1. Spiritual Assessment and Intervention Model: An Interactive Workshop Allison Kestenbaum, MA, MPA, BCC, ACPE Supervisor Jewish Theological Seminary Spiritual AIM Project Chaplain, Lead Investigator The Rev. Michele Shields, D.Min., BCC, ACPE Supervisor Fmr. Director, UCSF Spiritual Care Services Spiritual AIM Project Chaplain, Lead Investigator Laura B. Dunn, MD Professor of Psychiatry and Behavioral Sciences Director, Geriatric Psychiatry Fellowship Training Program Department of Psychiatry and Behavioral Sciences Stanford University Spiritual AIM Project Director
ALLISON
THANK AUDIENCE FOR COMING.
INTRODUCE US.

2. Objectives
Review Spiritual Assessment and Intervention Model (Spiritual AIM)
Describe process of creating manual for teaching Spiritual AIM
Utilize the new manual to learn this model
Highlight qualitative and quantitative research findings
Present future research directions
ALLISON – Just briefly state these (paraphrase, don’t need to read these verbatim)
DESCRIPTION of OUR WORKSHOP:
Although spiritual care is considered a critical part of palliative care, minimal work has described in detail the actual work of chaplains.
Workshop participants will have the opportunity to learn the basics of the Spiritual Assessment and Intervention Model (Spiritual AIM) through interactive exercises designed to teach how to identify a patient’s core spiritual need through assessment; design and implement specific interventions; and identify and assess outcomes specific to the identified core spiritual need.
The presenters, who include the core team members from the UCSF- based study, will also describe the process used to create the Spiritual AIM manual, and current and future research directions, including evaluation of the first “Spiritual AIM Manual.” Learning modalities will include didactic presentation as well as dynamic discussion.
Participants will be able to:

3. Self-Worth and Belonging Reconciliation/ To Love and Be Loved
Core Spiritual Needs
Self-Worth and Belonging
Reconciliation/ To Love and Be Loved
Meaning and Direction
PERSONA
Spirituality encompasses the needs to seek meaning and direction, to find self- worth and to belong to community, and to love and be loved, often facilitated through seeking reconciliation when relationships are broken.
When a person faces a crisis, 1 of 3 spiritual needs surfaces most urgently – referred to as the person’s “core spiritual need”
MICHELE:
In the field of Spiritual Assessment, categories of spiritual needs are named. In this model, there are 3, which exist in all of us by virtue of being human. Spirituality encompasses the needs to seek meaning and direction, to find self-worth and to belong to community, and to love and be loved, often facilitated through seeking reconciliation when relationships are broken. One of these needs emerges most strongly in a crisis. That is what the chaplain is assessing. Sometimes the patient is throwing you a "red herring" by telling you something about herself, "I'm really very easy to get along with," when she has just alienated 2 doctors, a nurse, and a physical therapist. That's the Persona, the self-description, she wants you to buy.
Shields M, Kestenbaum A, Dunn LB. Spiritual AIM and the work of the chaplain: A model for assessing spiritual needs and outcomes in relationship. Palliative and Supportive Care Mar 10:1-15. PMID:

4. You can read more about Spiritual AIM in the article that is provided as a handout.

5. Spiritual AIM: Background
Developed during 21 yrs of Spiritual Care/Clinical Pastoral Education (CPE) by Rev. Dr. Michele Shields, focused on what occurs between the patient and chaplain
Begun in chaplaincy mentorship in a CPE supervisory training group with Rev. Dennis Kenny, D.Min. for first 2 yrs
Developed with theological reflection and psychological theory, plus critique from professional peers and students
Refinement with the Spiritual AIM Research Team during this study for last 3 years
MICHELE:
Developed by me during 21 years of Spiritual Care and Clinical Pastoral Education Supervision focused upon what happens between the patient and the chaplain. It is not intrapersonal. It is interpersonal. Healing happens in relationship. And the focus is on that relationship.
The model was begun in chaplaincy mentorship in a CPE supervisory training group with the Rev. Dennis Kenny, D.Min. For the first 2 years.
It developed with theological reflection and psychological theory, plus critique from professional peers and students.

