 

* Although a PICO statement may  not be necessary, a clearer and more precise statement of the objection/research question should be offered. This gets us back to then what inclusion criteria should be.

Comments on the Quality of English Language

Sentence structure is OK, but paragraph structure is poor. English is OK.

Author Response

Comment 1: Re-think the inclusion criteria: Presently, any article about counseling for PC patients is included (according to the inclusion criteria listed). So that would include studies about psychotherapy etc that are not necessarily about addressing spiritual needs. So a very imprecise criteria that undermines the quality of this substantially. Likewise, the inclusion criteria state that only articles with an outcome of quality of life were included, yet when looking at Table 2, most studies measured other variables (eg, depression, ego integrity). Because these inclusion criteria were so loose, it is hard to see the findings as credible. And why not reports from prior to 2012?

Response 1: Including articles related to counseling for palliative care patients was intentional. We aimed to capture a comprehensive view of the various interventions, including psychotherapy, that could address the multifaceted needs of these patients. While our primary focus is on addressing spiritual needs, we recognize that psychological and emotional support often intertwine with spiritual care. Thus, we considered studies on psychotherapy relevant, as they may provide indirect benefits to spiritual well-being. We acknowledge the discrepancy you pointed out regarding the outcome measures. Our initial criteria aimed to include articles with outcomes related to quality of life, as this is a broad and encompassing measure of the patient's overall well-being. However, we also included studies measuring other variables like depression and ego integrity because these aspects significantly impact the quality of life. By including these studies, we aimed to provide a more holistic understanding of the interventions' effects.

We understand that the inclusion criteria may need to be fixed. This flexibility was deliberate to encompass a wide range of relevant studies and to avoid excluding potentially valuable data. We aimed to provide a broad overview of the existing literature, recognizing that studies might focus on various aspects of patient care. This approach enhances, rather than undermines, the credibility of our findings by offering a more comprehensive perspective.

Related to the timeline, we chose to include studies from 2012 onwards to ensure the relevance and currency of the data. The palliative care and counseling field evolves rapidly, and more recent studies are likely to reflect the current practices and understanding. Including studies prior to 2012 might have introduced outdated practices and viewpoints, potentially skewing the review's findings.

 

Comment 2: Yes, only 3 databases as recognized in the Limitations. I believe SRs are expected to have at least 4.

Response 2: Thank you for your observation. We have now included a fourth database in our search strategy. However, despite this addition, we could not increase the number of articles in our review. We appreciate your feedback, which has helped us improve the comprehensiveness and robustness of our search process.

 

Comment 3: Table 2 has a column for "Quality" yet nothing about how these scores were generated is given. 

Response 3: The quality assessment was conducted using the NIH Quality Assessment Tool. However, we should have included the detailed table in the manuscript. We can provide it as a supplementary file for further clarification. Additionally, we have specified the tool used for the quality assessment in the table.

 

Comment 4: Know that there is already SRs of Dignity Therapy. Perhaps it is time for a meta-synthesis for DT?

Response 4: Thank you for your suggestion. We acknowledge that there are already systematic reviews on Dignity Therapy. However, we did not conduct a meta-synthesis in our study. We focused on providing a comprehensive systematic review to summarize the current evidence on DT and spiritual support interventions in general.Additionally, due to the heterogeneity of the data, it would not be advisable to carry out a meta-synthesis.

 

Comment 5: The Results do not offer much synthesis; rather, it is more summarizing of single or a couple studies. It also often conveys confirmation was found for existing theories, rather than the authors generating their own observations from the SR.

Response 5: Thank you for your feedback. We appreciate your thorough review of our manuscript. We respectfully disagree with your observation regarding the synthesis of the results. Our approach aimed to comprehensively summarize the existing literature while identifying common themes and patterns across multiple studies. This method allowed us to confirm existing theories and highlight new insights from our systematic review. This approach offers a balanced and robust understanding of the topic.

 

Comment 6: The section on the impact of music shows the lack of precision with the inclusion criteria. Eg some studies summarized refer to music (but not as a spiritual tx) and to outcomes that are not overtly spiritual. 

