physical function. Various questionnaires exist, but an evaluation of these for use among palli- ative patients is needed. Line Oldervoll, PhD Department of Cancer Research and Molecular Medicine The Norwegian University of Technology and Science Trondheim, Norway doi:10.1016/j.jpainsymman.2006.10.002 References 1. Oldervoll LM, Loge JH, Paltiel H, et al. The ef- fect of a physical exercise program in palliative care: a phase II study. J Pain Symptom Manage 2006; 31(5):421e430. 2. Oldervoll LM, Loge JH, Paltiel H, et al. Are palli- ative cancer patients willing and able to participate in a physical exercise program? Palliat Support Care 2005;3:281e287. 3. Segal RJ, Reid RD, Courneya KS, et al. Resistance exercise in men receiving androgen deprivation therapy for prostate cancer. J Clin Oncol 2003;21: 1653e1659. 4. Pinto BM, Frierson GM, Rabin C, et al. Home-- based physical activity intervention for breast cancer patients. J Clin Oncol 2005;23:3577e3587. 5. Simmonds MJ. Physical function in patients with cancer: psychometric characteristics and clinical usefulness of a physical performance test battery. J Pain Symptom Manage 2002;24:404e414. Re: Caregivers and Existential and Spiritual Distress To the Editor: While Boston and Mount’s 1 recent thought- ful paper usefully seeks to explore caregivers’ perspectives on existential and spiritual distress in palliative care, there appeared an implicit as- sumption that these themes will almost always necessarily be present during these predica- ments, and, therefore, an exploration of them needs to be actively encouraged by caregivers. Furthermore, there seemed to be a further sup- position that spiritual concerns would always be usefully focused on at this time. This perspec- tive is underlined by statements in their paper such as ‘‘Spiritual/existential concerns are im- portant determinants of enhanced quality of life, the primary goal of palliative care.’’ 1 The authors support this implicit conjecture by arguing that patients who experience a deep sense of meaning and purpose in life may be better able to cope with difficult symptoms and live longer. This perspective reflects a bur- geoning emphasis on spirituality in thinking about health. The new convention appears to be that it is the neglect of spirituality that is frequently blamed for the limits to modern scientific medicine in improving well-being of populations. 2 Spirituality is gradually being ele- vated in the academic literature in an overall conception of well-being and coping skills, almost, it seems, as an attempt to compensate for medicine’s scientific orientation. The evidence, however, of the benefits of spirituality in terms of mental health appear more mixed than Boston and Mount’s paper appears to acknowledge, plus there are real difficulties in integrating spirituality into clini- cal practice and scientific research, which this paper, along with much current literature, ap- pears to side step. There have been, however, some recent fascinating advances in the scien- tific literature on this front. For example, in a recent study, spirituality was associated with lower depressive symptoms in a population of the HIV-positive, and also in a rare attempt at biological integration, decreased 24-hour uri- nary-free cortisol output. 3 Religious involve- ment also has been associated with lower mortality rates in a variety of populations 4 and enhanced immunological function ap- pears to mediate this relationship. 5 However, it is also important to note that when it comes to investigations of how spiritu- ality assists with coping in fields like cancer, the evidence is decidedly mixed. 6 For example, a recent meta-analysis of coping with cancer found that in seven studies there was some ev- idence for the beneficial effect of religious coping, but one of these also found religious coping to be detrimental in a subsample of their population. A further three studies found religious coping to be harmful and seven found nonsignificant results. 6 Much of this literature is produced by au- thors whose base is the United States and there may be a North American cultural bias in see- ing spirituality as lying so close to the heart of psychological well-being, which would stand in strong contrast to views of mental health from 516 Vol. 32 No. 6 December 2006 Letters