6. Spiritual AIM: Theology/Philosophy
The Golden Rule or Ethic of Reciprocity:
“Treat others as you wish to be treated.” “Love your neighbor as yourself.” (Lev. 18:18, Matt.22:37-40)
“What you do not wish for yourself, do not impose on others.” (Confucianism)
Spiritual maturity requires autonomy enough to love oneself and connection enough to achieve fairness in balancing love for oneself, others and God (if one’s belief includes God).
MICHELE:
The theology or philosophy in which this model is grounded is sometimes called the Golden Rule or the Ethic of Reciprocity. Love your neighbor as yourself. Sometimes it is stated in the negative: do not do unto others as you would not have them do unto you. Karin Armstrong, an expert in World Religions, states that this is universal in the great faith traditions.
The idea is that spiritual maturity requires autonomy enough to love oneself
& connection enough to achieve fairness in balancing love for oneself, others and God, if your belief includes God.

7. Spiritual AIM: Psychology
Object Relations:
Personality takes shape through people’s experiences of relationships and social context, specifically how a child appropriates, internalizes and organizes early experiences in the family.
Spiritual AIM:
Spiritual dynamics and spiritual needs are shaped in a similar manner and may be changed or met in relationships, even in adulthood.
MICHELE:
The Psychology in which this model is grounded is Object Relations because it focuses on relationships. In Object Relations, personality takes shape through people's experiences of relationships and social context. You get to be who you are as a child by how you appropriate, internalize and organize early experiences in the family.
In this model, spiritual dynamics and needs are shaped in a similar manner and may be changed or met in relationships, even in adulthood.

8. Spiritual AIM: How does it work?
Assessment of spiritual need based upon:
comments
behavior
attribution of blame
questions
concerns
chaplain’s own internal response to person
Assessment of where person is along path to healing
Spiritual AIM: How does it work?
MICHELE:
In the course of a conversation about how the patient is doing, the patient's primary concern may emerge. Do they blame themselves, others or no one? Do they have questions of meaning or what direction they should take? Are they worried about others or primarily self-concerned? Are they arrogant, self-effacing or seemingly lost? What is the chaplain's internal response to the patient? Is it typical of one spiritual core need? The assessment may come from many different things. A patient may express their spiritual need differently based upon where they are along the path to healing. (See our article "Spiritual AIM and the Work of the Chaplain")

9. Spiritual AIM: How does it work
Embodiment: stance of
Guide
Valuer
Truth-teller
Interventions in the process of healing
Healing happens in relationship
Desired outcomes to meet the spiritual need
MICHELE:
The chaplain embodies or takes the stance of a guide for the person whose spiritual need is for meaning and direction and walks down a path of specific interventions, designed to help the patient discern and commit to a decision or plan of action. Similarly, the chaplain embodies or takes the stance of a Valuer or Affirmer, walking side by side with the person who needs self worth, as the chaplain becomes a form of Community to help the person belong and gain a voice to advocate for him/herself, to do what's best for him/herself. The chaplain can also embody a Truthteller, taking a stance of Toughlove for challenging a person who needs reconciliation in broken relationships, to take responsibility to do what he can to repair those relationships.
The model spells out desired outcomes for these paths of specified interventions in each case of spiritual need.

10. Spiritual AIM: Distinctiveness
Assessments, corresponding interventions, desired outcomes
Psychological and theological/philosophical theory underpinnings
Broad definition of “spirituality”
Communicates well to the interdisciplinary team
Inclusive of a variety of faith—or no faith— traditions
Useful in fast-paced, clinical setting (it is not an interview approach)
MICHELE:
Many models lack specified interventions or outcomes. This one has all three: assessments, interventions & outcomes.
Many models do not have psychological or theological/philosophical theory underpinnings. I have briefly introduced those.
Many definitions of spirituality are shaped around meaning, when that does not interest everyone in crisis. This definition of spirituality is broader than meaning and direction.
This is a simple 3-spiritual need model to explain in an elevator ride to an interdisciplinary team member.
This model is inclusive of people who do not belong to a faith community because you may get your needs met by any community without reference to the Ultimate.
I have used it for years in an Emergency Room successfully. So, it can be used quickly. This model is distinctive in these ways.

