We have a middle-aged patient who appears troubled and anxious much of the time. When he is alone, his anxiety increases almost to the point of panic. His physical symptoms are well controlled, but he seems to be suffering emotionally and, perhaps, spiritually. He does not talk easily about what he is experiencing. How can we respond to his anxiety?

When patients are uncomfortable or in distress, even though their physical symptoms are well controlled, they may be experiencing spiritual pain. Spiritual pain is often experienced in the midst of a life-limiting illness and is “a great mimicker, often presenting as physical pain, anxiety or depression, anorexia, insomnia or shortness of breath.”[1] It may stem from troubled feelings, thoughts or relationships. Because spiritual pain is often expressed in physical or behavioural ways, it can be difficult to diagnose. As Kearney and Mount note, the recognition of spiritual pain is often more intuitive than empirical. “We instinctively begin to use words like ‘suffering,’ ‘anguished,’ and ‘tortured,’ rather than a more orthodox, scientific terminology.”[2]

Any of the following may point toward spiritual pain in the hospice setting [3]:

  • constant and chronic pain;
  • withdrawal or isolation from spiritual support systems;
  • conflict with family members, friends or support staff;
  • anxiety, fear or mistrust of family, physicians and hospice staff;
  • anger;
  • depression;
  • self-loathing;
  • hopelessness;
  • feelings of failure regarding one’s life;
  • lack of sense of humour;
  • inability to forgive;
  • despair; and
  • fear or dread.

These indicators and symptoms are related to the patient’s awareness of death and the struggles growing out of that awareness – struggles with losses of relationships, self, purpose and control.[4] Spiritual pain and suffering develop from the patient’s sense of helplessness as his illness diminishes or destroys what is meaningful in his life. Relief can only be found if the spiritual struggles at the heart of spiritual pain are addressed.

The relief of spiritual pain requires paying attention to the patient as a person. This involves looking beyond physical symptoms and medical treatments to the impact the illness and treatment is having on the person. Check on how your patient is coping with his situation. Begin by saying that people with his type of illness often have questions or worries about what is happening or what might happen in the future. You could follow this up by asking him if he has such questions or concerns. You might try a less directive approach by asking him what he thinks about when he goes to bed at night. If your patient is hesitant to open up about how he is experiencing his illness, you could let him know that if at any time he has questions or concerns, he can direct them to you or other team members. Assure him that you will do your best to get him the answers or support he needs.

If your patient does not respond to invitations to share how he is doing and continues to be agitated, anxious or panicky, you might need to be more direct in your approach. You could inform him that the team believes his agitation and anxiety may be related to the struggles he is having as a result of his illness. Health care professionals should exercise caution in not making him feel like he is pretending or that his pain is all in his head. One way to gently approach this topic is to say that suffering is never strictly physical but has an emotional or spiritual component, and that his health care team is just trying to get at the root of his distress. This might lead to a discussion about who might be best suited for talking with him about his suffering – a community spiritual leader he knows, a spiritual care provider on the team or another team member, a hospice volunteer, or a close and wise friend.

Determining the cause of spiritual pain is not easy, and eliminating it is not the goal. Spiritual pain is part of being human – it is how we deal with our mortality and limitations, respond to shattered expectations, and search for meaning in life and death. With spiritual pain comes a chance for growth and sometimes for transformation. As a health care professional, you can help patients embrace these opportunities by focusing on them as people. Invite them to share their questions and worries, and listen respectfully and attentively. By doing so, you can help them find the resources they need to make this season of life meaningful, and assure them that they are not alone and will not be abandoned.


1. Doyle D. Spiritual care: can we teach it? HKSPM Newsletter 2004;1:4-6.

2. Kearney M, Mount B. Spiritual care of the dying patient. In: Chochinov M, Breitbart W, eds. Handbook of Psychiatry in Palliative Medicine. New York, NY: Oxford University Press; 2000:357-373.

3. Hay MW. Principles in building spiritual assessment tools. Am J Hosp Care. 1989;6(5):25-31.

Other reference

Millspaugh CD. Assessment and response to spiritual pain: part I. J Palliat Med. 2005;(8)5:919-923.

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