María de la Luz Fajardo-Gámez,1 María Teresa Molina-Prado,1 Ingrid Rosa Korkowski-Zepeda,1 Laura Marcela Ambriz-Orozco,1 Rosa Zavala-Díaz,1 Daniel Luna-Pizarro,2 Luz Verónica García-Fajardo3
1Grupo de Tanatología, 2División en Investigación Médica, Hospital de Traumatología Lomas Verdes, Instituto Mexicano del Seguro Social, Naucalpan, Estado de México; 3Grupo Académico de Biotecnología Ambiental, Laboratorio de Biotecnología Ambiental y Agroecología, El Colegio de la Frontera Sur, Tapachula, Chiapas. México
Registro Comité Local de Investigación en Salud 1501, Hospital de Traumatología y Ortopedia Lomas Verdes, México, México Poniente. Number R-2011-1501-14.
Correspondence: Luz Verónica García-Fajardo
Received: September 9th 2014
Judged: December 10th 2014
Accepted: June 10th 2015
Objective: to evaluate the effect of Thanatology counseling in burn patients through the FaCIT-Sp12 spiritual well-being scale.
Methodology: the study population consisted of hospitalized patients with several burn injuries. Socio-demographic information was collected, and participants completed the FACIT-Sp12 scale for spiritual well-being assessment the first and last day of hospital stay. Thanatology counseling was provided to them through the complete hospitalization time. Descriptive statistics was calculated for socio-demographic variables and non-parametric tests to calculate differences between obtained scores.
Results: the sample included 107 burn patients and scored 35.7 in the FACIT-Sp12 scale applied at baseline. This score increased to 40.7 at the end of treatment, which indicates an improvement in the spiritual well-being of patients and this difference was statistically significant (Z = −6.53, p = 0.000).
Conclusions: thanatology counseling should be included as part of the integral treatment given to burn patients because it has showed to improve their spiritual well-being, therefore it has a positive effect in their recovery during their hospital stay.
Keywords: Spiritual therapies; Burns; Thanatology; Spirituality
More than 60% of the population suffers a traumatic event some time in their life, and the trauma caused by burns is considered among the most painful that human beings may suffer, coupled with the fact that not all people can achieve full recovery.1 The severity of a burn and, therefore, hospital treatment are determined primarily by the depth, size, and location of the burn. The first stage is called the critical stage and aims to stabilize the patient. Subsequently, in the acute stage (or second stage), care involves wound cleansing, debridement, and dressing changes, as well as the application of grafts, which are very painful procedures for the patient, who frequently experiences intense pain, stress, anxiety (in 13 to 47% of cases),2 anger, guilt, isolation, decreased self-esteem, and a sense of loneliness. Common reactions to these emotions are aggressiveness, nightmares, and in some cases even regression to juvenile and even infantile states.3 The third stage is medical discharge and rehabilitation, which usually occurs at home and it is often more difficult than the hospital stay for its social implications, since the patient must return to routine activities at home and work (or, given the case, school). Post-traumatic stress disorders and acute stress disorders are among the long-term pathologies experienced by burn survivors, and they are characterized by anxiety, depression (23-61% of cases),2 delusions, sleep disturbance, and nightmares.4 Because the psychological and spiritual needs of patients with burns are dwarfed by the overriding requirement of saving life, it is essential that hospital-based treatment be given holistically, and that it involve all relevant aspects of the patient, conceiving of them as a biological, psychological, social, and spiritual being. Doctors, nurses, social workers, psychologists, and psychiatrists should remember that anyone who interacts with a patient impacts their psychosocial world positively or negatively; consequently, the family is also a key instrument of psychotherapeutic intervention.5
Thanatological intervention responds to the need for communication between the patient, family, and the interdisciplinary health team.6 The thanatologist professionally provides spiritual and emotional support to the patient and their relatives. The thanatologist main goal is to guide the patient to accept his reality so that he can lead a better quality of life and, if death comes, to accept this with dignity and peace.7
Spirituality is often the only recourse that patients have to face suffering associated with their disease. Spiritual well-being emerges as a concept that encompasses the aspects of the spirituality of an individual: meaning and purpose of life; inner hope and strength; and the relationship between oneself and others and the environment; and belief and faith in a higher power and religion.8 When the patient is spiritual, he will find meaning and purpose in their suffering, and their life takes on value.9
Many health professionals did not consider spirituality an important aspect of care, although there are reports dating from 1859 stating belief in the spiritual component of human life10 and the existence of a connection between strong spirituality and improved health, which are the basis for wielding the ability to cope with the stress of illness and grief.11
