Do Not Play: Recognizing Spiritual Distress in Serious Illness.

Spiritual distress is a significant yet frequently underrecognized component of serious illness and palliative care. Although spirituality is recognized as a core domain of quality palliative care, patients often express spiritual suffering through grief, mistrust, anger, identity, trauma, or existential concerns rather than explicitly religious language. This article explores the role of spiritual assessment and open-ended inquiry in recognizing spiritual distress through the case of an 86-year-old Black male with metastatic prostate cancer who repeatedly refused to answer standardized questions regarding spiritual distress. Although he identified as agnostic, broader conversations revealed profound sources of meaning, suffering, dignity, and peace shaped by experiences of racism, institutional mistrust, family, music, and legacy. The case illustrates how spiritual distress may emerge indirectly and highlights the limitations of relying solely on structured screening tools. Common spiritual assessment frameworks are reviewed, along with the importance of therapeutic presence, compassionate curiosity, and culturally responsive communication. Nurses and advanced practice registered nurses are uniquely positioned to recognize subtle manifestations of spiritual suffering and facilitate whole-person care through open-ended, trauma-informed approaches to spiritual assessment.