Spirituality and spiritual care in palliative and terminal illness: a systematic review and epistemic meta-analysis from physicians’ hermeneutic and bioethical perspective

Abstract

Background

Spirituality is a fundamental aspect of palliative care; however, it remains insufficiently addressed by physicians, despite patient’s expressed preferences and substantial evidence supporting its benefits. This systematic review explores the reason behind this persistent gap, focusing on the sociological and axiological factors influencing physician engagement with spiritual care.

Aim

To develop a spirituality operative definition in the frame of healthcare and simultaneously identify and analyze the (value—based) axiological and sociocultural factors that influence physicians’ engagement with spiritual care to terminally ill patients.

Method

A systematic review was conducted according to PRISMA guidelines. Three databases (PubMed, Web of Science, BIREME) were searched up to September 2023. Studies were included based on their examination of physicians’ perspectives on spiritual care in palliative settings. Thematic synthesis was performed using Atlas.ti guided by Paul Ricoeur’s hermeneutic framework and Echeverría’s axiology or values system. Quality appraisal was conducted using cross functional approach.

Results

Physicians’ engagement with spiritual care is shaped by their own spirituality, including encompassing personal values (e.g., compassion, respect), individual beliefs and self-awareness regarding their own well-being and transcendent dimension of clinical practice. Additional factors include communication skills, established clinical routines and the nature of the care they provide their patients. The key barriers identified include insufficient training, ambiguity regarding the physician’s role in spiritual care and personal discomfort addressing spiritual matters. Cultural contexts and institutional dynamics, such as wether care is primarily nurse-led or physician-led care – also impact physician’s involvement.

Conclusion

Effectively integrating spiritual care into palliative practice requires not only technical competences grounded in evidence and values-based medicine but also reflective engagement with one’s own core values and beliefs. Understanding physicians’ perspectives highlights opportunities to embed spirituality and improve spiritual care provision by doctors within holistic care frameworks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-025-01916-x.

Background

Despite increasing recognition of spirituality as a vital component in palliative care, physicians often neglect this dimension in clinical practice. Although numerous definitions of spirituality are found in the literature, no single universally accepted one fully encompasses all its dimensions. One of the most widely recognized formulations was developed during the International Consensus Conference on Improving the Spiritual Dimension of Whole Person Care: The Transformational Role of Compassion, Love, and Forgiveness in Health Care [1]. “Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices.” Patients consistently express a desire for spiritual support during serious illnesses, and often wish to explore existential concerns with their physicians [2, 3]. Nevertheless, a persistent gap remains between patient preferences and the care they receive.

As stated by Steinhauser et al. [4] Spirituality, historically, was considered a process that unfolds within a religious context with established institutions designed to facilitate spirituality. Only recently has spirituality been separated from religion as a distinct construct. This trend is rooted in movement away from the authority of religious institutions in modern social life, together with a growing emphasis on individualism, particularly within Western cultures. These combined social forces have fostered beliefs and practices that are less tethered to traditional, communal practices, and belief systems and more linked to individual experience and expression. Spirituality may be broadly be understood as existentially contemplating one’s meaning, purpose, and goals in life, while religion as an organized set of beliefs or rituals regarding the supernatural [5]. Spirituality should not be confused with religion, which is an organized form of spiritual expression and a subset of human spirituality as a whole [3].

Even though there exist too many attempts to define spirituality in health care field, there is an epistemic gap for a definition focused on palliative care. That is why one of the objectives of this work is to develop an operational, scientifically grounded definition of spirituality that allows for unifying the field and promoting its integration.

In many healthcare systems, spiritual care is often delegated to chaplains or nurses [6], even though patients often view physicians as trusted interlocutors for addressing existential issues. Cultural differences, however, further influence and shape how spiritual care is institutionalized and perceived [7].

Understanding physician’s limited engagement in spiritual care requires examining not only practical barriers but also deeper value-based attitudes and social dynamics [8–10].

Values are normative guidelines that allow us to consider actions, objects or situations as good, desirable, pleasant, convenient or useful towards certain aims [8, 11].

It is important to note out that spirituality and religion have a different structure, purpose, expressions, meanings, tools, methodologies, and modes of expressions. Therefore, in this work they are not taken as synonyms. The relation between spirituality and religion and their impact in the health field could be explored in future research.

An axiological framework in healthcare refers to a structured approach to studying values, virtues, and vices of healthcare professionals, focusing on their beliefs, desires, and meanings that shape clinical practice. It involves analyzing these values to understand and improve ethical discernment, patient-doctor relationships and decision-making in medical settings [10, 12]. Values are related to spirituality as they guide physicians’ attitudes, decisions, and capacity for existential engagement [1, 13]. Addressing these factors is essential to foster a holistic model of care that truly responds to patients’ needs [8, 14, 15].

The aim of this systematic review is to answer the following research question:

"What axiological and sociological factors influence physicians’ professional perspective and engagement with spiritual care in palliative settings?"

By exploring these questions through an hermeneutic and axiological lens, this study aims to clarify the foundations needed to integrate spirituality meaningfully into clinical practice through an operational definition. Our main finding was the cross-functional perspective of spirituality as a cornerstone on medical attention in palliative care in which values are the core in medical decision making.

In this paper, we demonstrate how axiological networks are built and identify the facilitators and the barriers that can be taken as a vector of change for educational programs.

Methods

Article scaffolding

The global structure of the article is the following:

1. The process began with the formulation of the research question and objectives, which were then broken down into components using the PI (Participants/Intervention) framework. Next, keywords and MeSH (Medical Subject Headings) terms were searched across three databases, following both the PRISMA guidelines and the PI strategy.

2. Assessment and Revision of Retrieved Articles.

3. Epistemic Meta-analysis

Systematic review and assessment

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) Statement guidelines, the most used reporting guidance for systematic reviews, which covers the literature search [16] and employed a modified PI (Participants and Intervention) strategy derived from the PICO framework (a structured methodology for researchers in the construction of research questions. Acronym for Population, Intervention, Comparison, and Outcome). The traditional PICO method includes a comparison and outcome component; however, these were deliberately excluded to allow for a qualitative synthesis of perspectives, and a broader exploration of value-based and sociological factors, which are not easily captured through comparative analysis. Focusing on physicians’ perspectives across contexts justified limiting inclusion to Participants and Interventions which is methodologically consistent with the review’s qualitative nature and the research question.

Participants (P): The term “doctor” or “physician” was operationalized into three categories:

General terms: physicians, doctors, general practitioners.

Specialties related to palliative care: oncologists, medical oncologists, geriatricians, geriatric medicine physicians, internal medicine physicians, primary care physicians, family medicine physicians, critical care physicians, psychiatrists.

Physicians specifically providing palliative care: palliative care specialists, palliative care doctors, palliative medicine physicians, palliativists.

Intervention (I): Defined as Spiritual Care, encompassing:

Terms like spiritual care, spiritual support, spiritual needs, spiritual care provision, spirituality, spiritual issues, spiritual care perceptions, spiritual care integration, spiritual care priorities, spiritual care discussions.

End-of-life and palliative care.

Religion in healthcare.

Comparison (C): Not included, as the study focused on understanding facilitators and barriers to providing spiritual care without making comparative analyses.

Outcome (O): Excluded to avoid limiting the scope of the research question and to allow broader exploration of potential findings.

Search strategy

A diagnostic screening was performed on three data bases. Subsequently, a comprehensive search was conducted independently in each of them up to September 2023. The final search for each database was as follows: PubMed – 10.09.2023, Web of Science – 25.07.2023, and BIREME – 20.07.2023.

PubMed, the National Library of Medicine (a public agency under the U.S. National Institutes of Health), which, according to Cochrane (2012), contains around 16 million references to journal articles dating from 1950 onward, as well as 5,200 indexed journals. This makes PubMed/MEDLINE the most widely used database in the field of health sciences worldwide.

Web of Science, a bibliographic database platform produced by Clarivate Analytics, a company based in the United States. It compiles high-quality scientific literature across various disciplines, including science, technology, medicine, social sciences, and humanities.

Finally, the search was conducted in the BVS (Virtual Health Library) database, produced by Bireme (Latin American and Caribbean Center on Health Sciences Information), which is a specialized center of PAHO (Pan American Health Organization). The importance of this database lies in the fact that it indexes the most relevant scientific literature journals from Latin America and the Caribbean.

Search terms combined relevant MeSH terms and Boolean operators to capture studies related to physicians and spiritual care in palliative settings. The search was conducted from inception and up to September 2023. A search document was created using Medical Subject Heading (MeSH) terms and Boolean operators with the previously described criteria to obtain the articles. To analyze these results, they were grouped in a decision tree for each database. This search strategy is described in Fig. 1 and Additional File 1.

Fig. 1.

PubMed Decision Tree: P-I approach

References were managed using Mendeley Desktop as a reference management tool [16].

Eligibility criteria

Studies were included if they:

1. Focused on physicians providing palliative care to patients with incurable diseases (e.g., cancer, chronic-degenerative conditions),

2. Reported physician-specific perspectives on spiritual care,

3. Identified barriers or facilitators to such care,

4. Evaluated tools for spiritual/religious assessment in clinical practice,

5. Included educational interventions on spiritual care.

Exclusion criteria

1. Studies nonrelated to physicians or spirituality,

2. Duplicates or irrelevant content.

Assessment and revision of retrieved articles

Titles and abstracts were independently screened by two reviewers. After an iterative review to confirm the actual relevance of each paper, the eligible full-text articles were assessed for inclusion. Discrepancies were resolved through discussion with a third reviewer. Extracted data included author, year, setting, sample size, population, study design, and quality rating. Table 1 summarizes the characteristics of the 67 studies included in this review (available via QR code).

Table 1.