Various studies report the benefits of spiritual well-being in the lives of people with any disease. A descriptive cross-sectional study was conducted in patients with sickle-cell disease, finding that those with greater spiritual welfare had a better quality of life with their disease.12 This well-being has not yet been documented in burn patients in our country, but the effects of thanatological attention have been observed on improving spiritual well-being in women with breast cancer in the State of Durango,13 and also in patients with heart disease at the Instituto Nacional de Cardiología Ignacio Chávez.14 The Instituto Mexicano del Seguro Social (IMSS) has documented the importance of thanatological care in patients with neuropathies, and other psychological scales have been used to measure quality of life and depression in patients with chronic hepatitis C.15
Thanatological care currently provides support in palliative care, and these in turn have been incorporated as mandatory in the public health care plan in the health sector since 2010.16 Thanatological care has been provided in the Unidad Médica de Alta Especialidad Lomas Verdes for 10 years, and its volunteer members have observed positive effects on patient spiritual recovery, helping them cope with the loss of health or death. The aim of this study is to evaluate spiritual well-being in patients with burns receiving thanatological care during their hospital treatment, by means of a measuring instrument recognized and validated in the national and international scientific community that does this type of research; this instrument is the FACIT-SP12 survey from the FACIT Organization (Functional Assessment of Chronic Illness Therapy).
This is a descriptive cross-sectional study in the Plastic and Reconstructive Surgery Department - Acute Burn Section, of the Unidad Médica de Alta Especialidad Lomas Verdes of IMSS, over a period of eight months. The sample was selected by non-probability sampling for patient availability. Due to the nature of their injuries, burn patients usually have prolonged hospital stays, allowing better thanatological care and follow-up during hospitalization.
107 patients were included with the following characteristics: having suffered bodily burns, over age 16, able to speak, and without mental disorder. Once selected, the treatment protocol was followed as listed below:
It is worth mentioning that all patients admitted to the unit during the study period who requested thanatological support received it, whether or not they were included in the protocol. Ethical and legal aspects covered by the 18th World Medical Assembly in the Helsinki Declaration and Title II, Chapter I of the current Ley General de Salud in research were considered at all times.
The study variable was spiritual wellbeing, which is a multifactorial concept whose meaning can be understood as the aspect of the human condition that refers to how individuals seek and express meaning and purpose, and how they express a state of connection with time, with oneself, with others, with nature, and with what is meaningful or sacred.17
The FACIT-SP12 survey version 4.0 was selected because its sensitivity, validity, and reliability have been proven around the world. This survey is part of the FACIT evaluation system, which includes the estimation of the quality of life associated with health, both generally and disease-specific. FACIT assessments were initially designed for almost all types of cancers and numerous diseases and chronic conditions. In particular, the FACIT-SP12 survey is applied through a semi-structured interview which asks patients to provide information regarding the spiritual aspects that are most important to them, which are described as the meaning of life, harmony, peace, strength, life purpose, and satisfaction with the faith they adhere to. The questionnaire contains 12 items, each with five response options. These are: 0 = not at all, 1 = a little, 2 = somewhat, 3 = moderately, 4 = a lot. Internal reliability coefficients have been reported at 0.81 to 0.88, as well as moderate to strong correlations with other instruments measuring religiosity and spirituality.18 The FACIT-SP12 survey has been used to assess the relationship between spiritual well-being and the health status of patients with HIV / AIDS, with cancer during chemotherapy and radiation therapy, as well as in the long process of patients undergoing transplants.19 Like the conditions described above, the hospital stay of patients admitted with burns is usually long-term and treatments are difficult and painful, coupled with the traumatic experience they have lived; therefore, we believe that the FACIT-SP12 survey is suitable for this study. The score range is 0 to 48. A higher score indicates better spiritual well-being. It also has the advantage that it allows the thanatologist to engage the patient in a dialogue to identify their area of concern and determine the help they need. Prior to doing this study, authorization was requested from the FACIT Organization (www.facit.org) to use the FACIT-SP12 questionnaire translated into Spanish, and its evaluation was done following their methodology.20 This survey was validated with a pilot test applied in the patient sample, from which the corresponding Cronbach alpha coefficient was calculated.
