Utilization and perceptions of chaplaincy among hospitalized adults of Dharmic religions with cancer

Abstract

Background

Spiritual care provided by chaplains plays a key role in cancer care in the United States, yet little is known about chaplaincy utilization among people of Dharmic religions (Hinduism, Buddhism, Sikhism, Jainism) with cancer.

Methods

This multi‐methods study reviewed the records of patients (aged 18 years and older) who were hospitalized at a dedicated cancer hospital (2015–2019) and conducted interviews with chaplains and adults of Dharmic religions (2020). Primary outcomes included measuring chaplaincy utilization (at least one chaplain visit) across different religions and identifying perceptions of chaplaincy. Secondary outcomes involved measuring unmet spiritual needs on admission, types of spiritual care needs, and variables associated with chaplaincy utilization.

Results

Of 54,828 patients, 2% were of Dharmic religions (n = 1163; 58.4% Hindu, 33.2% Buddhist, 4.8% Sikh, 3.4% multiple, <1% Jain). Compared with others, those of Dharmic religions were younger (median age, 59 vs. 63 years; p < .001), predominantly East or South Asian (78.7% vs. 5.6%; p < .001), and had higher rates of advanced illness (22.6% vs. 15.2%; p < .001) but lower chaplaincy utilization (31.6% vs. 36.7%; p < .001). There were no significant differences in unmet spiritual needs on admission (Dharmic religions vs. others, 8.7% vs. 9.4%; p = .41). Ritual care was the most frequently documented spiritual care need (72%). Multivariable analysis indicated that longer length of stay, non‐Dharmic religion, and advanced illness were associated with higher chaplaincy utilization. Themes identified from the interviews included unfamiliarity with chaplaincy, concerns about faith‐discordant care, addressing spiritual care needs independently, and solutions for concordant care.

Conclusions

People of Dharmic religions with cancer were less likely to use chaplaincy services. Barriers included unfamiliarity and faith discordance. Spiritual care incorporating faith‐specific resources is urgently needed.

Short abstract

Hospitalized adults of Dharmic religions (Hinduism, Buddhism, Sikhism, Jainism) with cancer used chaplaincy services less often than those of other religions, with barriers, including unfamiliarity about chaplaincy and concerns about faith‐discordancy, resulting in individuals addressing needs independently. The findings suggest a need to develop models of concordant spiritual care.

INTRODUCTION

Dharmic religions (DRs [Hinduism, Buddhism, Sikhism, and Jainism]) account for 25% of the world population. ¹ These religions are related historically insofar as the latter are offshoots of Hinduism and derive foundational beliefs and practices around dharma, karma, and reincarnation that influence how individuals cope with cancer. ² , ³ , ⁴ , ⁵ Hinduism is the largest (1.1 billion followers worldwide; 94.3% in India), followed by Buddhism (487 million; 50% in China). India is also home to the largest Sikh (14.4 million; 1.9% of total population) and Jain (3.3 million; 0.4% of total population) communities. ⁶ Although DRs represent 2% of the US population, ⁷ Asian Americans were the fastest growing racial or ethnic minority between 2000 and 2019; the three most common countries of origin were China (25%), India (21%), and the Philippines (19%). ⁸ After Christianity (34%) and the unaffiliated (32%), Hinduism and Buddhism were tied for the third most common religious affiliations among Asian Americans (11%), followed by Islam (6%); Sikhism, Jainism, and other religions (e.g., Daoism) altogether accounted for 4%. ⁹ At the same time, 40% reported feeling close to at least another religion for other reasons (e.g., ancestry, culture). Although fewer Hindus (33%) and Buddhists (31%) report that religion is very important to their life compared with the US public (41%), this may reflect how religious and secular identities interact differently in their native countries, where religion is often more fully integrated into life and less regarded as a distinct construct.

Spiritual care is an interdisciplinary field within health care that acknowledges the spiritual considerations of patients and caregivers. ¹⁰ Spiritual care is vital to the care of patients who have serious illnesses. ¹¹ The American Society for Clinical Oncology and the American Academy of Hospice and Palliative Medicine consider spiritual care as one of the nine components of high‐quality palliative care in oncology. ¹² Spiritual care is also recognized as an integral component of cancer care by the National Comprehensive Cancer Network (NCCN) and by The Joint Commission. ¹³ , ¹⁴