Characteristics of included papers

	First author, year & Country of publication	Setting	Sample size	Sample characteristics	Design study	Studyquality
1	O'Connell 1996, USA [17]	Non specified	Non specified	Non specified	Critical analysis of the culture of dying in America, focusing on how institutionalization and technology have affected the experience of dying	80%
2	Daaleman 1999, USA [18]	National study of family physicians in the United States	756 family physicians, randomly selected response rate was 58%, with 438 physicians completing the survey	Anonymous random sample survey to active members of the American Academy of Family Physicians (AAFP) involved in direct patient care	Self-administered, anonymous survey mailed to eligible physicians. Self-directed questionnaires	100%
3	Ellis 1999, USA [19]	Family physicians, including residents and community physicians, in a state with a predominantly Judeo-Christian culture	170 family doctors who responded to the survey on physicians’ attitudes, practices, and perceived barriers to spiritual assessment on patients spiritual issues	41% were residents, 23% professors, and 34% community physicians, with 2% not responding	The study design was a quantitative survey. Ellison Spiritual Well-being Scale (ESWS) included. Response rate of 74% after two mailings	100%
4	MacLeod 2003, NZL [20]	Educational program at a medical institution where medical students have early clinical exposure to dying patients	58 student portfolios available for analysis. 51 contained personal comments or reflections and were used as a data source for the study	Preclinical medical students in contact with terminally ill patients as part of an educational program	Qualitative, using phenomenology as a method to identify themes in students' written reflections	100%
5	Monroe 2003, USA [21]	6 teaching hospitals, N. Carolina, Vermont, and Florida. Internal and Family Medicine	768 physicians surveyed, 476 responded, for a response rate of 62.0%	Physicians surveyed included internal medicine and family practice faculty and residents at participating programs, as well as those who completed their internal medicine residency during the preceding 5 years	Spiritual Wellbeing Scale (SWBS—Validated To Measure Religiosity and Spirituality) combined with a questionnaire they developed about doctor's attitudes and involvement with respect to religiosity and spirituality of the patient from focus groups, literature and discussions	100%
6	Chibnall 2004, USA [14]	Hospital setting, discussion groups with physicians. Clinical and academic setting where participants practice medicine and receive training	17 physicians, divided into two discussion groups	Areas: pediatrics, internal medicine, nephrology, pathology, pediatric and adult hematology/oncology, emergency medicine, geriatric medicine, vascular surgery, and orthopedic surgery. This sample provides a diversity of perspectives and medical experiences.	20 sessions, qualitative and exploratory. Discussion groups focus on physicians' perceptions and experiences/barriers to the incorporation of psychosocial and spiritual care approaches in the care of dying patients	100%
7	Holmes 2006, USA [22]	General medical practice (GMP) at an urban university medical center in a multicultural city on the U.S. West Coast	67 PCPs & 65 EOL patients	PCP and Patients	PCP and patients’ surveys about attitudes and practices regarding spiritual concerns	100%
8	Brown 2006, USA [23]	_	_p	_	Define terms and justifications for physicians to take an active role in addressing the spiritual needs of patients at the end of life	80%
9	Payás 2008, ESP [24]	Scope of palliative care units in Spain	202 responses received out of a total of 1,200 (17%)	72 physicians (35%), 73 nurses (35%), 19 psychologists (9%), 14 social workers (7%), and 14% from other categories	Anonymous self-administered questionnaire, quantitative and qualitative analysis	100%
10	Puchalski 2009, USA [6]	Consensus Conference	11 Physicians	40 national leaders (physicians, nurses, psychologists, chaplains, other spiritual care providers, administrators)	Consensus conference with discussion groups	100%
11	Pugh 2009, UK [25]	Survey of physicians and nurses in an acute care hospital	119 Clinicians	77 physicians (pulmonologists, diabetologists, cardiologists, gastroenterologists, surgeons, emergency physicians, orthopedists, radiologists, and pathologists)	. Postal questionnaire Survey	100%
12	Michiels 2009, BEL [26]	Survey of practicing Belgian physicians	1716 physicians	Specialists treating end-of-life patients: general practitioners, anesthesiologists, geriatricians, internists, neurologists, oncologists, pulmonologists, and surgeons	Structured Questionnaire (background characteristics, hypothetical cases and statements were presented, and questions were asked about attitudes, intended behavior and practices concerning end-of-life care	100%
13	Penderell 2010, CAN [27]	Physicians practicing palliative care in the central-west region of Ontario, Canada (invitation letters were sent)	14 potential physician participants. Of these, six volunteers joined the study	Most participants were women (n = 5), with an average of 16 years of palliative care practice, ranging from 13 to 20 years	Descriptive qualitative approach, using face-to-face interviews,to explore the experiences and perspectives of palliative care physicians to create a de- scription of how providing palliative care has influenced their own spirituality. (Semi-structured in-s depth interviews)	100%
14	Reinke 2011, USA [28]	Simple randomized trial in a medical center	64 physicians (geriatricians, general practitioners, pulmonologists)	Physicians and their COPD patients	Questionnaires and simple randomized trial,to describe communication practices in outpatient settings and identify factors influencing these discussions	100%
15	Vermandere 2011, BEL [7]	Outpatient settings, as well as hospital or hospice settings, were included	22 studies: GPs' experience in addressing or providing spiritual care	The sample and characteristics of the included qualitative studies are detailed in a table listing various studies with their respective authors and years of publication	Synthesis of qualitative evidence conducted through thematic analysis, to describe the views of GPs on their role in addressing or providing spiritual care, or the barriers and facilitating factors that GPs experience in addressing or providing spiritual care	100%
16	Vermandere 2012, BEL [29]	Home-based palliative care, aiming to identify the main elements of spiritual care in this context	35 experts in spiritual care and palliative care from the Netherlands and Belgium, including 17 physicians, professional spiritual caregivers, and researchers	35 experts in spiritual care and palliative care from the Netherlands and Belgium, including 17 physicians(49%; 12 GPs with special interest in palliative care, 2 geriatricians, 2 palliative care physicians and 1 oncologist); professional spiritual caregivers, and researchers	The study design was qualitative and used the Nominal Group Technique (NGT) to generate consensus among experts in four phases: generating ideas, recording them, evaluation and a group decision phase	100%
17	Phelps 2012, USA [30]	Multi-institutional and cross-sectional study/perceptions of spiritual care (SC) among patients with advanced cancer, oncologists, and nurses	68 cancer patients, 204 oncologists, and 114 oncology nurses	Patients with advanced and incurable cancer receiving palliative radiotherapy, oncologists, and nurses eligible if they cared for patients with incurable cancer	Cross-sectional study, semi-structured patient interviews, and provider web-based surveys—perspectives on the routine provision of spiritual care by physicians and nurses	100%
18	Ford D 2012, USA [31]	University of Washington in Seattle and Medical University of South Carolina	242 physician trainees who participated in:The Improving Clinician Communication Skills (ICCS sub-study)	Physician trainees' self-assessed competency in addressing religious and spiritual issues	Randomized trial of a communication skills workshop, with data collected from pre-intervention surveys completed by participants during the first 4 years of the study. To develop an improved understanding of physicians’ perspectives on their communication competence about religious and spiritual issues	80%
19	Dones Sánchez 2013, ESP [32]	The scope of palliative care (PC) in Spain, specifically among professionals and volunteers participating in PC teams	191 participants	Professional distribution: nursing (35.1%), psychology (24.6%), medicine (20.4%), volunteering (4.7%), social work (4.2%), pastoral care (4.2%), nursing assistants (3.1%), and others (3.7%)	Descriptive study based on a survey designed ad hoc by the researchers, grounded on the results of a previous study. About the perceptions of palliative care professionals regarding the spiritual needs of patients at the end of life. With questions about spiritual care professionals and self-perception of the care given by the teams	90%
20	Balboni 2013, USA [2]	4 hospitals in Boston	69 patients, 118 nurses, 204 physicians	Oncologists and palliative care specialists from 4 hospitals in Boston	Data collection through questionnaires developed by a panel of experts and tested with patients with advanced cancer, nurses, and physicians.To determine factors contributing to the infrequent provision of spiritual care (SC) by nurses and physicians caring for patients at the end of life (EOL)	100%
21	Delgado-Guay 2013, USA [33]	_	_	_	Symposium article addressing challenges in communication with geriatric oncology patients, emphasizing the importance of patient-centered communication and the spiritual perspective of the physician	80%
22	Balboni 2014, USA [15]	Academic medical centers in Boston, USA	322 participants, of which 204 were physicians and 118 were nurses	Oncology nurses and physicians	Survey evaluating perceptions of barriers to the provision of spiritual care (SC) at the end of life (multisite survey-based study).Aimed to describe nurses’ and physicians’ desire to provide SC to terminally ill patients and assess 11 potential SC barriers	90%%
23	Anandarajah 2014, USA [34]	Family physicians who graduated from the same residency program in Rhode Island, geographically spread across the USA	12 family physicians who agreed to participate in the study	Graduates of the same family medicine residency program in Rhode Island. Type of practice (community-based, private, academic, among others)	Qualitative study adopting a methodology of in-depth semi-structured individual interviews, allowing participants to express their opinions openly and thoroughly. Practicing physicians’ views regarding the relationship between compassion and spirituality in medical practice	100%
24	Ford 2014, USA [35]	Two internal medicine training programs, one in the southeastern and one in the northwestern United States	181 medical trainees	Medical trainees in internal medicine in years (PGY) 1–5, as well as fellows in geriatrics, nephrology, oncology, palliative medicine, and critical care/pulmonology	Prospective, observational, and survey-based study of self-assessments by internal medicine trainees compared to reports from their patients	100%
25	Olsman 2014, NLD [36]	Mainly hospitals, focusing on palliative care for cancer patients, but also mentioning patients with various terminal conditions	31 sufficiently high-quality articles	Most of these 31 articles described perspectives of nurses or physicians	Interpretative synthesis consisting of quality evaluation and thematic analysis of the included articles. What are healthcare professionals’ perspectives on hope of palliative care patients?	100%
26	Van der Steen 2014, NLD [37]	Physicians in the staff of 28 long-term care facilities	17 physicians from 28 facilities	17 physicians (EOL care) from 17 long-term care organizations covering the 28 facilities	Data from the Dutch End of Life in Dementia (DEOLD; 2007–2011) study. Generalized Estimating Equations (GEE) regression analyses	100%
27	Best 2014, AUS [38]	Physicians caring for patients with stage IV cancer, focusing on medical care in Australia and New Zealand. Oncology and palliative care units in four hospitals in the Sydney metropolitan region	24 healthcare professionals who participated in semi-structured interviews	Physicians from diverse specialties, with variable clinical experiences and differing levels of interest in spirituality	Semi-structured telephone interviews, qualitative approach with thematic analysis using Braun and Clarke's method. Face-to-face semi-structured interviews and completion of a demographic questionnaire	100%
28	Puchalski 2014, USA [1]	Consensus Conference	41 international leaders, including physicians, nurses, psychologists, social workers, theologians, spiritual care professionals, donors, researchers, and policy makers	_	Consensus Conference	100%
29	Vermandere 2015, BEL [39]	Home-based palliative care (HCPs); used the Ars Moriendi Model (AMM) for spiritual assessment of patients with progressive and potentially life-threatening illnesses	24 healthcare professionals who participated in semi-structured interviews	(17 and 4) nurses and (19 and 5) family physicians for the quantitative and qualitative phases, respectively	RCT with a quantitative and qualitative phase Quantitative phase: Survey using Likert scales Qualitative phase: Semi-structured interviews to explore the experiences of HCPs with the AMM	100%