The data obtained were analyzed using descriptive and frequency statistics. Wilcoxon’s signed rank test was applied and the correlation between the study variables was sought. Any p-value less than 0.05 was taken as significant. All determinations were done using IBM SPSS Statistics program, version 20.0.
Characteristics of the study population
According to the information gathered during the initial interview, most of the study population was male, with only 14% females. The age ranged from 17 to 76 years, and the average was 37.6 years. The majority of the population was married (77.6%) and professed the Catholic religion (81.3%), while the rest were single and professed a religious system other than Catholicism.
Regarding the level of schooling, most had basic schooling, meaning primary or secondary (57.9%); 33.6% had the middle level (high school), and only 6.6% of participants had advanced education. The remaining 2.8% did not have any degree of schooling.
Almost half of them worked as employees (45.8%), 39.3% were professionals, 8.4% worked in the home, 3.7% were students, and 2.8% were unemployed (Table I).
|Table I Socio-demographic characteristics of patients in the study (n = 107)|
|Age (CI in years)*
|*A 95% confidence interval (CI) of 17-77 was presented, with a mean ± SD of 37.67 ± 13.6|
Data of medical diagnosis and thanatology treatment
Study participants were admitted to the Plastic and Reconstructive Surgery Department of UMAE Lomas Verdes diagnosed with burns on different parts of the body surface. 7.5% had first-degree burns (n = 8), more than half of patients (n = 57) had second-degree burns (53.3%), three patients had third-degree burns (2.8%), and the rest had mixed burns, i.e. their injuries combined two or more different burn degrees. Thus 10.3% (n = 11) had first and second degree burns, 23.4% had combined second and third degree injuries (n = 25), one person had first and third degree (0.9%), and finally two patients (1.9%) had burns of first, second, and third degree.21 Medical treatment depended not only on the degree of injury but the cause. 38.3% of participants had burns from direct fire, 34.6% from electrical causes, 13.1% from scalding, 4.7% from thermal causes, 3.7% from chemical causes, and 5.6% from other causes.22
Thanatology staff determined the needs of each participant based on closed interviews with them, and provided care at different levels as part of their overall treatment throughout their hospital stay, with an average of two weekly visits. The total number of visits is shown in Table II. As we can see, the average number of thanatology sessions provided varied by interval of days of stay for each patient, which on average was 28.4 days. In all cases they were given the thanatological support until being discharged from the unit, even in times of crisis and episodes of shock from complications during medical treatment.
|Table II Number of thanatology sessions provided to patients with burns (n = 107)|
|Mean ± SD was 28.4 ± 23.9
CI = confidence interval; SD = standard deviation
Reliability of the measuring instrument
The FACIT-SP12 questionnaire consisting of 12 items was used. This survey is divided into three sub-scales which encompass the conceptual framework of spiritual well-being, which is mainly based on meaning and purpose of life (4 items); inner hope and strength of people (4 items); their relationship with others as well as their belief and faith, regardless of religion professed (4 items).23 The pilot test was done, determining the Cronbach's alpha coefficient for the survey (FACIT-SP12) applied to study participants, whose value was 0.846 for the total scale. In the subscale corresponding to meaning of life-peace, we obtained a value of 0.800 and the same value for the subscale of faith, which indicates the internal consistency of the study and therefore its reliability for our purposes;24 besides, these are comparable to those used in other similar studies.25
Level of spiritual well-being
107 patients had an average of 35.7 ± 6.6 points in the FACIT-SP12 survey applied at baseline. After receiving care sessions by thanatology staff, this score increased to an average of 40.7 ± 5.7, which indicates an improvement in the spiritual welfare of patients who received thanatological assistance during their hospital stay. This total score is the sum of the three subscales that comprise it, and for these we also find an increase in scores obtained before and after care given to patients. Each subscale has a maximum score of 16. In the meaning of life scale, an average of 13.5 ± 2.0 increased to 14.7 ± 1.6. In the part corresponding to peace we had an average of 10.1 ± 3.1, and 12.3 ± 3.0 after thanatological assistance. In the aspect of faith the initial average was 12.2 ± 3.4, and final was 13.7 ± 2.7 (Figure 1).