Whereas 79.8% of acute care/general acute care hospitals reported offering chaplaincy services, ¹⁵ psychosocial support care at NCCN‐designated cancer centers was most frequently delivered by mental health therapists (48%); chaplains, psychologists, and psychiatrists collectively delivered 30% of psychosocial care. ¹⁶ Patients with cancer who had unmet spiritual needs reported lower psychological quality of life, ¹⁷ lower ratings of quality of care, and lower satisfaction with care. ¹⁸ Greater support of the spiritual needs of patients with cancer by the medical team has been associated with improved quality of life, more utilization of hospice services, and less utilization of intensive care unit‐level care at the end of life (EOL). ¹⁹

Little has been published about the spiritual care needs or the utilization of chaplaincy services of hospitalized patients who identify with the DRs (Hinduism, Buddhism, Sikhism, and Jainism), some of which are growing in conjunction with a growing population of South Asians in the United States. ¹ , ²⁰ The overall goal of this study was to measure utilization and perceptions of chaplaincy services by DR patients admitted to a dedicated cancer hospital.

MATERIALS AND METHODS

Study sample

This study was conducted at Memorial Hospital, a dedicated cancer hospital within the Memorial Sloan Kettering Cancer Center (MSK) system. At MSK, 10 board‐certified interfaith chaplains (seven inpatient, three outpatient) are trained to visit and offer spiritual care to individuals of all faiths. Spiritual care services are advertised in informational material provided to individuals. The current study was approved by the local Institutional Review Board and was designed according to Good Clinical Practice Guidelines and the Declaration of Helsinki.

A retrospective review of the electronic health record (EHR) for all adult patients (aged 18 years and older) admitted to Memorial Hospital between January 1, 2015 and October 16, 2019 who identified as Hindu, Buddhist, or Sikh was conducted. Patients identified their religious affiliation during the patient registration process at the time of their first outpatient oncology visit to MSK. Although Jainism was not included on institutional list of religions (see Table S1), patients identified themselves as Jains in chaplaincy documentation.

In the second phase of this study, we used a qualitative descriptive approach involving semistructured interviews with patients and chaplains for in‐depth exploration of spiritual care delivery and needs of hospitalized DR patients. Eligibility criteria remained the same except that patients were hospitalized between March 1, 2020 and June 15, 2020. Patients who identified as Hindu, Buddhist, and Sikh were identified through a daily report generated from the institutional database and were approached sequentially to confirm their religious affiliation for study participation; the onset of the coronavirus disease 2019 pandemic prompted the institution to enact limits on how research was conducted, which prohibited purposive sampling to maximize representation of all four DRs. One of the co‐investigators (J.M.B.) was head of the Chaplaincy Department at the time of the study and shared study information with all employed chaplains and chaplain residents. All patients and chaplains provided informed consent for study participation. One chaplaincy resident was also included. No incentives were provided for participation.

Chaplaincy referral

On hospital admission, nurses routinely screened patients for spiritual needs as part of their initial intake using a modified version of the Rush Protocol, an accepted screening tool for religious/spiritual (R/S) needs (see Figure S1). ²¹ In addition, patients or other providers (e.g., clinicians, nurses) could request spiritual care at any time during the hospital stay. Chaplains then visited the patient, offered spiritual care, and documented the outcome of this encounter.

MEASURES

Patient characteristics

For the retrospective cohort, the following patient‐specific data were collected from the EHR based on documentation from the most recent admission: age, sex, religion, race (East or South Asian; Black or African American; Hispanic or Latino; Native American/Alaska Native; Native Hawaiian/Pacific Islander; Non‐Hispanic White; other; unknown; refused to answer), ethnicity (Hispanic; non‐Hispanic; unknown), primary language, primary cancer diagnosis, and chaplaincy utilization. For those interviewed, all variables were self‐reported (age, sex, race, religion, country of origin, time in the United States) except for the primary cancer diagnosis (EHR).

Chaplaincy utilization

Chaplaincy utilization by a patient was defined as at least one documented chaplain visit to the patient. In addition, we recorded the number of patients screened by nurses on admission, responses to each question in the screening protocol, and patients for whom the chaplain completed an initial spiritual assessment. Time to chaplaincy referral was measured by the number of days between hospital admission and the date of the first chaplaincy visit. The total number of patients visited by chaplains was counted by the number of chaplains' notes. The outcome of the chaplaincy visit was identified from chaplaincy documentation and categorized based on whether the patient or family accepted or declined services at the time of the chaplain's visit. If the patient or family was unavailable at the time of the first visit, the outcome of the final encounter was recorded.

Spiritual care needs

Chaplains documented their spiritual care encounter using an EHR template. Chaplaincy documentation was reviewed to identify spiritual care needs, as defined by the NCCN Guidelines for Distress Management. ¹⁴ Because the study period included several versions of the guidelines, all needs identified in the guidelines were included. Multiple instances of the same need for an individual patient were counted once. For ritual care, documentation was also reviewed to determine whether the specific need was addressed.