30	Best 2016, AUS [3]	Members of the Australian and New Zealand Palliative Medicine Society	158 physicians	150 palliative care specialists and 8 oncologists, geriatricians, or general practitioners	Survey sent by email to ascertain their spiritual care practices	100%
31	Anandarajah 2016, USA [40]	A family medicine residency program in New England, United States	26 physicians, divided into two groups: 13 in the intervention group and 13 in the comparison group	Cohort of 13 family physicians over 8 years, with training in spiritual care (SC) during residency	The study is qualitative and longitudinal, utilizing in-depth interviews and grounded theory analysis to evaluate the effects of the spiritual care curriculum over ten years	100%
32	Best 2016, AUS [41]	The Australian and New Zealand Society of Palliative Medicine (ANZSPM)	445 ANZSPM members invited to participate in the study, 158 (35.5%) completed the survey	Physician trained in and working primarily in palliative care-150 Another physician* 8 (5.0)	The 16-question survey developed for the MASCC (Multinational Association of Supportive Care in Cancer survey)	100%
33	Steinhauser 2017, USA [4]	Consensus Conference	_	_	Consensus Conference	100%
34	Balboni 2017, USA [42]	Consensus Conference	_	_	Consensus Conference	100%
35	Koenig 2017, USA [43]	Educational intervention conducted in the context of outpatient care with clinicians from various specialties	520 clinicians (427 physicians and 93 MLPs—midlevel practitioners = nurse practitioners or physician’s assistants))	427 physicians (1/3 in family medicine), 79% Christians, of whom 14% were Adventists	A 12-month educational intervention aimed at evaluating the effects on the attitudes and behaviors of outpatient clinicians regarding spiritual practices with patients. Questionnaire completed at baseline, 1 month, and 12 months	100%
36	Marin 2017, USA [44]	Hospitals and clinics: individual patients to groups of healthcare professionals and patients across multiple academic medical centers; primary care	Varies significantly among the studies mentioned	Physicians, patient surrogates in decision-making, WHO	Varies in design, ranging from surveys to qualitative analyses of clinical interactions	80%
37	Noguera 2018, SPAIN [45]	Scoping Review	15 articles	Medical students	Hidden curriculum (attitudes and behavior after PC teaching to undergraduate students)	100%
38	Smyre 2018, USA [46]	Medical environment in the United States	1156 physicians from specialties including family medicine/general practice, internal medicine, cardiology, nephrology, hematology/oncology, pulmonary/critical care, and geriatrics/palliative care and hospice	Participants were also grouped into general religious categories such as no religious affiliation, Hindu, Jewish, Muslim, Roman Catholic/Eastern Orthodox, Evangelical Protestant, Non-Evangelical Protestant, and other religions	Cross-sectional survey using a questionnaire sent to physicians on’ actual views and behaviors regarding engaging patients’ religious and spiritual concerns	100%
39	Appleby 2018, SCO [47]	Understanding and application of spirituality by primary care physician trainers (GP trainers) in northern Scotland	87 general practitioners	GP Trainers	The study design is quantitative, employing cluster analysis and latent class analysis. A questionnaire, Likert-scale responses, and multinomial trend tests were used to analyze relationships between the "concept of spirituality" and attitudes or practices of spiritual care in GP trainers	100%
40	Montagnini 2018, USA [48]	Large academic medical center/self-perceived competencies in end-of-life (EOL) care among healthcare providers	1197 participants	Nurses (51.2%), physicians (18.38%), and social workers (8.35%)	Descriptive and cross-sectional/electronic survey to evaluate self-perceived competencies in seven domains of palliative and end-of-life care	100%
41	Appleby 2018, SCO [9]	Primary care	19 general practitioners (GPs)	19 general practitioners (GPs)	Qualitative (in-depth interviews) to collect data. The interviews were conducted by a GP trained in qualitative interviewing.The paper discusses the varying perspectives of spirituality among Scottish GPs, highlighting different attitudes and approaches towards spiritual care	100%
42	Liu 2018, USA [49]	Narrative review	_	_	Narrative literature review, including a wide range of studies such as observational studies, quantitative research, reviews, and non-research commentaries	100%
43	Appleby 2019, SCO [50]	General Practitioners Practice	_	General Practitioners (GPs)	Refers to the "Signed up or Souled out" study, suggesting there might be a literature review component and analysis of previous studies	80%
44	Thompson 2019, USA [51]	National survey in the United States involving physicians from various specialties	2016 practicing physicians	1248 physicians from general specialties such as internal medicine, family medicine, general practice, cardiology, and nephrology 768 physicians specializing in end-of-life care (EOL) (palliative care and hospice, geriatrics, oncology, and critical care/pulmonary medicine)	Secondary analysis of data from a national survey conducted in 2010	100%
45	Yerramilli 2019, USA [52]	Radiation oncology, specifically in the context of palliative radiotherapy (PRT)	Responses completed by physicians from 140 consultations with patients referred for palliative radiotherapy (response rate: 86%)	Electronic survey targeting radiotherapy physicians who attended patients referred for palliative radiotherapy	Prospective methodology involving an electronic survey directed at radiotherapy physicians who treated patients referred for palliative radiotherapy. These surveys were sent immediately after each PRT consultation and completed within five business days	100%
46	Bornet 2019, CHE [53]	_	_	_	Debate & analysis of existing literature on the provision of spiritual care by primary care physicians	100%
47	Bar-Sela 2019, ISR [54]	Middle east Cancer Consortium nurses and physicians of oncology, 14 countries	770 respondents	300 physicians	Mail questionnaire, liker style in 4 languages regarding provision and barriers to spiritual care to advanced cancer patients	100%
48	Gijsberts 2019, BEL [55]	Long-term care, nursing homes (geriatricians) in the Netherlands	(303/642 respondents to whom the questionnaire was sent)	Geriatricians registered with Verenso (the Dutch Association of Elderly Care Physicians and Social Geriatricians, where the majority of elderly care physicians are registered)	A cross-sectional survey was conducted among a representative sample of practicing Dutch elderly care physicians to examine perceptions and experiences regarding providing spiritual care at the end of life of elderly care physicians practicing in nursing homes in the Netherlands, and factors associated with spiritual care provision	100%
49	Megan Best 2020, AUS [13]	White paper: Document review by the EAPCSC (European Association for Palliative Care (EAPC) spiritual care reference group	15 members of the EAPC Board	6 physicians	Discussion on multidisciplinary education for spiritual care in palliative care	100%
50	ORUÇ 2020, TUR [56]	Palliative care units in two training and research hospitals and one state hospital in Istanbul	81 healthcare professionals	Participants included nurses, physicians, and healthcare staff with varied gender and marital status distribution	Descriptive statistics	100%
51	Menegatti 2020, BRA [57]	Psychiatrists working at the Institute of Psychiatry at the University of São Paulo, Faculty of Medicine teaching hospital	592 psychiatrists took part in this study	Speciality in Psychiatry	The questionnaire used in this study was developed based on the instrument “Religion and Spirituality in Medicine: Physicians’ Perspectives” developed by Curlin et al	100%
52	Hsu 2021,NZL [58]	_	_	End-of-life patients and treating physicians	Essay on Physician–patient spiritual interactions including prayer in end-of-life care	80%
53	Kripalani 2021, USA [59]	Tertiary care hospital physicians likely to treat critically ill patients and engage in end-of-life conversations	111 physicians from various specialties	Intensive care, cardiology, palliative care, hematology/oncology, neurology, pediatrics, gynecologic oncology	Survey.A 21-item questionnaire was developed to explore the role of religion in physician patient communication in end-of-life care	100%
54	Johnson 2021, USA [60]	Literature review and focus groups (mixed methods)	Two groups of 5 participants each	Pastors, physicians, and researchers	Focus groups and analysis of patient spiritual content vignettes	80%
55	Alch 2021, USA [61]	ICU in an academic institution in the Midwest of the United States	11 intensive care physicians interviewed	4 fellows, 7 attendings	Qualitative research using semi-structured interviews and thematic analysis to identify patterns and emerging themes. The physicians discussed barriers to address spiritual and religious needs in the ICU	100%
56	Wenhamref 2021, AUS [62]	International medical education context, focusing on integrating spirituality into medical education. Systematic Review	17 studies/cohorts with study sizes typically ranging from 40 to 60 participants	Studies cover various teaching centers and levels of medical training, including medical students and resident physicians	Systematic Review (PRISMA), including randomized controlled trials (RCTs), quasi-experimental studies, evaluation studies, and mixed-methods research	100%
57	HEIDARI 2021, IRN [63]	Healthcare in university hospitals in Qom and Tehran	12 hospitalized patients and 40 experts in spiritual care (SC) and national policy formulation in the field of spiritual health	12 patients, 40 Spiritual Care experts (including 17 physicians: endocrinologists, internal medicine specialists, oncologists, and others)	Multifaceted approach: systematic reviews (RS), qualitative studies with healthcare providers and patients, and expert opinions to develop a charter of spiritual care for patients. Conventional content analysis	100%
58	Jones 2021, AUS [64]	Hospitals, nursing schools, and other healthcare training environments	55 papers outlining spiritual care training programs conducted with healthcare professionals or students	Nursing students and social workers to practicing doctors and nurses, with groups ranging from 12 participants to larger groups of 251 participants	A Mixed-Methods Systematic Review (including quantitative and qualitative studies, longitudinal studies, cross-sectional studies, randomized controlled trials (RCT), and mixed-methods (MM) studies)	100%
59	Anandarajah 2021, AUS [65]	Family medicine residency program. All participants attended the same program. A 20-year study, where participants have lived and practiced in a variety of settings across North America and internationally	Thirty-eight medical residents enrolled during the 2000–2001 academic year. Thirteen formed a longitudinal study group over 20 years (received SC training during residency)	A cohort of 13 family physicians followed over 20 years, with SC training during residency	The study design is qualitative and longitudinal, using in-depth individual interviews and covering the analysis of the entire dataset from 2000 to 2020	100%
60	Sena 2021, BRA [66]	systematic review of the spirituality concept for the healthcare field	166 articles, most of which in English, that were included in final analysis concerning spirituality definitions	Articles that addressed the meaning, concept, or definition of spirituality.All articles (letters to the editor, editorials, opinion essays, observational studies) were included	Systematic review based on the PRISMA statement
61	Whitehead 2021, UK [67]	Qualified GPs in England	177 practising GPs in England	177 practising GPs in England	A mixed- methods online survey asked practicing GPs in England qualitative free text questions—‘What does the term ‘Spiritual Health’ mean to you?	!00%
62	Kripalani 2022, USA [68]	Questionnaire for hospital-based physicians	65	Residents and Physicians	Survey that explores the impact of religion and spirituality on resident physicians' attitudes and interactions regarding death, dying, and end-of-life care during the COVID-19 pandemic	100%
63	Gijsberts 2022, BEL [69]	No specific setting (author's perspective)	_	_	Reflective analysis or narrative review, where the author reflects on their clinical practice and shares observations and opinions on the topic/no systematic approach	90%
64	Mächler 2022, GER [70]	Primary care setting, Heidelberg and Tübingen, Germany	30 physicians	30 general practitioners (GPs) who participated in the study	Cross-sectional study based on the evaluation of questionnaires completed by the GPs.To understand if GPs’ spiritual competence, their personal spirituality and attitude towards enquiring about spirituality in practice interrelate	90%
65	Williams 2022, USA [5]	_	_	_	literature review and discussion on topics related to spirituality and medicine, especially in the context of end-of-life conversations, rather than an empirical study with a specific design and a defined sample	90%
66	Dellenborg 2023, SWE [71]	Advanced Care at Home Units (ACH) for patients at the end of life in Sweden	_	Specialist physicians and residents who are part of medical care teams	Short-term ethnography, including participant observation and informal interviews with ACH physicians	100%
67	Gaignard 2023, CHE [72]	a full spectrum of persons engaged in end-of-life care and AS in Switzerland	20 interviews	(Palliative Care Providers, Primary Care Providers or EXIT Volunteers)	A qualitative study based on face-to-face interviews. Grounded theory approach according to Corbin and Strauss	100%