Figure 1 Effect of thanatological care on the spiritual well-being of patients with burns
The following null hypothesis was set: there is no significant difference in the value of the score of the FACIT-SP12 test before and after thanatological care; therefore, spiritual well-being does not improve in patients.
In the statistical analysis of the above results we used the Kolmogorov-Smirnov (KS) test and Wilcoxon’s signed rank test because our study measured the same participants at two different points in time.26 We noted that for the total score of the FACIT-SP12 test applied, we obtained a low level of significance in the KS test, indicating the absence of normality of the sample; also with the Wilcoxon test we found that the p-value is 0.000, lower than the expected value of 0.05. This means that the favorable change observed in the results of the survey conducted after thanatological care is due to a significant difference and that the difference is not random. We therefore reject the null hypothesis and prove with the Z-value of -6.53 that the participants’ spiritual welfare improved with care, since the scores in the surveys made after treatment were greater than those obtained at baseline. This is also observed at the level of the scores obtained in each of the FACIT-SP12 subscales (Table III).
|Table III Kolmogorov-Smirnov test and Wilcoxon signed rank test for FACIT-Sp12 questionnaire scales and subscales|
|Total||D||Meaning of life||D||Peace||D||Faith||D|
|Wilcoxon rank test|
|p (95%)||0.000||0.000||0.000||1.9 x 10 -5|
|K-S = Kolmogorov-Smirnov; SD = standard deviation; D = difference|
Thanatologists are professionals trained to help in the grieving process and in any kind of significant losses to the person suffering the loss and those surrounding them, treating them with respect, affection, and compassion.27 Study participants were patients with burns, most of them second-degree (53.3%), and medical treatment which causes them long periods of hospital stay (an average of 28 days in this study). In addition to physical recovery, these patients experience psychological and spiritual needs that go beyond medical treatment, so emotional treatment should start in the hospital and continue after they are released.28 The Thanatology Group of UMAE Lomas Verdes offered attention to these aspects during their hospital stay, and the effect of this assistance was measured by the FACIT-SP12 instrument used at national and global levels to assess the internal welfare (called spiritual well-being) of people with chronic or terminal diseases.13,29
The initial questionnaire given to participants resulted in an average total score of 35.7. This result is close to that obtained by Peterman et al., as in other studies in patients with cancer.18 When this total result is viewed from the point of view of the scales that compose it, we appreciate that the highest score is obtained in the aspect related to the meaning of life, followed by the scale regarding faith, and then the scale of inner peace, which has a lower total. After the hospital stay, we observed an increase in both overall scores and each of the scales; a larger increase was observed in the aspect of peace. In addition, we evaluated this increase statistically and found that it is significant with a p-value < 0.05 in both the total and the scales evaluated (Table III). This is independent of the number of sessions given to each patient (p = 0.667), so an improvement in patients’ spiritual welfare was observed even in those who received only two visits. Thus we can say that the care provided by the thanatology team of the UMAE Lomas Verdes helps improve the spiritual welfare of burn patients who participated in this study and that they left the hospital unit with elements that allow them to better meet the challenges of recovery. As in our study, the same effect of spiritual welfare has been seen in the quality of life of patients with terminal diseases,29 and even in patients with chronic diseases such as heart disease14 and type 2 diabetes30 there has been a decrease in the levels of depression, anxiety, anguish, and anger after receiving attention from thanatology nurses, with which they have been able to accept and live with their condition.