Perceptions of spiritual care

Two semistructured interview guides were developed by the principal investigator (R.V.P. [palliative care]) with interdisciplinary input (J.M.B. [chaplaincy], J.E.N. [palliative care]) to explore: (1) hospitalized DR adults' perceptions of spiritual care and chaplaincy and (2) chaplains' experiences caring for DR patients.

Analysis

Quantitative methodology

Data are presented with counts (and percentages) and medians (and ranges) as appropriate. Patient demographics and disease and treatment characteristics are compared between DR and non‐DR (NDR) patients using Fisher exact tests for categorical variables and Kruskal–Wallis tests for continuous variables. Modeling to estimate the odds of chaplaincy utilization was performed using logistic regression; a multivariable model was fit to estimate the association of religious group and chaplaincy utilization independent of age at hospital admission, race/ethnicity, primary language, advanced illness), and hospital length of stay (LOS). Sensitivity analyses were performed for religion to ensure the results did not change significantly with the exclusion of missing data.

Qualitative methodology

The principal investigator (R.V.P.) interviewed hospitalized patients at MSK who identified with a Dharmic faith (Buddhism, Hinduism, Jainism, Sikhism). The first seven interviews were conducted in person; however, because of institutional restrictions on research to minimize patient contact with the onset of the coronavirus disease 2019 pandemic, the remaining interviews were completed by phone. Interviews lasted 45–60 minutes and were audio‐recorded. One interview was excluded from the final sample because the patient revealed during the interview that she initially identified as Buddhist but had stopped practicing following her cancer diagnosis.). Two investigators (A.E.S., S.E.G.) with extensive training in qualitative research methods led the analysis of the interviews. Neither practiced a DR nor claims expertise in the principles of these faiths. For this reason, collaboration with the principal investigator, a physician of Hindu background and familiarity of the major tenets of each DR, was prioritized at all stages of the analysis to guide interpretation of the data. A.E.G. and S.E.G. reviewed the patient transcripts and developed a codebook to capture concepts found in the textual data using a combined inductive‐deductive approach. ²² First, deductive codes were developed to align with a priori domains of interest, and then open coding was conducted on a subset of transcripts to inductively identify additional, emergent codes. The codebook was reviewed with R.V.P., who provided direction and clarifications, before being applied to the full data set. Data were managed with ATLAS.ti software, version 9.0. ²³ A.E.S. and S.E.G. independently coded the transcripts in groups of two to four transcripts and met after each group of transcripts was coded to compare their coding. The codebook was adjusted as needed, based on discussions of code meanings and application. Discrepancies in coding were discussed and resolved iteratively. Segments of text were then reviewed by code or groups of codes and summarized. Summaries were synthesized into themes using the principles of reflexive thematic analysis. ²⁴ Preliminary findings were reviewed and discussed with R.V.P. to draw on the combined insights of the qualitative analytic team. After discussion, the investigators refined the findings and identified illustrative quotes from the interview transcripts.

The investigators also assessed saturation by determining the point within the data set at which no new relevant ideas emerged. ²⁵ The transcripts were organized in chronological order, and the progression of concept identification within each interview was documented. First, a matrix was created in Microsoft Excel (Microsoft Corporation) with a code‐by‐transcript display. After each coding session, one investigator recorded the number of new codes with each successive transcript. A stopping criterion of three transcripts was used, meaning that, once no new concepts were identified in the data, the investigators reviewed another three transcripts for confirmation. ²⁶ By using this method, saturation was reached at 18 interviews.

RESULTS

Sociodemographic characteristics

Among 54,828 adult patients with cancer who were hospitalized between January 1, 2015, and October 16, 2019, 58.0% identified as Christian, 13.7% identified as Jewish, 1.9% identified as Muslim, and 2.1% identified with a DR (n = 1163; 58.3% Hindu, 33.2% Buddhist, 4.8% Sikh, 3.4% multiple DRs, 0.1% Jain). DR patients were younger than NDR patients (N = 53,665; 98.2%; median age, 59 vs. 63 years p < .001) and were more likely to identify as East or South Asian (78.7% vs. 5.6%; p < .001). NDR patients were more likely to speak English (91.8% vs. 81.3%; p < .001). After English, the most common languages spoken by DR patients included Mandarin Chinese (35.8%), Cantonese Chinese (27.1%), and Hindi (8.7%).