11. Objectives
Review Spiritual Assessment and Intervention Model (Spiritual AIM)
Describe process of creating manual for teaching Spiritual AIM
Utilize the new manual to learn this model
Highlight qualitative and quantitative research findings
Present future research directions
(I put this here just to remind us where we are in the workshop)

12. Development of the Spiritual AIM Manual
Met with an oncology/integrative medicine colleague
He had manualized an Ayurvedic medicine intervention for fatigue in cancer patients
He walked us through his process and referred us to two articles on manualization
Aha! We realized manualization isn’t rocket science
We had a manual from another study, which was based on yet another manual
ACT for Fear of Recurrence in breast cancer patients
We met with Dr. Anand Dhruva and he sent us some papers on manulization:
"Bridging the Gap in Complementary and Alternative Medicine Research: Manualization as a Means of PromotingStandardization and Flexibility of Treatment in Clinical Trials of Acupuncture" by Rosa N. Schnyer and John J.B. Allen
"Manualization of Occupational Therapy Interventions: Illustrations From the Pressure Ulcer Prevention Research Program" by Erna Imperatore Blanche, Donald Fogelberg, Jesus Diaz, Mike Carlson, Florence Clark
"Development of a Manualized protocol of Massage Therapy for clinical trials in osteoarthritis" by Ather Ali, Janet Kahn, Lisa Rosenberger and Adam Perlman
He talked to us about setting up a study with a Factorial Design (on which I have notes).  The aims of the study would be to 1) develop the model and 2) test and refine it in clinical trials with 3 cohorts of ten patients and X chaplains.  To discern: feasibility, acceptability, positive religious coping, effect size, efficacy positive in small size.
We developed the outline from your manual on the breast cancer fear of recurrence study, I recall.  Then, we started filling in material from our previous journal article into the chapters.  We determined that we needed examples to test the readers.  We could take these examples from the study transcripts.
Allison got working on the examples.

13. Development of the Spiritual AIM Manual
Outlined chapters.
Filled in material from our previous journal article into the chapters. 
Determined that we needed examples to test the readers
Realized we could take these examples from the study transcripts.
Allison got working on the examples.
We met with Dr. Anand Dhruva and he sent us some papers on manulization:
"Bridging the Gap in Complementary and Alternative Medicine Research: Manualization as a Means of PromotingStandardization and Flexibility of Treatment in Clinical Trials of Acupuncture" by Rosa N. Schnyer and John J.B. Allen
"Manualization of Occupational Therapy Interventions: Illustrations From the Pressure Ulcer Prevention Research Program" by Erna Imperatore Blanche, Donald Fogelberg, Jesus Diaz, Mike Carlson, Florence Clark
"Development of a Manualized protocol of Massage Therapy for clinical trials in osteoarthritis" by Ather Ali, Janet Kahn, Lisa Rosenberger and Adam Perlman
He talked to us about setting up a study with a Factorial Design (on which I have notes).  The aims of the study would be to 1) develop the model and 2) test and refine it in clinical trials with 3 cohorts of ten patients and X chaplains.  To discern: feasibility, acceptability, positive religious coping, effect size, efficacy positive in small size.
We developed the outline from your manual on the breast cancer fear of recurrence study, I recall.  Then, we started filling in material from our previous journal article into the chapters.  We determined that we needed examples to test the readers.  We could take these examples from the study transcripts.
Allison got working on the examples.

14. Chapter Outline
Chapter 1: Introduction Chapter 2: Overview of Spiritual AIM Chapter 3: Assessments Chapter 4: Embodiment and Interventions Chapter 5: Outcomes Chapter 6: Case Studies Chapter 7: Communicating with Chaplains and Other Professionals Chapter 8: Clinical Issues Bibliography List of Additional Resources Appendices

15. References on Manualization
Schnyer & Allen: Bridging the Gap in Complementary and Alternative Medicine Research: Manualization as a Means of PromotingStandardization and Flexibility of Treatment in Clinical Trials of Acupuncture
Blance et al.: Manualization of Occupational Therapy Interventions: Illustrations From the Pressure Ulcer Prevention Research Program

16. What is coding? Marking that data
Describing the themes – what is going on?
In grounded theory we use something called open coding
This means that when I get my first transcript of an interview I just start going through and writing down notes about what I think is going on. These could be a couple things
I could mark one section as “family” that way I’ll have all the paragraphs where the patients talked about their family and look at them collectively
Or I might mark something as “loss” to describe the patients experiences of loss. But, because I’m being open and interative, these codes might change. I might decide that I need to split loss into two codes – one describing grief or less of loved ones and others that describes the loss of future potential – such as seeing chidlren grow up and another that describes the loss of hair or apperance.