Response 6: Thank you for your insightful comments. We appreciate your feedback regarding the precision of our inclusion criteria, particularly in the section on the impact of music. We acknowledge that some studies included in our review refer to music interventions without explicitly defining them as spiritual treatments and report outcomes that are not overtly spiritual. However, we included these studies based on the broader understanding that music therapy can encompass spiritual elements and contribute to overall well-being, integral to holistic palliative care.

 

Comment 7: Check the numbering on the references as they are not in sync (between Table 2 and narrative).

Response 7: Thank you for your comment. We will review and correct the numbering of the references to ensure they are in sync. We apologize for any inconvenience this may have caused.

 

Comment 8: Whereas synthesis is missing in the analysis of the data, even the summarization is sometimes limp. Worst example may be at the end of the section where it is stated that "benefit" was demonstrated, but what benefit is never described.

Response 8: Thank you for your valuable comments. We have taken your observation regarding the lack of synthesis in data analysis and the weakness in summarization seriously. We have made significant changes to address this issue and improve the clarity and precision of our review. At the end of each section, we describe the benefits observed, providing a more comprehensive and detailed understanding of the findings.

 

Comment 9: Often there are 1-sentence paragraphs. Please reconsider paragraph structure.

Response 9: We have addressed the issue of one-sentence paragraphs by restructuring the text to ensure a more cohesive and readable format. We have combined related sentences into well-formed paragraphs to enhance the overall flow and clarity of the manuscript.

 

Comment 10: Discussion section is basically another lit review, with summarization of single studies. 

Response10: We would like to clarify that the discussion section of our manuscript is not merely another literature review. Instead, it compares the results obtained in our review with those of other studies, highlighting the existing consistencies and discrepancies. This comparative analysis forms the basis of our discussion, allowing us to contextualize our findings within the broader literature and to draw meaningful conclusions. This approach provides a deeper understanding of the topic and underscores the significance of our results about the existing body of knowledge.

 

Comment 11: How the limitations of working with AI/Rayyan were addressed is never discussed in the Methods. 

Response 11: We appreciate your feedback regarding the limitations related to working with AI/Rayyan in the Methods section. We have included a detailed discussion of how we addressed these limitations to ensure transparency and rigor in our review process.

 

Comment 12: Although a PICO statement may not be necessary, a clearer and more precise statement of the objection/research question should be offered. This gets us back to then what inclusion criteria should be.

Response 12: We appreciate your suggestion for a clearer and more precise statement of the objective/research question. We agree that improving the clarity of our research question will enhance the understanding and relevance of our inclusion criteria. We have revised the manuscript to include a more precise research question that aligns better with our inclusion criteria and overall objectives.

Reviewer 3 Report

Comments and Suggestions for Authors

This research is very important and your study should be published. "Spirituality can be ineffable and tacit, and thus challenging to conduct research on.....and you have taken it on, connected with the quality of life for patients. I commend you for this.

* My main issue with this document is the style of presenting your research. Thus, I will give some  suggestions to hopefully assist you to make a few              alterations. 

69-73   You have a "good research design"  but you need to better explain it

Readers may not understand what is meant       by a protocol number.  What is a systemic review?  What is meant by "prospero? 

Add more content to this paragraph, to better explain your study design...and some terms you have used. 

1. In your abstract, you should include a summarized meaning of spirituality , as found in "44"  introduction....where a good definition is presented.

51-66:  ( and throughout your written document) you need to re-write some of your very short paragraphs,  and include then into one longer paragraph, with  connecting statements.  Many of your paragraphs are   too short

       You have done a great literature review.

86-" your criteria for inclusion is good.  But 87 " the study design was experimental"  could also be at the beginning of your 2..1 study design.

95:  Usually "tables" are  placed at the end of a study,

3.1   ( 114)  A strong statement related to your common findings in the literature could be a good way to start the "results"

137-44: usually tables and diagrams       and 

summaries of selected studies are placed at the end of your study.  ( You can make reference to them  ( see attachments/ and the page number)

3.4.1-3.44: well written; may be able to combine some paragraphs

The emphasis on dance and music connected with spirituality speaks loudly about some of your main findings

258: "based on the findings" ( put some references here)  What findings?