Although the median LOS was 4 days for both religious cohorts, the distribution of LOS was significantly shorter for DR patients (range, 1–157 vs. 1–320 days; mean, 7.7 ± 10.9 vs. 6.9 ± 10.2 days; p < .001). DR patients were more likely to have a solid tumor diagnosis (81.4% vs. 68.7%; p < .001) and advanced illness (22.6% vs. 15.2%; p < .001).

Spiritual screening and chaplaincy utilization

Most patients completed spiritual screening on intake (DR, 96.2%; NDR, 97.6%), and no significant differences were observed in the proportions of patients who screened positive for unmet spiritual care needs (8.7% vs. 9.4%; p = .41; see Figures S1 and S2). During the study period, chaplaincy utilization decreased for both cohorts, although the number of total admissions increased (Figure 1).

FIGURE 1.

Chaplaincy utilization by year.

For both cohorts, the median time to the first chaplaincy visit was 1 day, and the median number of visits was one; however, significant differences were noted in the distributions of both variables (Table 1). No significant differences were noted in the proportion of patients accepting the initial visit (DR vs. NDR: 97.5% vs. 98.7%; p = .07). DR patients were less likely to have at least one chaplaincy visit (31.6% vs. 36.7%; p < .001). In multivariable analyses, NDR affiliation (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.28–1.72; p < .001], advanced illness (OR, 1.14; 95% CI, 1.08–1.19; p < .001), and longer LOS (OR, 1.69; 95% CI, 1.66–1.72; p <0.001) were associated with at least one chaplaincy visit (Table 2).

TABLE 1.

Overall characteristics.

	No. (%) or median [range]
Characteristic	Dharmic religions, N = 1163	Non‐Dharmic religions, N = 53,665	p
Age, years	59 [18–92]	63 [18–101]	< .001
Female	621 (53.4)	28,075 (52.3)	.48
Religion
Hinduism	679 (58.4)
Buddhism	386 (33.2)
Sikhism	56 (4.8)
Jain	2 (0.2)
Multiple faiths a	40 (3.4)
Christianity		31,801 (59.3)
None		10,894 (20.3)
Judaism		7514 (14.0)
Islam		1019 (1.9)
Other/spiritual, not religious		446 (0.8)
Unknown		1991 (3.7)
Race			< .001
East or South Asian	915 (78.7)	3014 (5.6)
Black or African American	16 (1.4)	4001 (7.5)
Hispanic or Latino	3 (0.2)	3607 (6.7)
Native American/Alaska Native	9 (0.8)	72 (0.1)
Native Hawaiian/Pacific Islander	2 (0.2)	19 (<0.1)
Non‐Hispanic White	119 (10.2)	40,199 (74.9)
Other	36 (3.1)	566 (1.1)
Unknown/refused	63 (5.4)	2187 (4.1)
Language			< .001
English	945 (81.3)	49,262 (91.8)
Other	218 (18.7)	4279 (8.0)
Unknown	0 (0.0)	124 (0.2)
Length of stay, days	4 [1–157]	4 [1–320]	< .001
Cancer type b
Solid tumor	780 (81.4)	31,313 (68.7)	< .001
Hematologic	82 (8.6)	4102 (9.0)
Multiple sites	96 (10.0)	10,164 (22.3)
Admitting team			.89
Medicine	495 (42.5)	23,222 (43.3)
Surgery	666 (57.3)	30,350 (56.5)
ICU	2 (0.2)	92 (0.2)
Advanced illness	260 (22.6)	8171 (15.2)	< .001
Admitted to the ICU	87 (7.5)	3146 (5.9)	.02
Died inpatient	105 (9.2) c	3734 (7.0)	.006
Discharged to hospice	115 (9.9)	2991 (5.6)	< .001
Spiritual needs			.41
Met	1022 (91.3)	47,447 (90.6)
Unmet	97 (8.7)	4951 (9.4)
One or more chaplaincy visit(s)	368 (31.6)	19,679 (36.7)	< .001
Days to first visit	1 [0–52]	1 [0–208]	.03
Total no. of visits	1 [1–23]	1 [1–80]	.03
Accepted visits	357 (97.5)	19,269 (98.7)	.07

Abbreviations: DR, Dharmic religion; ICU, intensive care unit; NDR, non‐Dharmic religion.

^a Identified with at least one DR.

^b Data were missing for 8291 patients (8086 NDR, 205 DR).

^c Excluded data for 15 DR patients because of conflicting information between data sets.

TABLE 2.

Multivariate association for chaplaincy utilization by hospitalized patients.