17. Codebook (example) Code Definition Example Sees both sides
Patient sees and articulates both sides of most situations. Does not place blame. On the one hand, but on the other hand;
P23: “It was very much not cool. But on the one hand, then I didn’t have any money so I could get on MediCal and that’s what I’ve been on since then and it’s been pretty good.”
Past decisions/coping
Chaplain asks how patient has coped with similar crises. Chaplain asks how patient has made decisions in the past.
“Yeah. Well I’m just curious about how you made the decision. It seems like a big decision to have gone and I’m so excited for you to be able to go tonight. But how did that come about” (P9)
Types of codes
Apriori – based on the model, examining assessment, intevention and outcomes through that lens
Able to learn how the chaplains conduct sessions, how they respond to what patients say, what the intervention looks like in practice,
Able to reflect back based on chaplains notes and conversations during our meetings
We also coded based on themes that we saw emerging such as: the way patients talk about death, cancer, family, relationships with providers and look for how various themes come up with patients of different core spiritual needs

18. Key Questions in our study
How do chaplains assess patients’ spiritual needs?
How do chaplains intervene to address these needs?
What outcomes do chaplains seek?
How can chaplains tell if these outcomes are achieved?
This project sought to fill a specific and fundamental gap in chaplaincy research, namely, what do chaplains DO?
We wanted to, in our team’s way of describing it, “pull back the curtain” and see what was happening, essentially in real time, between chaplains and patients.
We wanted to look at several main aspects of spiritual care –
How chaplains assess patients’ spiritual needs;
How chaplains intervene to address these spiritual needs,
What kinds of outcomes do chaplains seek, and how do they know if these outcomes have been achieved.
We intended this study to be a jumping off point for more research in this area and gathered descriptive data to help build a basic understanding of how Spiritual AIM is used.
Through this study we are able to examine 30 unique trajectories of the patient-chaplain relationship. We are able to analyzing how they form rapport, the assessment and intervention made and what if any outcomes can be seen at the end of three sessions. And we had some fairly powerful outcomes. We had patients reconcile relationships with estranged family members. We had a jewish patient make the difficult decision to be cremated – in line with her own wishes but controversial in her faith. We had a patient tell us about a major spiritual breakthrough after attending church for decades as an atheist and another patient who was able to step back from a daunting schedule of alternative therapies to focus on what she really loved doing.
In addition to these individual case studies that can be presented, we are able to look at themes across patients
Because we have examined each transcript looking at the same set of codes we can begin to try and answer really an infinite number of questions.
We could look at how death was discussed across faith traditions or within a certain core spiritual need.
We can examine the values and priorities of patients and how that impacts treatment and end-of-life decision making
Etc etc

19. Exercise #1: How do you evaluate a spiritual assessment model?
This exercise will acquaint you with the building blocks of spiritual assessment models by guiding you through evaluating a model. Integrative Exercise #1: Choose one model and evaluate it using the Spiritual Assessment Evaluation Matrix. Fun fact: If you develop or claim a spiritual assessment model, you can replicate our study using that tool.

20. Spiritual Assessment Evaluation Matrix
Theological underpinnings (a.k.a goal for spiritual healing)
Theory about human personality/development
Modalities/vehicles (i.e. dialogue with patient)
Guidance on how to make assessment (suggests there is more than one assessment that can be made)
Offers corresponding interventions
Suggests possible outcomes
Limitations of model (e.g. cultural competence)
Print handouts
Give 5 minutes to fill in the matrix
Ask everyone to hold up their sheet when done. Which lines have the most filled in?
Ask ~2 people to share what it was like to do this exercise.

21. Coding & Manual Development
Coding - analysts mark passages of data according to a unique “coding scheme” to facilitate later retrieval and analysis.
Coding schemes - reflect the project’s substantive questions and conceptual framework; evolves over time in an iterative fashion.
Coding gave us the foundation for the manual.
It yielded empirically collected and analyzed examples/quotations of the various bullet points of Spiritual AIM assessment, interventions and outcomes.

22. What is coding? Marking that data
Describing the themes – what is going on?
In grounded theory we use something called open coding
This means that when I get my first transcript of an interview I just start going through and writing down notes about what I think is going on. These could be a couple things
I could mark one section as “family” that way I’ll have all the paragraphs where the patients talked about their family and look at them collectively
Or I might mark something as “loss” to describe the patients experiences of loss. But, because I’m being open and interative, these codes might change. I might decide that I need to split loss into two codes – one describing grief or less of loved ones and others that describes the loss of future potential – such as seeing chidlren grow up and another that describes the loss of hair or apperance.