258-61: could also be included in the abstract and the introduction....as this is  a very strong part of your research 

263: your conclusions are good, but you could combine some of the paragraphs, and also include some implications for your study.  How can your study inspire better quality palliative care?  Where could it be the most useful. What kind of further research could be inspired by yours?

        This is an excellent study that just requires some "style" alterations.

  Best of luck to the researchers and congrats  on studying such a challenging topic. 

 

Author Response

Comment 1: 69-73   You have a "good research design” but you need to better explain it. Readers may not understand what is meant by a protocol number.  What is a systemic review?  What is meant by "prospero?

Response 1: Thank you for your feedback. We appreciate your comments regarding a clearer explanation of our research design. We will include clarifications in the manuscript to ensure readers understand our research design and terminology.

 

Comment 2: In your abstract, you should include a summarized meaning of spirituality, as found in "44” introduction.... where a good definition is presented.

Response 2: We have included a brief definition of spirituality in our abstract

 

Comment 3: 51-66: (and throughout your written document) you need to re-write some of your very short paragraphs, and include then into one longer paragraph, with connecting statements.  Many of your paragraphs are   too short

Response 3: We appreciate your suggestion regarding the structure of our paragraphs. We will revise the manuscript to combine shorter paragraphs into longer, more cohesive ones, ensuring the use of connecting statements to improve the flow and readability of the text.

 

Comment 4:  86-" your criteria for inclusion is good.  But 87 " the study design was experimental” could also be at the beginning of your 2.1 study design.

Response 4: Thank you for your observation. However, the type of design of the articles included in our review is primarily an inclusion criterion. Therefore, we do not consider placing it in the study design section appropriate, as it could confuse the reader.

 

Comment 5: 95: Usually "tables" are placed at the end of a study,

Response 5: We will revise the manuscript to ensure that all tables are placed at the end of the study, in accordance with standard practice.

 

Comment 6: (114) A strong statement related to your common findings in the literature could be a good way to start the "results"

Response 6: We agree that starting the "Results" section with a strong statement related to the common findings in the literature would enhance its clarity and impact. We will revise the manuscript accordingly to incorporate this recommendation.

 

Comment 7: 137-44: usually tables and diagrams and summaries of selected studies are placed at the end of your study.  (You can make reference to them (see attachments/ and the page number)

Response 7: We will revise the manuscript to ensure that all tables are placed at the end of the study by standard practice.

 

Comment 8: 3.4.1-3.44: well written; may be able to combine some paragraphs. The emphasis on dance and music connected with spirituality speaks loudly about some of your main findings.

Response 8: Thank you for your positive feedback. While we appreciate your suggestion to combine some paragraphs and emphasize the connection between dance, music, and spirituality, the current structure best presents our findings clearly and cohesively. The separate paragraphs allow us to highlight each intervention's unique aspects and contributions distinctly.

 

Comment 9: 258: "based on the findings" (put some references here) What findings?

Response9: Thank you for your feedback. We have reformulated the paragraph and included references.

 

Comment 10: 258-61: could also be included in the abstract and the introduction....as this is a very strong part of your research 

Response 10: Thank you for your suggestion. We have included the statement in the abstract.

 

Comment 11: 263: your conclusions are good, but you could combine some of the paragraphs, and also include some implications for your study.  How can your study inspire better quality palliative care?  Where could it be the most useful. What kind of further research could be inspired by yours?

Response 11: Thank you for your valuable feedback. We have revised conclusions, combined paragraphs, and added implications for the study.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors' thorough responses are appreciated. While there is considerable improvement, I would continue to encourage continued improvements in the following:

* I realize you can't change your study; it is what it is. But the inclusion of "counseling" as a spiritual intervention without specification of it as spiritual counseling leaves the findings incomplete and unfocused. I would address this as a limitation and be clear in the methods or purpose statement as to why it was done. 

* The comment is made that the study designs varied widely. How so? I think instead of identifying themes that later get unpacked, the introduction to the Results should summarize things like (in section 3.2): the types of outcome variables, the types of interventions tested, the settings/samples (eg family vs pt). So merge the added content in to the place where it belongs. I'd start the Results with 3.1, and move the intro paragraphs into 3.4 or the Discussion. 

* Section 3.2-- let us know what "good" means; what are the other categories (other than "fair")?