Variable	Odds ratio (95% CI)	p
Non‐DR	1.48 (1.28–1.72)	< .001
Age a	1.01 (0.99–1.02)	.10
Race/ethnicity		.26
East or South Asian	1.08 (1.00–1.17)
Black or African American	0.99 (0.92–1.05)
Hispanic or Latino	0.99 (0.92–1.06)
Other	1.08 (0.93–1.27)
Non‐Hispanic White	Reference
English as primary language	0.98 (0.91–1.05)	.56
Advanced illness	1.14 (1.08–1.19)	< .001
Hospital length of stay b	1.69 (1.66–1.72)	< .001

Abbreviations: CI, confidence interval; Non‐DR, non‐Dharmic religion.

^a Reported in 10‐year intervals to facilitate interpretation.

^b Reported in 7‐day intervals to facilitate interpretation.

Spiritual care needs

Among DR patients who were seen by chaplains, 100 of 368 (27.0%) had documented spiritual care needs; the majority had no spiritual care needs documented. The most comment needs were ritual care (72.0%), grief/loss (39.0%), and concerns about dying/death and/or the afterlife (26%; Figure 2). Within ritual care, the most commonly reported needs included prayer (n = 57), requests to connect with a faith community (n = 16), scripture (n = 4), chants (n = 3), objects of worship (n = 3), and EOL rituals (n = 1). Based on documentation, all ritual care needs were addressed except requests to connect with a faith community or EOL rituals.

FIGURE 2.

Spiritual care needs.

Perceptions of spiritual care

Of 31 eligible patients approached for the study, 23 were interviewed; reasons for declining participation included medical illness (n = 4), not interested (n = 3), and incorrect religious affiliation (n = 1). All 11 chaplains approached for the study consented to the interview. (Table 3). No chaplain identified their religious affiliation as a DR. Only two patients had one chaplain visit before their interview. Reflecting on their experiences, chaplains reported interacting or providing spiritual care for few DR patients. They reported caring for more Hindu and Buddhist patients than Sikh and Jain patients. Four themes were identified (Table 4).

TABLE 3.

Interview participants.

	No. (%) or median [range]
Characteristic	Patients, n = 22	Chaplains, n = 11
Age, years	52 [21–82]	59 [22–72]
Female	14 (63.6)	6 (54.5)
Race
Asian Indian	22 (100.0)	0 (0.0)
White	0 (0.0)	9 (81.8)
African	0 (0.0)	1 (9.1)
African American	0 (0.0)	1 (9.1)
Religion
Hinduism	20 (90.9)	0 (0.0)
Sikhism	2 (9.1)	0 (0.0)
Christianity	0 (0.0)	7 (63.6)
Islam	0 (0.0)	2 (18.2)
Judaism	0 (0.0)	2 (18.2)
Chaplaincy experience, years	—	10 [2–30]
Time at MSK, days	—	3 [0–32]
Country of origin
India	18 (78.3)	—
Guyana	2 (8.7)	—
United States	2 (8.7)	—
Kenya	1 (4.3)	—
Time in the United States, years a	29 [8–52]	—
Cancer
Solid	15 (68.2)	—
Hematologic	5 (22.7)	—
Noncancer b	2 (9.1)	—

Abbreviation: MSK, Memorial Sloan Kettering Cancer Center.

^a One patient resided in India.

^b Two patients admitted for workup of a solid mass were later found not to have cancer.

TABLE 4.

Interview themes.