Each selected article was read and codified independently by two authors, and discrepancies were resolved through discussion with a third reviewer. Atlas.ti 25.0.1 software was utilized in order to identify, analize and acquire a deep understanding of the factors related to our research question and the way they had been approached in the existing literature. A deep qualitative analysis was done based on the different codes, their relations, co-occurrences, and their networks.

Quality appraisal

Each study was evaluated using an adapted version of Juarez et al. [73] and Monroy-Fraustro et al.’s [74] quality appraisal tool. Articles where assessed for: clarity of objectives and research question, methodological rigor, clear identification of terms, solid resorts and validated conclusions.

Each criterion was worth 20% with a maximum quality score of 100%. Only studies scoring ≥ 75/100 were included. A total of 67 articles met the quality criteria. They are listed in Table 2 (Quality assessment of the articles), available via QR code.

Table 2.

Quality assessment of the articles

Author/Country		Year	Clear objective and research question	Solid and comprehensive methodology	Terms identification	Solid sources	Validated conclusions	Total
O'Connell	USA	1996	20	NO	20	20	20	80%
Ellis	USA	1999	20	20	20	20	20	100%
Daaleman	USA	1999	20	20	20	20	20	100%
MacLeod	NZ	2003	20	20	20	20	20	100%
Monroe	USA	2003	20	20	20	20	20	100%
Chibnall	USA	2004	20	20	20	20	20	100%
Ford D	USA	2005	20	NO (10 points)	20	20	10	80%
Holmes	USA	2006	20	20	20	20	20	100%
Brown	USA	2006	20	NO	20	20	20	80%
Payás	SPAIN	2008	20	20	20	20	20	100%
Pugh	UK	2009	20	20	20	20	20	100%
E Michiels	BELGIUM	2009	20	20	20	20	20	100%
Puchalski	USA	2009	20	20	20	20	20	100%
Penderell	CAN	2010	20	20	20	20	20	100%
Vermandere	BELGIUM	2011	20	20	20	20	20	100%
Lynn F. Reinke	USA	2011	20	20	20	20	20	100%
Phelps	USA	2012	20	20	20	20	20	100%
Vermandere	BELGIUM	2012	20	20	20	20	20	100%
Dones Sánchez	ESP	2013	20	NO (10 points)	20	20	20	90%
Delgado-Guay	USA	2013	20	NO (10 points)	20	20	NO (10 points)	80%
Balboni	USA	2013	20	20	20	20	20	100%
Anandarajah	USA	2014	20	20	20	20	20	100%
Balboni	USA	2014	20	NO (10 points)	20	20	20	90%
Van der Steen	Netherlands	2014	20	20	20	20	20	100%
Olsman	Netherlands	2014	20	20	20	20	20	100%
Ford D	USA	2014	20	20	20	20	20	100%
Best	AUS	2014	20	20	20	20	20	100%
Puchalski	USA	2014	20	20	20	20	20	100%
Vermandere	BELGIUM	2015	20	20	20	20	20	100%
Best	AUS	2016	20	20	20	20	20	100%
Anandarajah	USA	2016	20	20	20	20	20	100%
Best	AUS	2016	20	20	20	20	20	100%
Marin D	USA	2017	20	NO (10 points)	20	20	NO (10 points)	80%
Steinhauser	USA	2017	20	20	20	20	20	100%
Balboni	USA	2017	20	20	20	20	20	100%
Koenig	USA	2017	20	20	20	20	20	100%
Smyre	USA	2018	20	20	20	20	20	100%
Appleby	SCO	2018	20	20	20	20	20	100%
Noguera	ESP	2018	20	20	20	20	20	100%
Liu	USA	2018	20	20	20	20	20	100%
Montagnini	USA	2018	20	20	20	20	20	100%
Appleby	SCO	2018	20	20	20	20	20	100%
Appleby	SCO	2019	20	NO (10 points)	20	20	NO (10 points)	80%
Thompson	USA	2019	20	20	20	20	20	100%
Bornet	SWI	2019	20	20	20	20	20	100%
Gijsberts	BELGIUM	2019	20	20	20	20	20	100%
Yerramilli	USA	2019	20	20	20	20	20	100%
Bar-Sela	ISR	2019	20	20	20	20	20	100%
Menegatti	BRA	2020	20	20	20	20	20	100%
Oruc	TUR	2020	20	20	20	20	20	100%
Megan Best	AUS	2020	20	20	20	20	20	100%
Jones	AUS	2021	20	20	20	20	20	100%
Heidari	IRAN	2021	20	20	20	20	20	100%
Sena	BRA	2021	20	20	20	20	20	100%
Alch	USA	2021	20	20	20	20	20	100%
Whitehead	UK	2021	20	20	20	20	20	100%
Anandarajah G	USA	2021	20	20	20	20	20	100%
Jerry Chia-wei Hsu	NZ	2021	20	20	20	20	20	100%
Rebecca Johnson	USA	2021	20	20	20	20	20	100%
Wenham	AUS	2021	20	20	20	20	20	100%
Kripalani	USA	2021	20	20	20	20	20	100%
Simran Kripalani	USA	2022	20	20	20	20	20	100%
Gijsberts	BELGIUM	2022	20	NO (10 points)	20	20	20	90%
Mächler	GER	2022	20	Small sample-30 GP'S (10 points)	20	20	20	90%
Williams	USA	2022	20	NO	20	20	20	90%
Gaignard	SWI	2023	20	20	20	20	20	100%
Dellenborg	SWE	2023	20	20	20	20	20	100%

Code groups were created according to the following six major themes: barriers, palliative care, spirituality, facilitators, methodology and values. This themes and their respective codes were created by two of the authors based on their relevance during the process of diagnostic screening on the subject (see Table 3).

Table 3.

Codes description

Codes on spiritual care for patients with health-related suffering and non curable disease
Code Group	Contained Codes
Barriers	• Workload • Doctors’ Beliefs • Doubt • Focus on the Physical • Lack of Training • Lack of Clarity • Lack of Awareness • Lack of Consensus
	• Lack of Time • Ignoring • Discomfort • Interpretation • Not Identifying • Not the Doctor’s Responsibility • Offending • Rejecting • Resistance • Responsibilty • Overstepping
Palliative Care	• Attitudes • Patient-Centered Care • Spiritual Care • Palliative Care • Primary Care • Self-Knowledge • Self-Care • Well-being • Burnout • Quality of Life • Chaplain • Awareness • Conscious • Spiritual Screening • Primary Caregiver • Culturally Sensitive • Decisions • Challenge • Diagnosis • Advanced Cancer • Advanced Non-Cancer Disease • Nursing • Transdiciplinary Team
	• Listening • Euthanasia • Spiritual Assessment • Family Members • Reliability • End of Life • Futilility or Therapeutic Aggressivness • Medical History • Spiritual History • Nursing Home • Holistic • Important • Information • Comprehensive • Research • Therapeutic Effort Limitation • General Practitioner, Family Doctor, or Primary Care Physician • Doctors • Treatment Goals • Fear • Palliative Care Models • Spiritual Needs • Others • Other Specialists • Outpatient
	• Patients at Home • Patients in Hospice • Hospitalized Patients • Patients • Palliative Care Specialists • Forgiveness • Treatment Plan • Advanved Care Planning • Preferences • Provision • Psicho-Affective • Treatment Rejection • Doctor-Patient Relationship • Mental Health • Palliative Sedation • Survival • Social • Suffering • Spiritual Suffering
Spirituality	• Accompainment • Love • Self-Realization • Concept of Spirituality • Connection • Questionnaire • Definition • Divine • Spiritual • Expression of Spirituality • Lifestyles • Practices • Rituals • Guidelines • Tools • Nature • Spiritual Needs • Presence • Purpose • Referring • Relevance • Religion • Religion as Spirituality • Religiosity • Sacred • Sese • Meaning • Transcendence
Facilitators	• Acceptance • Self-Knowledge • Training • Communication • Clear Definition • Enthusiasm • Listening • Standardization • Humanization • Identifying • Intuition • Getting Involved • Holistic Model • Comprehensive Model • Patients at Home • Patients in Hospice • Hospitalized Patients • Educational Programs • Patient Request
Methodology	• Analysis • Thematic Analysis • Concept of Spirituality • Qualitative • Quantitative • Questionnaire • Surveys • Interviews • Open Questions • Recruitment • Bias
Values	• Love • Support • Autonomy • Authority • Benefit • Well-Being • Quality • Clarity • Coherence • Compassion • Trust • Cost • Duty • Dignity • Discipline • Effectiveness • Efficiency • Equity • Hope • Faith • Happiness
	• Reliability • Strength • Equality • Care • Justice • Legality • Freedom • Improvement • Mystery • Precision • Prudence • Respect • Responsibility • Health • Safety • Solidarity • Tolerance • Transcendence • Truth