* Section 3.4 refers to 4 main "approaches"; explain what these were approaches to.

* Explain with the Mixed Methods studies, what type of quant design was used (in Table 2 and elsewhere). 

* Might make Table 2 more helpful if the spiritual variable/s are placed in bold font, so the reader can readily see how the study is related to the study purpose.

 

 

Comments on the Quality of English Language

Much improved, but still could improve paragraph structure.

Author Response

Comment 1: I realize you can't change your study; it is what it is. But the inclusion of "counseling" as a spiritual intervention without specification of it as spiritual counseling leaves the findings incomplete and unfocused. I would address this as a limitation and be clear in the methods or purpose statement as to why it was done.

Response 1: Thank you for your thorough review and valuable feedback on our manuscript. We appreciate your insights, particularly regarding the inclusion of "counseling" as a spiritual intervention. 

We have addressed this concern in the Limitations section of the manuscript. Specifically, we clarified that "counseling" was included in the broad category of spiritual interventions, which may have led to some ambiguity in the findings. We acknowledged that the lack of explicit differentiation between general counseling and spiritual counseling might result in an incomplete or unfocused interpretation of the results. This was done to encompass the diversity of interventions reported in the literature, but we understand the importance of distinguishing these subcategories more clearly in future research.

The revised limitations now explicitly state this as a potential limitation of our study, and we have provided a rationale for this approach within the methods and purpose statement. We believe these changes will help contextualize our findings more accurately and guide future research in this area.

 

Comment 2: The comment is made that the study designs varied widely. How so? I think instead of identifying themes that later get unpacked, the introduction to the Results should summarize things like (in section 3.2): the types of outcome variables, the types of interventions tested, the settings/samples (eg family vs pt). So, merge the added content into the place where it belongs. I'd start the Results with 3.1 and move the intro paragraphs into 3.4 or the Discussion. 

 Response 2:  In Section 3.2, we have now provided a comprehensive summary that outlines the types of outcome variables, the interventions tested, and the settings/samples involved (e.g., family vs. patient). This summary precedes the detailed thematic analysis, ensuring a clear understanding of the study's scope and the diversity of the included research.

Additionally, we have reorganized the Results section to start with Section 3.1, as suggested.

We believe these changes enhance the clarity and coherence of the manuscript. If there are any further revisions required, please do not hesitate to let us know.

 

Comment 3: Section 3.2-- let us know what "good" means; what are the other categories (other than "fair")?

Response 3: In Section 3.2, the quality of the studies is assessed using the NIH Quality Assessment Tool. The studies were categorized as "good" or "fair." To clarify these terms:

• Good: Studies rated as "good" demonstrated strong methodological rigor, with clear and appropriate study designs, well-defined and relevant outcome measures, and thorough statistical analysis. These studies had minimal risk of bias, robust sample sizes, and comprehensive reporting of results.
• Fair: Studies rated as "fair" had some methodological limitations, such as smaller sample sizes, less robust statistical analysis, or potential biases that were not adequately addressed. While these studies still provided valuable insights, they did not meet the higher standard set for the "good" category.

Other potential categories could include "poor" or "uncertain," typically used in quality assessments to denote studies with significant methodological flaws or insufficient information to assess quality properly. However, in this review, only "good" and "fair" were utilized

 

Comment 4: Section 3.4 refers to 4 main "approaches"; explain what these were approaches to.

Response 4: We would like to inform you that we have provided a brief description of the four main approaches identified in our study within Section 3.4.

 

 Comment 5: Explain with the Mixed Methods studies, what type of quant design was used (in Table 2 and elsewhere). 

Response 5: Thank you for your comments regarding the need to specify the type of quantitative design used in the Mixed Methods studies. We have included this information in Table 2 and throughout the manuscript where relevant.

 

Comment 6: Might make Table 2 more helpful if the spiritual variable/s are placed in bold font, so the reader can readily see how the study is related to the study purpose.

Response 6: We have now placed the spiritual variables in bold font within the table. This adjustment will allow readers to easily identify how each study relates to the study's purpose of exploring spiritual interventions and outcomes. We appreciate your feedback and believe these changes enhance the clarity and usefulness of the table.