Themes	Patient quotes	Chaplain quotes
DR patients lacked familiarity with inpatient spiritual care or chaplaincy.	“Spiritual care? In what regard? Care does not—the care that I get, I don't know if it's spiritual. I'm a little at a loss, I don't understand your question.” (ID 119) “Chaplain, what is that?” (ID 100) “Chaplain. Church, right?…Or somewhere to pray, right?” (ID 116)	“If the patient comes from South Asia or mainland China, they don't know what a chaplain is unless they've lived in the Western world or they've been educated anywhere in the world in some kind of secular academic education.” (ID 205) “I think especially for people of Eastern traditions where clergy is not central to their belief and their practice. Clergy says the prayers in the temple and is paid to do ceremonies and does things like that…in Western faiths the clergy is more present to the day‐to‐day and is more pastoral and gives more advice and more direction to people as to how their lives should go and how they should look.” (ID 200)
DR patients and chaplains identified faith discordance as a barrier to inpatient spiritual care.	“…in the hospital because it is more Christianity driven, or maybe because I don't ask for it I don't know, I don't feel a lot of spirituality here.” (ID 114) “No, I don't want it [altar or murtis] here. I didn't see any Hindu person here. So it wouldn't look nice to them. They would not understand.” (ID 122) “…as long as they don’t think it’s some Pagan religion…like some rock age, stone age kind of thing because that’s generally what I’m’ apprehensive about because it’s not easy to explain faith and spirituality.” (ID 106) “Probably not because I feel like it’s [Hinduism] not something that’s recognized as much as perhaps some other faiths. So, I would feel a little uncomfortably about what to ask or what to expect. So, I would probably back off.” (ID 105)	“Mostly people don't think that we know anything about any of those faiths and so they will generally say, I have no needs. So if we try to press a little and say I may not know much about your faith but I would like to respectfully provide that which you need, they might say something, but generally they just reinforce that, no, they don't want anything.” (ID 200) “That may be because they see me as an outsider.” (ID 205) “Well, I think most people, when they hear the word chapel and they hear the word chaplaincy, chaplain, they put this barrier up right away, that this is not for me, for the Eastern perspective.” (ID 202)
DR patients addressed spiritual care needs independently without chaplaincy.	“I still try to do my paath [prayer] in the morning…prayer in the morning and in the evening on my own. It's important for me to do, not the whole hospital.” (ID 121) “To be honest with you I'm not that spiritual person in the sense like when I come into the hospital, I don't expect somebody to provide me with my requirement of spiritual care.” (ID 120) “…my parents and my family, they're like—you know, my in‐laws, they are doing too much. So I think there's enough.” (ID 117) “I didn’t have a reason to ask but I don’t have a problem with it.” (ID 115) “What is there to be ashamed to ask spiritual care? That's, the only thing one should ask for.” (ID 103)	“I have found those families—it's just an interesting point—to be, like, 'we don't need your help but thank you so much. It's like a different—like genuine appreciation. Like we're taken care of.” (ID 208) “I think most people are just happy to have somebody in the room with them that is showing them some attention and compassion. So, yeah, even if, like, the word chaplain itself doesn't really click, the experience of chaplaincy kind of remains. I haven't been declined because they didn't know what a chaplain was.” (ID 209)
DR patients and chaplains identified opportunities for hospitals to improve spiritual care for DR patients.	“[A panditji] would also act as a companion while you’re doing a mantra jap. You can speak to him about the negativity that’s sort of affecting you, and he can help guide you like tell you not to—how not to focus on it.” (ID 102) “…when somebody comes and talks to me about Jesus or maybe about any other religion, I might not relate as much because I haven’t practiced that ever. But if somebody comes and tells me, even if not everything about devis [goddesses] and all that, but once in a while if they have a story about something which is devi related [goddess] or something, I might connect to that. So, that’s why it’s more important for me to have a Hindu person come and talk to me…we would share the same ideas maybe and then that would help.” (ID 100) “…if I'm talking to a Hindu, I don't have to explain all the fundamentals to that person…when I'm saying puja, he will understand that word puja, right? If I'm talking to an American Christian if I say puja, that person won't understand what puja is, right? I have to say prayer. So that kills that moment…that's the only reason they would want Hindu, of course to connect.” (ID 117)	“…I mean in the privacy of a chaplain's office, you can ask the stupid questions to your colleague…What should I or should I not say to this person? And, yes, we're all—we can Google this stuff. We can whatever. But, from someone who is living that tradition every day and who has worked in it—whatever. I think that's invaluable.” “We haven't devoted the resources to bringing on chaplains of those traditions who can provide and—even in an interfaith context and all of those things—who can provide that care at a more intentional level than a bunch of amateurs like me.” (ID 206) “… the didactics that I've had have also been pretty basic because one person can just give you enough for 1 hour and a half long session. Right? That's what a didactic is. You bring somebody from the outside to teach them things in a very short amount of time. And so I think that there's a lot of rich knowledge in all four of these traditions that, if we begin to delve into, we will better understand how these four specific traditions differ and how our spiritual approaches would differ accordingly. But I think right now we're going in with a general idea of how Eastern traditions are different from Western traditions.” (ID 209) “I've really tried to do a little bit of sort of learning on the side where I could when I had a Hindu patient that I wanted to try to be more responsive to and more intentional with. But it's basically a little like, okay, let's go home and Google things I might need to know about Hinduism, and that's pretty bad.” (ID 204) “We need to reach out to [patients], educational‐wise. And we need to put together some brochures, speaking to a particular faith traditions, of services that are available here for them so they don't feel like they are isolated…we need to send information out for those faith groups that are marginalized and say, you are welcome to be here, we want your services, we want you to practice.” (ID 202)

Abbreviations: DR, Dharmic religion; ID, identifier.