In examining the effect of sociodemographic variables in this study, we found that gender shows a negative correlation with the scores of the survey (-0,024, p = 0.806), which is expected, since most of the participants are men (84.1%), unlike other studies in women with cancer that associate this variable with a higher degree of spirituality.31 Age is a variable that appears to have different effects on the results of different patient groups. In our work it has an inverse effect on the score of the meaning of life scale of the questionnaire (-2.17, p = 0.025), consistent with other authors who studied spirituality in patients with breast cancer32 and melanoma.33 However, in studies of people with lung cancer, age shows a strong positive correlation with the level of spirituality.34 We also note that the meaning of life scale is associated with the participants’ level of education, so a greater degree of schooling means greater ability to find meaning in life (0.199, p = 0.04).
Religion is an important aspect of many people's lives and is often confused with spirituality; a person can be religious and spiritual at the same time, or have only spirituality without religion and viceversa.35 Spirituality is an essential part of religion but not vice versa. Individuals with high levels of spirituality (with or without religion) show high levels of self-fulfillment and meaning of life.36 In our study we found a relationship between the religion of the participants, who are mostly Catholics (81.3%), and the total level of spiritual wellbeing or the scales each of its components; however, as in other studies,37 the patients reported that spirituality and religion were important to cope with high levels of pain, depression, stress, and anxiety resulting from their burns.38
The results of this study provide further evidence of the importance of the relationship between spiritual well-being, patient quality of life, and psychological adjustment to their condition. It is now accepted that spirituality is an important component of health, but this phenomenon is not only observed in terminal or chronic conditions.39 These assessments are being implemented in other areas and vulnerable groups such as people with disabilities,40 abused women,41 and seniors.42 For example, in the case of school children, spirituality together with religion can be a protective factor against risk behavior. There has been a decrease in alcohol and drug use among university students, coupled with a decrease in stress.43 In hemodialysis patients, spiritual welfare is a factor that can predict mental health.44 The FACIT-SP12 survey can also help evaluate the effect of thanatological assistance provided to patients, the same way other thanatological assessment instruments have served to determine the resolution of grief in other ailments.14
Statistics show that, with advances in the care of patients who have suffered burns, life expectancies have increased and burns that were lethal a decade ago can now have a good prognosis for survival. In addition to this, dysfunctions in the burned organs and other detrimental consequences of burn injuries or inhalation such as pneumonia or infections can now be prevented and treated better. As this is being achieved, it may be time to focus on aspects of these patients’ quality of life (physical, psychological, spiritual, and family) for their survival have a reason to exist.45 Although the curriculum of medical careers and professions in the health area does not include thanatological training, an effort is being made at the national level, as shown at the Instituto de Neurología y Neurocirugía, to train staff in this vital aspect for the quality of life of patients.46 However, the experience in this area in many hospitals has basically emerged from local needs, as in the case of the UMAE Lomas Verdes group and other support groups in other units. This study showed that there is indeed an effect from thanatology visits made to burn patients during their hospital stay, and it is reflected in an increase in the score from the FACIT-SP12 survey used to measure the spiritual welfare of participants. This increase is statistically significant and implies greater internal peace, faith, and the ability to find meaning in life despite the situation they face, which is reflected in a better quality of life during recovery. The score is positively associated with the number of sessions received and the level of education; it is also independent of the patient’s religion and the days of hospital stay. These results are proof that the efforts of the multidisciplinary health care team should include thanatological care to successfully complement the care given to their patients.
Special thanks to Dr. María Guadalupe Garrido Rojano, head of the División de Educación en Salud, Dr. Ricardo Cienfuegos García, chief of Plastic and Reconstructive Surgery at UMAE Lomas Verdes, and the nurse Irma Lima Galindo, head of nursing in the Plastic and Reconstructive Surgery Department.
We also thank the nurses Hilda Montoya Millán, Jazmín Alfaro Aguirre, Yolanda Cuandón Vargas, Hortencia Serino Díaz, Julia Santiago Trejo, and Salvador Tapia Ibarra for their invaluable support during this work. Also to science teacher Francisco Javier Valle Mora of the Colegio de la Frontera Sur, for his valuable advice.