We considered them to be the most relevant themes, required to investigate the axiological and sociological factors that influence physicians’ engagement with spiritual care in palliative settings.

Every code (Table 3) has an operational definition, which was applied upon the different quotations recognized in the text: “the codes were hunted” from the different articles as the reading progressed (Table 6).

Table 6.

Quotes to explain the relationship between value and use identified in clinical practice

Axiological Networks and Spirituality: Spiritual Care as a Catalyst for Change in Comprehensive Palliative Patient Support
	Quotation
Improvement: To advance, to increase something, making it move to a better state	“The majority of these patients said they thought that these spiritual discussions would better enable their physicians to encourage realistic hope and to give better medical advice, which, together, may lead to a change in the medical decision-making” [39] “Spiritual care (SC)—recognition and support of the R/S dimensions of illness—is considered by patients to be an important aspect of EOL care and is also associated with key patient outcomes, including patient QOL, satisfaction with hospital care, increased hospice use,decreased aggressive medical interventions, and medical costs.” [2] “In the embedded model, spirituality is addressed by spiritual care providers and health professionals, which helps with building care plans that offer a better understanding of the patient, lead to better shared decisions (empowerment and autonomy) and increased resources (coping), and take into account potential suffering (spiritual distress).” [53]
Benefit: To take advantage of something or someone	“Large majorities of patients, nurses, and physicians rated their SC experiences positively, and no participants indicated that SC had a negative impact” [2] “The current package of primary care reform offers great opportunities to embrace spiritual care as benefiting patients’ health and wellbeing, and leading to increased efficiency and effectiveness for the whole health system.” [53]
Support: Refers to reciprocity, help, and collaboration between people or groups for mutual benefit	“When patients feel spiritually supported by staff, we find increased use of hospice and reduced use of aggressive treatments at end of life, yet substantial barriers to staff spiritual care provision still exist.” [54]
Well-being: State of the person in which the proper functioning of his somatic and psychosocial activity becomes sensitive	“A rapidly increasing body of literature shows that spiritual care is very important for both practitioners and patients and should not be ignored. There are growing evidences on the contribution of spiritual care to patient experience, well-being and health outcomes”. [63] “De hecho, en estos últimos años, se han propuesto los constructos bienestar espiritual, que se considera constituye una parte importante del índice de calidad de vida, y síndrome de desmoralización, como reflejo del malestar existencial de pacientes oncológicos o al final de la vida. Ambos constructos están siendo actualmente empíricamente validados.”* [24]
Health: A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity	“Spiritual care is a main part of health care if it is intended to be regarded fully and has a main role in his/her recovery. Lack of a definite framework for spiritual care is a barrier of addressing this dimension of care. Issuing a charter for spiritual care can be helpful in increasing the sensitivity to this need of patients and improving the health-care quality.” [63]
Responsibility: The quality of being able to respond to one's own actions	“Los profesionales de paliativos deben, por tanto, estar abiertos a acompañar y proporcionar apoyo a las necesidades espirituales de los enfermos, probablemente con tareas diferenciadas, pero sabiendo que la responsabilidad debe ser compartida por todos los componentes del equipo, independientemente de su disciplina.”** [24] “Primary motivators for pro- viding SC was their desire to alleviate patient suffering and provide whole-person care, including SC: “Yes, I definitely think it’s part of my role. It’s such an important part of someone’s personality and their psyche, I think it does make a difference in their healing.” [65]
Compassion: Recognition of suffering when it is present, rather than avoiding or denying it, coupled with a genuine desire to try to alleviate and prevent it	“En algunos cuestionarios el profesional menciona haber rezado conjuntamente con un paciente, y señalan el posible sentimiento de inadecuación de algunos enfermos que sienten vergüenza a la hora de expresar estas necesidades. Algunos de los participantes dan ejemplos de cómo el paciente se siente aliviado ante la invitación del propio profesional en esta dirección. Todo ello sugiere que el profesional debe adelantarse a menudo e identificar y poner palabras a estas necesidades de los pacientes.”*** [24] In addition, by engaging with patients dealing with end-of-life issues, physicians report an increased cognizance of the presence and role of spirituality in providing compassionate care for these patients: “I think I am more aware of [my spirituality] in palliative care just because you are confronted with mortality all the time... you think about these courageous battles... the dignity they show and everything. And you think about your own situations and how you would be.” [27]
Caring: To have interest in a person or thing	“En este sentido, resulta muy interesante destacar que profesionales con tanto interés en el acompan ~amiento espiritual se declaran en un 70,6% como personas no religiosas, confirmando que la preocupación por la dimensión espiritual no exige vivir como significativa la experiencia de lo religioso.”**** [32] “Access to spiritual supports was also facilitated when doctors were aware of the patient’s primary source of support and ensured they had access to this source of support during treatment and hospitalization.” [38]
Effectiveness: Ability to achieve the desired or expected effect	“Training of other professionals and volunteers to attend to patients’ spiritual needs is currently being developed and tested for effectiveness. Physicians who had 2 years of additional training in palliative care (with attention to all the domains of palliative care including spiritual care) reported significantly more frequently that they provided spiritual end-of-life care, independent of their score on the Religious and Spiritual Beliefs and Practices Scale or having a current religious denomination.” [55]
Quality: Something that meets a set of standards has a quality	“Promoting the provision of the full scope of services by PCPs will help ensure improved continuity of care while providing the highest quality of care for patients, both in the United States and around the world.” [49] “Patients often experience spiritual distress at the end of life, and alleviation of spiritual distress contributes to spiritual and psychosocial well-being, and improves quality of life and quality.” [55]

^*Author translation: “In fact, in recent years, the spiritual well-being constructs have been proposed, the IR is considered to be an important part of the quality-of-life index and demoralization syndrome, as a reflection of the existential discomfort of oncological patients or at the end of life. Both constructs are currently being empirically validated.”

^**Author translation: “Palliative professionals must, therefore, be open to accompanying and providing support to the spiritual needs of the sick, probably with differentiated tasks, but knowing that responsibility must be shared by all team members, regardless of their discipline”

^***Author translation: “In some questionnaires, the practitioner mentions having prayed together with a patient, and they point out the possible feeling of inadequacy among some patients who feel embarrassed when expressing these needs. Some participants give examples of how the patient feels relieved by the practitioner's invitation in this direction. All of this suggests that the practitioner should often be proactive and identify and give words to these patient needs”

****Author translation: “In this sense, it is very interesting to highlight that 70.6% of professionals with such an interest in spiritual accompaniment declare themselves to be non-religious, confirming that concern for the spiritual dimension does not require living the religious experience as significant”

Epistemic-hermeneutic-axiological meta-analysis

An epistemic meta-analysis is an approach used in research to analyze and synthesize existing knowledge, theories, or findings on spirituality highlighting its strengths, limitations, and areas for further investigation [75]. This process includes a comprehensive qualitative analysis using Paul Ricoeur’s hermeneutic framework (naïve reading, structural analysis, interpretation) [76, 77]. In regards to the values theme group of codes, Javier Echeverría’s modified axiological approach [10, 77, 78] was used as a value system model. As previously mentioned, each quotation in an article relevant to our research question was codified. Atlas.ti 25.0.1 software supported coding and thematic synthesis. This approach enabled exploration of core values and sociocultural dynamics underlying physicians’ approaches to spiritual care.

This study was conducted by a cross-functional group consisting of medical doctors and palliatives, with experience in spirituality and bioethics.

Results

Intersections of spirituality and medical care: a critical review of attention to patients with terminal illnesses

For the systematic review, using the PI approach 4,792 articles were obtained from PubMed, as is shown in Fig. 1, the same approach was used for the other two databases.

A total of 480 articles were obtained from Web of Science and 402 from BIREME, with a total of 5674.

A first screening of 399 records was done excluding 358 by title and abstract and leaving 41 for retrieval. After reviewing references from those 41 articles, 42 records were manually added. The systematic review findings included the classification and quality assessment of the final 67 selected articles which are shown in Fig. 2.

Fig. 2.

Flow chart diagram. Summary 5,674 records were initially retrieved based on the PI search strategy and PRISMA approach. 721 records were removed as they were duplicates. 4,554 records were excluded due to irrelevance to the research question. 358 articles were rejected during the title and abstract screening process as they were not pertinent to the research. 42 additional articles (found in references of assessed articles) were included by the authors as they were deemed relevant to the analysis. Out of the remaining 83 records, 16 articles did not meet the quality criteria and were excluded

The articles included, consisted of:

Original articles, review articles, letters, abstracts, viewpoints, observation studies and systematic reviews. Articles published from inception and up to September 2023. Articles written in English or Spanish.

Mapping epistemic trajectories of spirituality: an operational framework

One of the main results of this investigation was to develop an operational definition of spirituality that is the guiding thread of the study. The concept of spirituality varies depending on the perspective taken and the focus given to it. Although the aim was to capture a general view, the definition was expected to lean toward its use in the clinical context and medicine.