Theme 1: DR patients lacked familiarity with inpatient spiritual care or chaplaincy

Most patients were unaware of inpatient spiritual care or chaplains; however, some patients said that they would have appreciated it. Some associated chaplains with Christianity, whereas others understood the word chaplain to mean a chapel. Most chaplains felt patients of all faiths were unaware of their services or associated their presence with the EOL, and several attributed this unfamiliarity to stereotypes.

Theme 2: DR patients and chaplains identified faith discordance as a barrier to inpatient spiritual care

Some patients did not feel that their religion would be recognized by the hospital and that others lacked an understanding of the basic tenets of their faith. Similarly, several chaplains expressed that patients may think that interfaith chaplains are not knowledgeable about their faith or may prefer a same‐faith spiritual care provider, which leads them to report that they have no needs and thus require no help. Although chaplains expressed a desire to learn more, some patients noted that it could be burdensome to have to explain one's faith to another person, especially in times of critical illness.

Theme 3: DR patients addressed spiritual care needs independently without chaplaincy

While hospitalized, patients focused on independent practice of their religion through prayer, meditation, and/or worship of God with murtis (sacred images) and reported not needing or expecting any accommodations from the hospital. Others were not practicing or did not feel it was the hospital's role to provide spiritual care. Both patients and chaplains also noted how families provided spiritual care to their loved ones. However, most patients stated that they would be comfortable asking for spiritual care during their hospital stay if they needed anything. Chaplains also noted that unfamiliarity with their role among DR patients did not preclude them from meeting their needs.

Theme 4: DR patients and chaplains identified opportunities for hospitals to improve spiritual care for DR patients

Both patients and chaplains recommended the hospital hire more DR chaplains. Specific needs noted by patients included providing encouragement, praying or chanting with them, or providing sanctified food and water. Chaplains noted that DR chaplains could also assist with improving knowledge of the beliefs and practices specific to these faiths. In addition, chaplains recommended increasing awareness of their services, particularly to marginalized groups, and developing relationships with community‐based faith organizations.

DISCUSSION

By using a multi‐methods approach, this study is the first to measure screening for spiritual care needs, the utilization of spiritual care services, and specific spiritual care needs using NCCN criteria among hospitalized DR adults with cancer in the United States. Little is known about spiritual care preferences of adults with cancer who identify with religious minorities in the United States, a topic that has been identified as a priority for health research. ²⁷ , ²⁸

We found slightly lower proportions with unmet spiritual care needs across both the DR cohort and the NDR cohort compared with other analyses that included cancer patients with cancer who had moderate‐to‐high spiritual needs (10%–25%). ²⁹ , ³⁰ , ³¹ , ³² , ³³ This variation across studies can be accounted by differences in how spiritual needs are defined and measured. For example, two studies conducted in ambulatory hematology/oncology clinics using self‐administered surveys found that 73%–79% reported at least one spiritual need using a validated spiritual assessment tool, although 11%–18% reported having unmet needs when asked, “Do you feel your spiritual needs are being met?” ¹⁸ , ³⁴ Other work has identified that needs vary by severity of illness, other comorbidities, cultural context, sex, and age. ³⁵ Of note, spiritual screening tools developed in the United States have primarily been validated in cohorts of adults of Jewish or Christian faiths. ³⁶ , ³⁷ The sensitivity and specificity of the screening tool used in our hospital has been reported as 42% and 81%, respectively, indicating that it better identifies those without unmet needs. ²¹ Thus the lack of a gold standard for measurement limits the calibration of existing tools and warrants clinician judgment and consultation with chaplains. ³⁸

Although there were no significant differences in the proportion of patients who screened positive for unmet spiritual care needs, DR patients were less likely to access chaplaincy services. Even after accounting for advanced illness, LOS, and English as a primary language, religious affiliation remained an independent predictor of chaplaincy utilization. Compared with non‐Hispanic White patients, patients of ethnic minorities have reported religion/spiritual considerations as integral to their care. ¹¹ , ³⁹ However, interviews with patients revealed that unfamiliarity and perceived discordance prohibited access to inpatient spiritual care. Several individuals noted the perception of the hospital as a Christian institution and felt uncomfortable practicing their faith in the inpatient environment. Although hospital chaplains can support hospitalized patients in their religious practices, the adults interviewed in this study were confused by the term chaplain and frequently associated it with Christianity. This association is not entirely surprising, with the earliest descriptions of the DRs originating from British chaplains involved in Christian missionary work in India. ⁴⁰ However, this historical precedent risks unequal access to spiritual care because consensus recommendations have identified chaplains as spiritual care specialists. ¹¹ , ⁴¹ Conversely, the term, spiritual care, confused patients. With the secularization of modern medicine over the past 2 centuries, clinicians may be unaware of how the construct of spirituality became associated with the removal of DR teachings from their original devotional context. ⁴⁰ Furthermore, the Western distinction between religion and spirituality may be incongruent with DR beliefs and may inadvertently lead to marginalization. ⁴² , ⁴³ Prior work has demonstrated how unmet spiritual needs are associated with lower satisfaction with care, which highlights the need to develop concordant models of spiritual care. ¹⁸ , ²⁷ , ³⁴

