Transmutation of Spiritual Credence During COVID-19 Era in Cancer Patients: A Case Series

The Corona Virus disease 2019 also known as “COVID-19” was declared a pandemic by WHO on 12th March 2020 [1]. It has created havoc all over the globe and impacted every country on various fronts including economic, social and political [2]. In India also the count is rising steadily. The patients with underlying serious health conditions for example cancer, have an increased risk of admissions into intensive care units [3-4]. The estimated case fatality rate in cancer patients with COVID-19 is 6%, [5] as compared to 1% among the general population [6]. With the estimated number of cancer cases in India being approximately 2.25 million the impact of this pandemic on cancer patients will be grave affecting both survival as well as quality of life [7]. The diagnosis of cancer in itself creates a feeling of desolation in patient’s life. It not only affects the physical and mental well-being of Abstract


Introduction
The Corona Virus disease 2019 also known as "COVID-19" was declared a pandemic by WHO on 12 th March 2020 [1]. It has created havoc all over the globe and impacted every country on various fronts including economic, social and political [2]. In India also the count is rising steadily. The patients with underlying serious health conditions for example cancer, have an increased risk of admissions into intensive care units [3][4]. The estimated case fatality rate in cancer patients with COVID-19 is 6%, [5] as compared to 1% among the general population [6]. With the estimated number of cancer cases in India being approximately 2.25 million the impact of this pandemic on cancer patients will be grave affecting both survival as well as quality of life [7]. The diagnosis of cancer in itself creates a feeling of desolation in patient's life. It not only affects the physical and mental well-being of during this pandemic. On the basis of our assessment we also suggest few solutions which can be incorporated by the clinicians in their practice to help the patients overcome the spiritual dogma.

Materials and Methods
Thirty consecutive cancer patients who attended the outpatient department of cancer pain and palliative clinic of a tertiary care centre were included in our case series. Basic demographic information in form of age, gender and address was noted along with diagnosis and ECOG (Eastern Cooperative Oncology Group) performance status. The spiritual assessment was done with the help of nine questions which assessed the spiritual and religious beliefs, the level of distress they were undergoing and their coping mechanism (Table 1).

Results
Out of thirty respondents, fourteen were females and sixteen were males. Sixty percent (18) of the patients when asked about their perception of spirituality answered that they feel it is a sense of connection to some higher power or almighty. Seventeen percent (5) of patients felt that spirituality is connecting with oneself and others. For equal number (5) of respondents' spirituality gives them purpose of life ( Figure 1).
Regarding the perception of patients about their health problems fifty percent (15 cases) did not blame anyone for their disease or the current ongoing COVID pandemic and said that they are sad about what is happening with them and what is happening around in the world. One third (10 cases) of the respondents blamed it on destiny and karma together. Only two cases blamed God for all the sufferings ( Figure 2).
The COVID-19 pandemic has brought tremendous change in the spiritual practices of the cancer patients. Eighty three percent of cases (25) felt that they are not able to go out to their religious places to devote time to God. Fifty percent of cases (15) felt that there is lack of spiritual clarity. Seven cases had feeling of fatalism. Eight patients reported both lack of spiritual clarity and sense of fatalism Figure 3.
To deal with all the stress related to disease and ongoing COVID-19 pandemic patients also expressed their coping mechanisms. Fifty percent (15 cases) felt that their belief in God gives them strength. Sixty six percent patients (20 cases) use praying or chanting to deal with the stress and anxiety. Eight patients were grateful for life in general and had no qualms about the whole disease. Seven patients felt that the there is immense role of their spiritual community programs and sessions in providing them strength which they are attending online nowadays. One sixth (5 in number) of cases felt that helping out other people in the times of need gives them solace ( Figure 4). Sixty percent (18) of the respondents told that that the health care teams should address the spiritual concerns during the hospital visit.   about their disease and ongoing pandemic, the transitional shift that pandemic has caused in their spiritual practices and their coping mechanisms. In our case series, majority patients felt that for them spirituality means connection with almighty. Even though religion and spirituality are two distinct entities but they are often conflated into one. Cohen et al [11] also suggested that religion is one of the components of spirituality and same is evident from our series. Half of the patients did not put blame on anyone about their disease, but at the same time the other half said that the current pandemic and all their sufferings is because of fate, their past karmas and because of almighty.

Discussion
Cancer patients and their caregivers face lot of hardships and challenges throughout the process of diagnosis and treatment. It takes a toll not only on the physical health but also on the emotional well-being. Ongoing novel coronavirus pandemic has made the task even more uphill for all the cancer patients. To deal with the emotional stress spirituality is often contemplated as a helping hand and makes decision making easier [10]. The case series tries to highlight four things-the perception of spirituality, the view point of the patients   This highlights the fact that almost all the patients are either worried about their situation or are trying to find answers to their problems through God. Almost sixty percent cases emphasized that they want the health care workers to discuss about their spiritual concerns and needs during their hospital visit which is often an overlooked component in our day to day clinical practice. It thus illustrates that spiritual issues needs to be addressed in the broader context in all the cancer patients [12]. It gives them a sense of belief and impetus to lead their life in a more positive way. As far as the COVID-19 pandemic is concerned, whole world has been inflicted, more so the patients who are suffering from debilitating illness like cancer. Cancer patients who are already striving hard to cope with their primary illness also have to worry now about getting affected by corona virus infection because of their immunocompromised state. Because of policies of nationwide lockdown majority respondents felt that they could not visit their religious places of worship, developed lack of spiritual clarity during these tumultuous times and had feeling of fatalism. People have been forced to remain indoors most of the time but now have started to pray from home and use liturgy and prayer resources provided to them. People have started to understand that compassion, kindness, sympathy and caring are the spiritual virtues that will help them to sail through. To deal with the stress and anxiety of disease and the pandemic, patients are using various coping mechanisms in the form of prayer and helping out others. Few were grateful to life in general whatever may be the circumstance in their life, rest felt that God and their spiritual community and sessions provided them strength and hope. After assessment of the spiritual needs, beliefs and challenges we suggest that all cancer patients should adopt spiritual care plans in the form of practices like meditation. They should try to follow their hobbies like art, craft, music, writing whenever feasible and should try to participate in spiritual community programs. From healthcare setup point of view clinicians should engage in the discussion about the spiritual concerns during the patient's visit to the hospital and may refer the patient to spiritual professional if he/ she wishes to. Clinicians may also adopt hope stimulating strategies in the form of developing interpersonal connect with the patient. Patients should be encouraged to attain small specific goals. This will ultimately help them in optimizing their courage, determination and serenity.
In conclusion, the case series highlight that addressing the spiritual needs is an important component of the whole treatment strategy in cancer patients. Cancer patients face lot of challenges on spiritual front also apart from the physical domain. COVID-19 pandemic has aggravated the challenges and problems the cancer patients are already facing. Cancer patients perceive spirituality in different ways, have different beliefs related to their disease and have different coping mechanisms but the novel corona virus pandemic has led to transformation and transmutation in their spiritual practices and beliefs. It thus becomes imperative for the health care professionals to understand the changing needs of the cancer patients and the care givers during the pandemic so that holistic health care services can be provided to them.