Currently, there is an epistemic gap regarding the definition of spirituality (Table 4). Numerous definitions exist without absolute consensus to guide clinical practice and research conclusively. Therefore, it was decided to construct an epistemically grounded operational definition of spirituality that is, a definition based on a clear theory of knowledge that allows spirituality to be studied, assessed, or observed empirically or through interaction and communication and that is coherent with the methodology of both research and clinical context. This could serve as a basis for our analysis and for addressing our specific objectives.

Table 4.

Quotation that shows the epistemic gap of the definition of spirituality for clinical use

Mapping Epistemic Trajectories of Spirituality: An Operational Framework
	Quotation
Epistemic gap for clinical use	Spirituality is, in many respects, a concept that is deeply personal, often viewed as intangible, and something difficult to capture with empirical measures [64]

The development of the operational definition of spirituality followed the same process as the rest of the research (Fig. 3).

Fig. 3.

Development of the operational definition of spirituality. A naive reading was conducted to understand the state of the art regarding the use of the concept of spirituality in clinical practice, as well as how this term has been approached. Explicit definitions used by some authors were identified, and then a deeper epistemic analysis was carried out to discover implicit definitions. During the coding process, these definitions were identified under the code “Concept of Spirituality.” The support definition given to this code already hinted at some of the elements that the subsequent operational definition of “spirituality” would include, but the aim was also to identify more precise and specific elements in each article to construct a more comprehensive definition applied to clinical practice

Conceptual mapping of spirituality

A network of concepts was constructed as a graphic proposal of the relationships found between the main concepts of spirituality. The conceptual “web” begins, as shown in Fig. 4, with the concept of spirituality and its associations with elements like spiritual care. Spiritual care is also presented as a response to patients’ spiritual needs.

Fig. 4.

Co-occurrence Network with Concept of Spirituality

Spiritual care is also linked to the attitudes adopted by those involved and the beliefs of physicians, which can either facilitate or hinder this type of care. The provision of care is part of spiritual care, as is the role of the general practitioner, family doctor, or primary care physician. This last point is grounded in the idea that every physician, regardless of their specialty, should be prepared to address the spiritual needs of their patients:

“Our study supports some previous findings, while revealing new insights that may positively contribute to the development of primary palliative care, especially PCP’s SC provision throughout their careers.” [65].

“Many GPs acknowledge that spiritual care should be an integral part of primary care” [79].

The concept of spirituality is also part of a broader idea of individual spirituality, an element that, among other things, is associated with religiosity. Religiosity in our study is understood as the "set of beliefs and practices centered on questions about the meaning of life, which may include worship of a supreme being." It is worth noting, as explored further, that spirituality and religion are not synonymous, as they have different meanings; however, for some people, religion is an expression of spirituality.

The meaning is a central element of spirituality, as it is precisely what spirituality seeks to achieve for individuals. Spirituality aims to give meaning and significance to daily actions performed for the overall good, suggesting that everything is done for a higher purpose, sometimes associated with the idea of divinity; in this last element, spirituality may intersect with religion.

Finally, the concept of spirituality is also linked to lifestyles as an expression of spirituality. This means that the daily actions, thoughts, and attitudes of individuals develop in accordance with their personal ideas, beliefs, concepts, skills, etc. about what spirituality is.

This exploration allowed, among other things, to identify undeniable components of spirituality, which are presented in Fig. 5 [1]. These components range from the fact that it is something purely human to its essential difference from religion.

Fig. 5.

Undeniable components of spirituality for the construction of the operational definition of spirituality

Operational definition

We constructed an operational definition of spirituality, which responds to our objectives and serves as a basis for the development of other types of materials to continue with the analysis of spirituality, spiritual care, and related factors in clinical practice:

"Spirituality is an intrinsic and dynamic aspect of the human being that focuses on the search for meaning and purpose for good beyond the purely material and is phenomenologically constituted (lessons learned from life experience). It is oriented towards transcendence and is sustained in inter, intra and transpersonal relationships, manifesting itself in beliefs, values, traditions, personal and cultural practices such as resilience and inner peace. In addition, it is related to personal discovery, self-reflection, emotional support, and the orientation of behaviors towards personal growth to have the liberty to perform overall good. These manifestations vary between cultures and people, generating diverse responses. It is often differentiated from religion in that it is less structured, but both address spiritual connection and integral human development. Talking about spirituality in varied contexts can be uncomfortable because of its personal and profound nature."

This definition recovers undeniable components of spirituality, taken from various proposals used in another research, some of the most relevant are included in Table 5.

Table 5.

Quotations used for the construction of the operational definition of spirituality

Operational definition
	Quotation
Intrinsic and dynamic aspect of human beings	Spirituality is a universal part of human experience, but many people are not comfortable speaking about spirituality. [6] “Spirituality is universal, deeply personal and individual; it goes beyond formal notions of ritual or religious practice to encompass the unique capacity of each individual. It is at the core and essence of who we are, that spark which permeates the entire fabric of the person and demands that we are all worthy of dignity and respect. It transcends intellectual capability, elevating the status of all of humanity.” [13]
Confer meaning and purpose	“A definition of spirituality was agreed at a consensus conference in 2009: ‘Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature and to the significant or sacred.” [1] Spirituality was described by participants as a concept of questioning a sense of purpose and meaning of life, striving to experience personal growth and development, understanding one’s existence in relation to others, extracting meaning from life experiences, and having a sense of connectedness to others [43]
Has an ultimate end or a cause beyond the material	“Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices” [1] “Spirituality is the personal quest for understanding answers to ultimate questions about life, about meaning, and about relationship to the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of community” [43]
Supported by relationships with oneself and others	“Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred” [47]
Different from religion	“Spirituality can broadly be understood as existentially contemplating one’s meaning, purpose, and goals in life, and religion as an organized set of beliefs or rituals regarding the supernatural.” [1] “Similar to other studies, participants described religion as a separate entity from spirituality which was viewed as a construct more accessible and less structured” [80]

For the sake of our qualitative analysis, we defined the Spiritual Care code as: “Any type of care that meets the spiritual needs of the palliative patient”.

An operational statement about Spiritual care built from our findings, focused on observable clinician behaviours and the generalist–specialist model mentioned by Best et al. [13] and Marin et al. [25] among others: Spiritual care is the generalist responsibility of clinicians and an approach that recognizes and honors the patient’s personhood and dignity by addressing spiritual needs in an integral manner. It is embodied in attentive presence and compassionate communication, beginning with the identification of spiritual concerns and considering them in relation to the patient and their support network. These needs are then stratified and incorporated into a collaborative plan of action that respects the patient’s freedom and individuality. Spiritual care also entails providing appropriate.

resources—whether spiritual, material, medical, or psychological—so that support is holistic (biopsicosocial model of care). The process is sustained through active listening, ongoing accompaniment, documentation of spiritual concerns relevant to care, and when appropriate, referral to specialist providers for deeper support.

To expand the understanding of the concept of spiritual care, an acronym was developed consisting of its core elements:

• SPIRIT CARE

• Supporting patients’ dignity and personhood

• Presence that is attentive and compassionate

• Identifying spiritual concerns

• Relating needs to the patient’s context and network

• Integrating into a collaborative plan of care

• Tailoring resources—spiritual, medical, material, psychological

• Communication that is active and empathetic

• Accompaniment throughout the illness journey

• Recording/documenting spiritual needs relevant to care

• Ensuring referral to specialist providers when needed

This acronym reflects both the generalist responsibility and the structured process of spiritual care, while being easy to remember and aligned with your operational statement.

Linking values and spirituality: a framework for holistic patient care

One of the innovative points of this study is the proposal of axiological relations of spiritual care. Axiology, understood as the study of values, their nature, and applicability to human life, serves as a basis for understanding spirituality by exploring the human aspects on which it is based [73].

We found not a specific theory that addresses the axiological aspect of spirituality in healthcare, highlighting the need for deeper exploration. Values guide and provide meaning to interpersonal relationships, forming the basis for personal development. Spirituality, by itself, contemplates forms of behavior based on axiological principles, but justified by their own ideas of human behavior.

The most frequent codes (values) found in our analysis were: improvement 384(times), support 206, benefit 163, well-being 163, compassion 156, health 144, responsibility 137, care 121, respect 106.

In a spiritual view, axiology helps understand interactions between personal beliefs and differing ones, fostering value-based interactions. A strong axiological foundation supported by a clear understanding of spirituality creates a framework for purposeful action (Table 6).

In clinical settings, physicians often act based on system values, not only epistemic values but also basic, technical, economic, social, moral, and ecological values, many of which, even when practiced implicitly, help them better respond to their patients' spiritual needs. These values were recognized as qualities essential for ensuring high-quality spiritual care. The following diagram (Fig. 6) illustrates the most frequent values found in the analyzed texts, as well as the relationships among them.

Fig. 6.

General axiological network of spirituality

As can be observed, some of the values included in this group are not strictly considered values, such as Health, Well-being, Benefit, and Improvement. However, they are included because they result from the interaction and application of other types of values. When a palliative care physician genuinely seeks to reduce suffering and acts with that goal in mind (compassionately), they are immediately supporting the patient and their family, promoting improvement that implies greater well-being and health, in terms of reducing “total pain” [3, 81]. This is not about curing but about alleviating. Spiritual care relates to the meaning and relevance the physician attributes to spirituality and its presence and importance in the patient. Additionally, it appears to be an action that promotes or improves the physician’s spirituality. Now, all the values observed in the diagram are essential for the professional activities of a physician aiming to provide comprehensive, holistic, and patient-centered palliative care, which includes spiritual care.

The axiological review determined that respect, responsibility, and compassion act as core values in clinical practice. From a theoretical perspective, respect can be understood as the practice of the value of tolerance, which leads to a genuine interest in others. It is one of the guiding values physicians must uphold in their professional routines. However, in spiritual care is indispensable when dealing with patients’ beliefs, especially those unfamiliar to the physician.

Practices of respect toward different beliefs involve attitudes of acceptance and understanding of what is different, as well as efforts to navigate these beliefs during spiritual care. Of course, respect is manifested both toward others and oneself, which involves being empathetic without compromising one’s own ideas and beliefs.