Both patients and chaplains noted that greater representation of DRs in the chaplaincy workforce could enhance knowledge of their beliefs and practices, particularly in the context of advanced illness, when patients may not be well enough to participate in lengthy conversations. Although several spiritual care needs, like prayer, were documented to be addressed, it remained unclear how well the care aligned with DR patients' preferences. We found no documentation that requests for faith communities or EOL rituals were addressed, a gap that was further corroborated by the chaplain interviews, which may reflect an unrecognized opportunity for hospitals to establish relationships with community‐based faith organizations.

These data are limited to the patient population of one specialized cancer hospital in the United States and may not reflect findings elsewhere. Although the surrounding metropolitan area is home to one of the largest communities of DRs in the United States, ⁴⁴ DRs constituted only 2% of the overall cohort. Because the DRs constitute roughly 2% of the entire US population, ⁷ replicating this analysis in other settings to confirm generalizability could be limited by smaller DR cohorts. However, our findings align with emerging updates from an ongoing, community‐based, participatory research project focused on how beliefs and values influence the palliative care preferences of Hindu adults with cancer and their caregivers living in Charlotte, North Carolina (e.g., improving chaplains' awareness about faith‐based considerations for Hindus when a DR chaplain is unavailable). ⁴ , ⁵ , ⁴⁵ Our sample was predominantly Hindu and Buddhist, and further research should explore the needs of Sikh and Jain adults with cancer. Although Sikhism was available for identification on intake, Jainism was only identified from chaplaincy documentation, so we may have underestimated their representation in our cohort. We were unable to account for additional variables, such as education level, insurance status, relationship status, and religiosity. However, we included variables noted to be associated with chaplaincy utilization, like LOS and severity of illness. ⁴⁶ Furthermore, self‐identification as practicing a DR is a surrogate for shared beliefs and values. Although most adults were not of US origin, the median length of time lived in the United States was 29 years. We could only interview patients who were well enough to participate. Hence their observations may not reflect those with more advanced illness, although several patients reflected on their prior experiences as a caregiver for a loved one with advanced illness.

Despite the limitations, this study suggests that inequities exist in the delivery of spiritual care for DR adults with cancer. Future work should focus on improving training for health care professionals about DR‐specific needs, enhancing DR representation in the chaplaincy workforce, and creating standards around partnerships between hospitals and community‐based faith organizations. In addition, more research is needed to identify the spiritual care needs of caregivers of DR patients and how they can be incorporated into spiritual care delivery. This collective effort will help realize concordant and equitable spiritual care for DR adults with cancer.

AUTHOR CONTRIBUTIONS

Rushil V. Patel: Conceptualization; methodology; writing—review and editing; writing—original draft; funding acquisition; investigation; data curation; validation; visualization; project administration. Jill M. Bowden: Formal analysis; writing—review and editing. Danielle Boselli: Formal analysis; writing—review and editing. Ashley E. Strahley: Formal analysis; writing—review and editing. Sydney‐Evelyn L. Gibbs: Formal analysis; writing—review and editing. Komal P. Murali: Writing—review and editing. Viraj R. Patel: Writing—review and editing. Ritesh R. Kotecha: Writing—review and editing. Judith E. Nelson: Resources; conceptualization; methodology; writing—review and editing.

CONFLICT OF INTEREST STATEMENT

Rushil V. Patel reports personal/consulting fees from for the Hospice & Palliative Nurses Association and has served on advisory committees for the Yeshiva University School of Social Work Gerontology and Palliative Care Program for Interfaith Clergy, Pallium India, and the Coalition to Transform Advanced Care outside the submitted work. Ritesh R. Kotecha reports grants/contracts from Allogene Therapeutics, Arsenal Bio, Exelixis, Novartis, Pfizer, Takeda Oncology, the US Department of Defense, and Xencor; and personal/consulting fees from Eisai outside the submitted work. The remaining authors disclosed no conflicts of interest.

Supporting information

Supplementary Material

Patel RV, Bowden JM, Boselli D, et al. Utilization and perceptions of chaplaincy among hospitalized adults of Dharmic religions with cancer. Cancer. 2025;e35797. doi: 10.1002/cncr.35797

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.