23. Codebook (example) Code Definition Example Sees both sides
Patient sees and articulates both sides of most situations. Does not place blame. On the one hand, but on the other hand;
P23: “It was very much not cool. But on the one hand, then I didn’t have any money so I could get on MediCal and that’s what I’ve been on since then and it’s been pretty good.”
Past decisions/coping
Chaplain asks how patient has coped with similar crises. Chaplain asks how patient has made decisions in the past.
“Yeah. Well I’m just curious about how you made the decision. It seems like a big decision to have gone and I’m so excited for you to be able to go tonight. But how did that come about” (P9)
Types of codes
Apriori – based on the model, examining assessment, intevention and outcomes through that lens
Able to learn how the chaplains conduct sessions, how they respond to what patients say, what the intervention looks like in practice,
Able to reflect back based on chaplains notes and conversations during our meetings
We also coded based on themes that we saw emerging such as: the way patients talk about death, cancer, family, relationships with providers and look for how various themes come up with patients of different core spiritual needs

24. Sneak Peak at the Manual
We are going to give you the opportunity to test drive some parts of the manual during our session today. This will help you:
deepen your knowledge about spiritual assessment
allow you to learn more about Spiritual AIM that you can use in your clinical practice
Your participation will also help us strengthen the manual.

25. Exercise #2 – What is assessment and how do you do it?
This exercise will allow you to learn more about the art and science of assessment, as described by Spiritual AIM.
[Michele will paraphrase this section of the manual; after, we will use socrative.com to do audience polling with a quiz and test their learning].

26. Exercise #3
This exercise will provide you with the opportunity to practice making assessments. Break up into groups of 3. Use the handout to: 1) Name the patient’s core spiritual need and 2) Provide a rationale for your choice Remember to include language from the Table in the article.

27. Example
Quote from M&D patient – “Something was going astray. And so the marital counseling, she [my wife] and I thought well, this is the best we can do to try to analyze or objectify whatever the imbalance was.” P37
Question: Name the patient’s core spiritual need and provide a rationale for your choice (include language from the Table)
Sample answer: The patient’s core spiritual need is Meaning & Direction. The patient indicates that “something” was going “astray” but does not assign blame to self or others (“Patient does not place blame”). The patient’s comment about marital counseling is intellectual. He uses the word “thought” and relies on “analysis” to identify and address the problem (“Patient tends to intellectualize circumstances”).
(From coding scheme: “sees both sides” and “intellectualizes”)

28. Name the patient’s core spiritual need and provide a rationale for your choice
1) “I’ve found that helpful partly because I’m not as bad off as a lot of people in the [support] group. In a way that’s a terrible way to feel, but I think oh, my goodness, I don’t have any problems compared to this person.”

29. Name the patient’s core spiritual need and provide a rationale for your choice
2) “She was just this stranger who comes across kind of harsh, who’s been hurting her father for years and years and years. She just disappears for two, three years at a time and then will call him up when she needs money or something.”

30. Name the patient’s core spiritual need and provide a rationale for your choice
3) “I’m back at the starting point. I’ve trudged out and trudged back – I grew up in the Midwest and your field is hard, it’s been plowed under and it’s going out in those fields during winter and it’s usually been rainy and it’s just pretty bloody mucky. It’s not easy walking and you sort of walk several yards and your boots are full of mud and you go back. So it’s tiring. And that’s how I’ve been feeling, I think, this last year – more so than I had before.”

31. Feedback about Exercises
What did you learn?
Which modalities were most/least helpful?
Didactic presentation
Socrative polling
Breaking up into small groups
Working with patient quotations to practice making interventions
If you were engaging in an in depth training in Spiritual AIM, what would you hope to learn?