Responsibility, understood as the quality of being able to respond to one’s actions, reflects the physician’s duty to attend to their patient and address their needs, even if they go beyond the physical. Part of a physician’s professional responsibility is to provide the best possible care to their patients, which, in certain aspects, encompasses the need for comprehensive care—and this is what should be prioritized. As stated, “spirituality remains a sensitive area for physicians. However, spiritual values and the need to address patients’ spirituality are increasingly recognized as an integral part of care” [3, 25].

Other values ​​that were identified throughout the analysis and that are fundamental to the discussion of spirituality were love and freedom. To provide spiritual care, the physician must possess a deep affection or genuine interest in the other person and their well-being. This has been identified in research, such as that of Dones Sánchez [32], where participants were asked to describe “the essence of spirituality” using a single word. A notable percentage of participants used the word “love” to express it.

Another important aspect is that both the physician and the patient must enjoy freedom (understood as “the power or right to act according to one’s own values”) to achieve, on one hand, the pursuit of a treatment, and on the other, the ability to do good by providing the necessary care under the best possible conditions.

Emerging Paradigms in Spirituality and End-of-Life Care: A Hermeneutic Analysis of Barriers and Facilitators in Physicians' Spiritual Care Provision:

Barriers: factors that cause the doctor not to be involved in spiritual care

Barriers can be understood as cultural, social, or spiritual factors that hinder physicians from engaging in the provision of spiritual care for their patients. Within the analysis, physicians' personal beliefs represented one of the main barriers to spiritual care. Speaking of personal beliefs does not imply reducing any type of belief to a refusal to provide holistic care. On the contrary, beliefs themselves could become a facilitator for this type of care, depending exclusively on what beliefs are held and how they may affect the provision of care. For the purposes of this study, physicians' beliefs are understood as those thoughts formed from their life experiences, which determine part of their worldview and help them interpret their reality. The beliefs on which doctors base their reality can be seen as an obstacle to incorporating and responding to other types of beliefs (Table 7).

Table 7.

Quotes to explain the barriers in Physicians’ Spiritual Care Provision. *Authors translation: “Many professionals feel uncomfortable and lack the tools to begin exploring psychological-existential-spiritual concerns and therefore avoid listening and speaking about it, limiting their activity to biomedical exploration, where they predictably feel safer”

Barriers in Physicians’ Spiritual Care Provision
Code	Quotation
Physicians’ Beliefs	“Some previous studies have hinted that personal belief structures influence GPs’ attitudes to spiritual care. This study strengthens and confirms this connection.” [9] “Barriers that stand in the way of HCPs properly addressing patients’ spiritual needs include a lack of education, confidence, and the right vocabulary; a belief that spiritual care is someone else’s responsibility; and various influences of secularism and diversity in society.” [82] “Indeed, our results show that staff members have real concerns about raising the topic of religion or spirituality with patients coming from a different back- ground than theirs, perhaps feeling it could lead to negative inter- actions” [54]
Not Doctor’s Responsibility	“Swedish healthcare providers generally experience difficulties in navigating these needs, and a general assumption exists that competence to provide spiritual care is restricted to hospital chaplains and religious representatives.” [71]
Ignoring	“A small minority of respondents (6%) reported that spiritual health conveyed no meaning, or was unclear, to them, but there was little elaboration on this assertion”* [67]
Overstepping	“muchos profesionales se sientan incómodos y sin herramientas para iniciar la exploración de las preocupaciones psicológicas-existenciales-espirituales y por tanto eviten escuchar y hablar de ello, limitando su actividad a la exploración biomédica, donde previsiblemente se sienten más seguros” [83]
Lack of Training	“Only nine respondents (10%) felt they had received appropriate training in spiritual care and 54 respondents (62%) disagreed or strongly disagreed that they had received appropriate training.” [47] The rarity of SC may be primarily due to the frequent lack of SC training” [2] “Barriers that predicted less frequent SC for all medical professionals included inadequate training” [15]
Referring	“Without a shared understanding, holistic assessment of patients’ needs and referral for appropriate support will be an ongoing challenge.” [67] “The physician, in the role of a spiritual care generalist, should be capable of assessing the need for spiritual care for their patient and make appropriate referrals to the spiritual care specialist, the chaplain, when more in-depth spiritual care is deemed necessary.” [44]

In spiritual care, when a physician's concept of spirituality differs from the patients, and the physician is unwilling to explore the patient’s perspective, they cannot provide adequate spiritual care because they fail to truly understand the patient's spiritual needs.

Another significant factor is a lack of perceived responsibility for addressing spiritual needs. The analysis revealed that many physicians believe that their responsibility is limited to physical care, leaving other dimensions unattended. Ignoring spiritual needs often intertwine with factors like discomfort and perceived overstepping. Addressing spirituality remains challenging for physicians, as it is seen as a deeply personal topic. Spirituality is also sometimes perceived as overstepping professional boundaries into the patient's private domain, especially if patients are reluctant to share, fearing it might offend [9].

Lack of training appears as another significant barrier, since without theoretical foundations, addressing spirituality becomes nearly impossible, as physicians struggle to identify spiritual needs or initiate conversations. As a result, physicians may refer patients to other specialists, operating under the belief that "spiritual care is better assessed by other team members" [17, 61]. While referral can be beneficial, it may also hinder the continuity of holistic care, as referred specialists may lack the established doctor-patient relationship essential for addressing the patient's needs comprehensively.

Further analysis of these barriers revealed co-occurrences such as lack of training and time constraints (Fig. 8), the inability to identify needs and ignoring them, and the physicians’ beliefs linked to avoidance and discomfort.

Fig. 8.

Co-occurrence of barriers to spiritual care. The dark tones in the table allow us to identify greater co-occurrences between barriers

Many physicians indicated that their medical training did not prepare them to address spiritual topics or respond to patients' spiritual needs effectively. The health system also prioritizes physical concerns, limiting time for spiritual exploration during consultations. Consequently, physicians often ignore spiritual needs out of discomfort, lack of training, or fear of crossing professional boundaries.

Moreover, a lack of self-awareness regarding their own spirituality often prevents physicians from integrating it into their practice. Physicians who fail to recognize their own spiritual needs for connection, meaning, and transcendence struggle to address their patients' spiritual needs holistically.

Facilitators: factors enabling spiritual care

In contrast to barriers, facilitators are factors (mainly attitudes and conditions) that enable spiritual care for both providers and recipients. Throughout the analysis, several factors were identified and described as facilitators of spiritual care provision (Table 8), where the most frequent were communication, training, attitudes of involvement, and overall care of the good of the patient.

Table 8.

Quotes to explain the facilitators in Physicians’ Spiritual Care Provision

Facilitators in Physicians’ Spiritual Care Provision
Code	Quotation
Physicians’ Beliefs	“As with patient surveys, these studies, show that most physicians believe they should be aware of patients’ religious or spiritual needs and sometimes address them” [21] “Having personal religious or spiritual belief correlated with a perception that it helped coping with death and dying” [68]
Communication	“It highlights the need for appropriate communication with the patient during their illness to determine their wishes.” [25] “They also Identify a set of qualities that may help GPs to address their patients’ spiritual needs including communication skills, awareness of one’s own spirituality, and a respectful, confidential, and patient-centred approach” [53]
Training	“Patients, nurses, and physicians view SC as an important, appropriate, and beneficial component of EOL care. SC infrequency may be primarily due to lack of training, suggesting that SC training is critical to meeting national EOL care guidelines.” [2]
Getting Involved	“Undergoing training correlated in our study with a more positive attitude toward the provision of spiritual care, but even within the sub- group of those who think spiritual care should be provided (Table 5), training is a key factor in determining actual care pro- vision.” [54] “In addition, by engaging with patients dealing with end-of-life issues, physicians report an increased cognizance of the presence and role of spirituality in providing compassionate care for these patients” [27]

A co-occurrence analysis was conducted to determine the relationships between facilitators and their occurrence in texts. Among the various connections identified, the link between training and educational programs was particularly prominent. This finding underscores the need to integrate spiritual care into both undergraduate and postgraduate medical curricula. Structured training programs equip physicians with the skills and sensitivity required to deliver truly holistic care that addresses patients' physical, emotional, and spiritual needs.

Other important relationships can be seen in Fig. 9, such as physicians-patient communication and physician’s involvement in the patient’s care and needs. Communication also intersects with training, which supports the observation on the importance of incorporating educational plans that prepare physicians in the field of holistic care.

Fig. 9.

Co-occurrences of facilitators of spiritual care. The dark tones in the table allow us to identify greater co-occurrences between facilitators 

The transformative role of holistic care training

This analysis reveals that facilitators and barriers to spiritual care are often direct opposites. For example, the presence or absence of training is a key determinant: while inadequate training hinders spiritual care, proper education enables it. Addressing this gap through educational reform—by embedding spirituality as a core element of health curricula—better equips physicians to deliver truly comprehensive care. A holistic approach, consistent with the biopsychosocial model, emphasizes the integration of both physical and spiritual dimensions of patient well-being.

Spiritual care training, complemented by communication skills, bridges theoretical knowledge with practical application, enabling physicians to provide care grounded in experience and evidence.

Axiological networks and spirituality: spiritual care as a catalyst for change in comprehensive palliative patient support

One of the foundations of this research was identifying the axiological support of spirituality in clinical settings and spiritual care. This was achieved through an analysis of co-occurrences between values and elements of spirituality, as illustrated in the following figure (Fig. 9). This diagram adopts a web structure, developing connections stemming from four main elements of spirituality (highlighted in purple or blue) and surrounding them with essential values (in gray).

The result is an axiological network of spirituality, which explains the values upon which physicians should base their practice to provide high-quality spiritual care. The values most frequently co-occurring with spirituality were improvement and benefit. Although these are not values in a strict sense, they are considered essential for understanding and measuring the impact of spiritual care.

The presence of spirituality in a physician’s daily life translates into its application in clinical practice. This connection is associated with greater openness, willingness, and capacity to provide spiritual care, thereby generating greater benefits for patients in addressing their spiritual needs.