32. Study Aims
Aim 1. To describe the content and processes of spiritual assessments conducted by chaplains to identify core spiritual needs among patients with advanced cancer.
Aim 2. To describe the content and processes of spiritual care interventions developed based on these assessments.
Aim 3. In order to calculate effect sizes for future intervention research, to measure changes in spiritual, psychological, and physical symptoms and to assess the value added to outpatient palliative care interdisciplinary teams (IDTs) by certified chaplains.
Aim 4. To evaluate the feasibility and tolerability of recruitment, assessment, and intervention research focused on evaluating Spiritual AIM in the outpatient palliative care setting.
LAURA

33. Project Description
Adults with advanced cancer (target n=30, recruited 31)
Symptom Management Service (outpatient palliative care service of UCSF HDFCCC)
Each participant had three individual sessions with a chaplain; audiotaped and professionally transcribed
Pre- and post-intervention booklet of self-report rating scales
Exit interview with research coordinator
Weekly team meetings (audiotaped, transcribed  auto-ethnography)
LAURA

34. Study Measures (1) Symptoms (ESAS) - e.g., fatigue, pain
Spiritual well-being (“I feel at peace”)
Overall quality of life (1 item)
Spirituality (FACIT-Sp-12; 3 subscales: Faith, Meaning, Peace)
“I find comfort in my faith or spiritual beliefs”
“I feel a sense of purpose in my life”
Religious coping (Brief R-COPE; Positive & Negative)
“Sought help from God in letting go of my anger”
“Wondered what I did for God to punish me”
The quantitative, self-report measures we collected included at baseline and after the completion of the three chaplain sessions were:
The Edmonton Symptom Assessment Scale, which asks about the most common symptoms experienced by cancer patients;
A one-item measure of spiritual well-being, “I feel at peace” rated on a 5-point Likert scale
A one-item measure rating overall quality of life
A measure of positive and negative religious coping, (two subscales) – called the R-COPE

35. Study Measures (2) Dignity (Patient Dignity Inventory)
“Feeling like I am no longer who I was.”
Cancer-related adjustment (Mini-MAC)
5 subscales: Fatalism, Fighting Spirit, Helplessness/Hopelessness, Anxious Preoccupation, Avoidance
Alternatively: 2 subscales Adaptive, Maladaptive Coping
State anxiety (STAI-S, “now”)
“I feel at ease”; “I feel nervous”
Depressive symptoms (CES-D, “past 7 days”)
“I felt sad”; “I could not get ‘going’”
The Mental Adjustment to Cancer (MAC) scale is one of the most widely used instruments to measure copingresponses in individuals with cancer [20]. The 29-item mini-MAC is a refinement of the original MAC scale
Five cognitive coping responses: helplessness-hopelessness (e.g., ‘I feel like giving up’ ); anxious preoccupation (e.g., ‘I am apprehensive’ ); cognitive avoidance (e.g., ‘Not thinking about it helps me cope’ ), fatalism (e.g., ‘At the moment I take one day at a time’ ), and fighting spirit (e.g., ‘I see my illness as a challenge’ ).
A number of studies examining the psychometric properties of the mini-MAC have supported the reliability of all five subscales [21-29]. However, studies have also proposed that some of the subscales can be combined to form more general coping subscales. Anagnostopoulos et al. [24] proposed the ‘ adaptive’ (fighting spirit, cognitive avoidance, and fatalism subscales) and ‘ maladaptive’ (helplessness-hopelessness
and anxious preoccupation subscales) subscales.

36. Demographic and Clinical Characteristics
Mean (SD)
N (%)
Age (years)
59.4 (9.9)
[Range 34-80]
Female
Male
20 (64%)
11 (36%)
Christian
Jewish
Buddhist
None
18 (58%)
4 (13%)
3 (10%)
6 (19%)
White
Asian
Hispanic
27 (87%)
1 (3%)
Breast cancer
Gynecologic GI
Prostate
Head/Neck
Other
7 (23%)
5 (16%)
The patients’ demographic and clinical characteristics were as follows:
They were on average 59 years old, but the age range was actually 34 to 80 years old.
Nearly two-thirds of the sample were women.
We had a fairly heterogeneous sample in terms of religious affiliation.
The sample was primarily White.
There were a number of cancer diagnoses represented in the sample.

37. Core Spiritual Needs
In terms of the patients’ “core spiritual need,” as assessed by the chaplain assigned to the patient, we were interested to see that the three “core spiritual needs” were approximately equally represented, as you can see here.

38. Core Spiritual Needs by Age Group
Interestingly, we found that younger patients (those younger than 60) were statistically more likely to be assessed as having a core need of “Self-Worth and Belonging” compared to older patients. Older patients were more likely to be assessed as having a core need of “Reconciliation” or “Meaning and Direction.”
p < 0.05

39. Baseline Symptom, QOL, Spiritual, and Psychological Measures
Mean (SD)
Range
ESAS - Total
25.0 (12.7)
2 - 52
“I feel at peace”
3.1 (1.1)
1 - 5
Overall Quality of Life
3.5 (0.8)
2 - 5
RCOPE Positive
RCOPE Negative
14.0 (5.7)
9.2 (2.6)
7 – 28
7 - 16
STAI – State Anxiety
43.6 (12.5)
CES-D-10 (Depressive sxs)
4.2 (2.2)
0 - 8
In terms of baseline measures, the patients in the study, on average,
Had a relatively low level of symptoms on the Edmonton (ESAS) scale
Endorsed feeling “somewhat” at peace
Felt they had an overall fairly good quality of life
Endorsed low to medium levels of positive religious coping (the RCOPE positive subscale)
Endorsed low levels of negative religious coping (the RCOPE negative subscale)
Had moderately elevated levels of anxiety on the State Anxiety scale
Had moderate levels of depressive symptoms on the brief CES-D scale.

40. Changes in Measures from Baseline to Post-Spiritual AIM
Mean
Post-Spiritual AIM Mean
p-value
ESAS - Total
25.0
24.4
0.646
CES-D-10
4.2
4.1
0.502
STAI-S
43.6
41.9
0.294
FACIT-Sp-Ex-12
Meaning
Peace
Faith
11.8
9.0
7.6
10.6
9.2
8.8
0.136
0.405
0.018*
Brief RCope
Positive
Negative
14.0
15.0
9.3
0.082
0.803
We also compared the scores on these measures from pre- to post-intervention to see if we could detect any effect in this small sample. Given the small sample size, we took a look at changes in scores, p-values, as well as effect sizes.
- Specifically, although the overall symptom scale and overall quality of life did not change significantly, we did see a trend and a medium effect size (i.e., 0.34) for the RCOPE Positive subscale, meaning that positive religious coping increased.
- State anxiety also decreased, although this was not statistically significant, there was a small effect size (i.e., -0.20).

41. Changes in Measures from Baseline to Post-Spiritual AIM
Mean
Post-Spiritual AIM Mean
p-value
Patient Dignity Inventory
53.6
51.6
0.280
Mini-MAC
Fatalism
Fighting spirit
Helpless/hopeless
Anxious preoccupation
Avoidance
11.2
10.7
14.1
20.7
9.0
11.6
11.8
13.4
20.2
9.2
0.084
0.036*
0.382
0.478
0.510
Maladaptive coping
Adaptive coping
34.8
30.2
32.3
32.6
0.178
0.018*
LAURA

42. Future Research Directions
Evaluate the feasibility and efficacy of manual for teaching and implementing Spiritual AIM
Expand scope of Spiritual AIM research to other patient and caregiver populations
Compare efficacy of Spiritual AIM to other interventions, controls (RCT)
Develop and evaluate method/measure for identifying a patient’s core spiritual need (assessment tool)
Identify “mechanism of action” of Spiritual AIM
Michele

43. Michele
Thank you!! Please contact us:

44. Acknowledgements
With gratitude to the John Templeton Foundation and HealthCare Chaplaincy
UCSF Helen Diller Family Comprehensive Cancer Center
UCSF Symptom Management Service
UCSF Spiritual Care Services
The Jewish Theological Seminary – Center for Pastoral Education
The patients
We have many people to thank – in particular, the John Templeton Foundation and the HealthCare Chaplaincy.
And the remarkable leadership and vision of George Handzo and Linda Emanuel in leading this project.
The faculty on the project, some of whom you have been hearing from this week, as well as the other research teams, have also contributed to shaping our work, and have become a wonderful community for us, so we want to make sure to thank all of them as well.

45. Project Team Laura B. Dunn, MD - Project Director
Allison Kestenbaum, BCC, MA, MPA, ACPE Supervisor - Project Chaplain, Lead Investigator
The Rev. Michele Shields, D.Min., BCC, ACPE Supervisor – Project Chaplain, Lead Investigator
Michael W. Rabow, MD, FAAHPM - Co- Investigator
The Rev. Will Hocker, MSW, MDiv, BCC – Consultant/ Interviewer
Jennifer James, MSW, MSSP - Research Coordinator
Daniel Dohan, PhD - Consultant (Qualitative Research)
Stefana Borovska, BS and Joshua Carroll, BA – Medical Students
Our project team was a rich interdisciplinary collaboration, with representation from palliative care, psychiatry/psycho-oncology, chaplaincy, sociology, nursing, and medical education.