The first value to address is support, understood in this research as reciprocity, assistance, and collaboration between individuals or groups for mutual benefit. This value had important co-occurrence with attitudes, such as accompaniment and connection between physician and patient. Both elements are crucial for the provision of spiritual care as they underscore the importance of human support in the recovery and/or improvement of patients. Accompaniment—primarily from the patient’s support network but with essential involvement from the physician—is indispensable for maintaining the patient’s emotional health, preventing moments of loneliness that could deteriorate their condition.

Although less frequent compared to other co-occurrences, the relationship between spiritual needs and duty presents a significant point for analysis. Duty is understood as "a moral obligation imposed by a higher structure." Professional duty refers to the responsibility’s individuals assume in their work, and for healthcare professionals, these responsibilities involve attending to and caring for others. For physicians, this duty encompasses ensuring the health and well-being of individuals by providing comprehensive, compassionate, appropriate, and professional care. Such care includes recognizing patients' spiritual needs and addressing them, whether within or outside the context of palliative treatment.

Finally, we find compassion, defined as "the recognition of suffering when it is present (rather than avoiding or denying it), combined with a genuine desire to try to alleviate and prevent it." Compassion can be understood as a value that makes us sensitive to the pain of others, inevitably involving an effort to address it. Physicians often show compassion toward patients in palliative care, at the end of life, or those dealing with advanced illness, among other situations. Compassion can drive physicians to provide holistic care to assist their patients as much as possible. Spiritual care is part of this type of attention, justified as a method of support and accompaniment during moments of suffering. When faced with others’ pain, physicians may also become open to participating in their patients’ spiritual expressions, such as prayer, meditation, etc., even if these practices do not align with the physician’s personal spirituality.

Compassion, according to Anandarajah et al., is essential to achieving holistic care, as they explain that “the vast majority of participants [in their research] believed that addressing patients’ spiritual needs is integral to holistic care, and many described links between spiritual care, healing, and compassion: ‘Medical practice is about healing. We tend to focus on healing the body, but there are other parts that may need healing. Spirituality is one aspect’” [65].

Discussion

In this investigation, we integrated an operative definition of spirituality that is the tracking route of this research and point out several components that amalgamate spiritual care (Tables 4, 5, 6, 7 and 8, Figs. 3, 4, 5, 6, 7, 8 and 9). We demonstrate that the spiritual care (provided by medical professionals at the end of life integrates actions, attitudes, values, and qualities such as quality of life, patient satisfaction, their support network [84], the quality of accompaniment in the health-illness-death process [5], and even a reduction in the economic burden of illness [85] (Figs. 4, 6 and 9. Table 4 and 6). This finding points out that spiritual care strengthens the physician–patient relationship, enabling the health care professional to understand how the patient’s beliefs and values influence decision-making and how to incorporate them into treatment plans (Fig. 9).

Fig. 7.

Values network. Most frequent codes and concept clouds

Spiritual support from the healthcare team is also predictive of excellent and integral care at the end of life, a result achieved only through the formation of a trans functional team providing comprehensive care [3]. This cross-functional team typically includes various healthcare professionals, such as physicians, nurses, social workers, psychologists, physical therapists, and religious leaders (Figs. 5, 6, 9, 7 and 8. Tables 4, 5, 6, 7 and 8).

This review reveals a significant gap between what patients’ desire and what physicians provide. While most physicians believe spiritual care is part of their duty or responsibility, this belief does not always translate into practice (Fig. 7 and Table 7).

Nature, purpose, limits, and scope of spirituality

Providing spiritual care requires a clear understanding of what spirituality refers to. This study proposes an operational definition of spirituality for clinical and research purposes, built around common and essential elements identified in prior definitions, including the International Consensus Conference on Improving the Spiritual Dimension of Whole Person Care (Geneva) [1]. This operational definition can lead to new perspectives on spiritual care in clinical practice in general and palliative care in particular. It paves the way for the development of educational plans and programs that consider holistic care as a key component of the training of health professionals (Figs. 3, 4 and 5. Tables 4 and 5).

Core elements of spirituality—such as the cultivation of and the search for meaning and purpose—are particularly relevant amid current efforts to integrate spirituality into clinical practice and broader societal frameworks. The operational definition presented in this study emphasizes transcendence and overall wellness of the patient. It is grounded in inter-, intra, and transpersonal relationships, manifesting in beliefs, values, traditions, cultural practices, personal resilience, self-discovery, self-reflection, emotional support, and behaviors oriented toward personal growth. (Fig. 4, 5 and 9. Tables 5 and 6).

This definition also provides a foundation for qualitative studies on value systems and sociological constructs that underpin spiritual care provided by physicians. A phenomenological approach could explore how physicians interpret their spiritual experiences and how these influence their medical practice. Such culturally sensitive studies could examine barriers and values influencing physicians' willingness to address spirituality, particularly when caring for patients from diverse backgrounds. The study also underscores the distinction between religion and spirituality, with spirituality offering a more flexible and less doctrinal approach to fostering holistic human development [9, 24] (Figs. 3, 4, 5 and 6. Tables 5 and 6).

Value-based medicine in spiritual care

The axiological analysis of spirituality offers a novel framework that emphasizes the essential role of values in clinical practice, showing that values are key to understanding and applying spirituality in medicine. Despite its clinical relevance, the relationship between values and spirituality remains underexplored (Figs. 6 and 9. Tables 4 and 6).

For physicians, foundational values are critical for guiding their practice, particularly when working with physically and mentally vulnerable individuals. Understanding the values underpinning spiritual care opens discussions and broadens the epistemic horizon about the importance of high-quality care as part of comprehensive patient care, a topic that warrants greater attention. This study provides a starting point for building connections between values and spirituality, offering a clearer perspective on the significance of addressing spirituality in clinical practice and enhancing spiritual care in palliative settings (Figs. 6,7,8, and 10).

Fig. 10.

Axiological network of Spirituality Care, including values

This study’s axiological findings demonstrate that spirituality and spiritual care embody intrinsic values such as support, benefit, improvement, respect, accompaniment, and compassion. Together, these form meta-values like justice, aligning with the role of a "Consociate." A consociate physician fosters genuine, empathetic cooperation with patients and their families to identify and achieve shared goals that respect the patient's needs, desires, and worldview.

Key works by Guevara, Bornet, and Vermandere [7, 39, 53, 86] align with this study's vision of the family physician’s role in providing palliative care. Family physicians, supported by transdisciplinary teams, are ideally positioned to deliver holistic care, including spiritual support, rather than leaving this responsibility solely to palliative care specialists. Spiritual care, as well as palliative care in general [7, 17, 65, 87], is a duty of all physicians, regardless of specialty. Therefore, incorporating spiritual care training into medical education programs is essential.

The physician as a facilitator of spiritual care

The role of the family and palliative care physicians extends beyond clinical expertise; it is deeply rooted in ethical, epistemic, sociological, moral and economic values. These values are not abstract ideas but are lived and shaped through the physician’s professional and life experiences. Recognizing themselves as equals to their patients enables physicians to foster a deeper physician–patient relationship, which Lain Entralgo [88] describes as an encounter between two multidimensional individuals (Fig. 9 Table 8).

By viewing the patient holistically, the consociate physician considers broader impacts beyond physical health, including moral, economic, and social dimensions. This role emphasizes the physician’s need for self-awareness regarding their own spirituality to integrate it into professional practice. Without a clear understanding of their spirituality, physicians may face uncertainty about how to address spiritual issues, underscoring the importance of self-knowledge [29, 84] (Fig. 9 Table 8).

Limitations and future directions

The main limitation of this study is that there is a very limited research investigation in this field, and this research promotes continuing the exploration and unveiling of new issues in spirituality.

This study, based on a hermeneutic and axiological, analysis gives us an epistemic horizon and new routes to continue exploring the topic, for example using empirical studies in multicentric hospitals.

This could help explore local sociocultural realities and reassess the validity of these findings across different settings.

Conclusions

Spiritual care is a critical, yet underutilized, dimension of palliative medicine. Physicians' willingness to engage is shaped by personal values, training, and institutional structures. Without explicit training and structured support, physicians are left to navigate spiritual issues intuitively, leading to inconsistent care practices.

This systematic review highlights the urgent need for educational interventions and value-based professional development to enable physicians to provide compassionate, holistic care that includes addressing patients' spiritual needs. Training programs must move beyond the theoretical to equip physicians with practical communication skills, self-awareness to do overall good for the patient, and ethical frameworks grounded in axiological reflection.

Furthermore, integrating spirituality into palliative care not only honors patient preferences but strengthens the therapeutic alliance, promotes dignity at the end of life, and supports more humane, meaningful medical practice. Institutions must prioritize creating environments where addressing spiritual needs is seen as a fundamental component of quality care.

Future research should operationalize and validate the proposed definition of spirituality and develop context-specific training models that can be adapted across cultural and healthcare settings. By doing so, we can close the persistent gap between patient expectations and clinical realities, ensuring that spiritual care becomes an integral part of palliative medicine worldwide.

Abbreviations

AAFP

American Academy of Family Physicians

ESWS

Ellison Spiritual Well-being Scale

SWB

Spiritual Wellbeing Scale

GMP

General medical practice

PCP

Primary care Physicians

GP’s

General Practitioners

NGT

Nominal Group Technique

SC

Spiritual Care

ICCS

Improving Clinician Communication Skills

EOL

End of Life

PGY

Post Graduate Year

DEOLD

Dutch End of Life in Dementia

GEE

Generalized Estimating Equations

HCPs

Health Care Providers

AMM

Ars Moriendi Model

ANZSPM

Australian and New Zealand Society of Palliative Medicine

PRT

Palliative Radiotherapy

EAPCSC

European Association for Palliative Care Spiritual Care Reference Group

ICU

Intensive Care Unit

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RCTs

Randomized controlled trials

SR

Systematic reviews

MM

Mixed-methods

ACH

Advanced Care at Home Units, EXIT (a right to die Swiss organization)

Authors’ contributions

Designed the research, M.M.A.-B and AD.; Performed the experimental research, AD, IC, and M.M.A.-B.; Analyzed and edited the data, AD, IC, UG and M.M.A.-B.; Supervised the paper M.M.A.-B. All authors have read and agreed to the published version of the manuscript.

Funding

The authors declare no funding.

Data availability

All data generated or analyzed during this study are included in the article.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.