# Presentation: 416343

## Gary RolphChaplainVA Medical CenterManchester, NH 03104(603) 624-4366 x 6185Gary.Rolph@med.va.gov

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## Spirituality in Patient Care

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## Learning Objectives

- Define healing, faith, spirituality, religion
- Discuss when to talk to patients about spirituality, and how
- Share effective and ethical ways to help end-of-life patients activate their own spiritual resources

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## Mr. B and Mr. W.

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## Joint Commission on the Accreditation of Health Care Organizations

- “Each resident has a right to have his or her cultural, psychosocial, spiritual, and personal values, beliefs, and preferences respected” (Long Term Care Standard RI 2.10, Performance Element 2)

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## Spirituality – Something New?

- No, the care of the spirit has a long and noble history

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## 370 AD Eastern Orthodox Christians found the first great hospital in Asia Minor
Middle Ages – hospice begun (welcoming the dying into homes of Christian priests)
Early 19th century – moral treatment
1969 – St. Christopher’s hospice

- Middle Ages – hospice begun (welcoming the dying into homes of Christian priests)
- Early 19th century – moral treatment
- 1969 – St. Christopher’s hospice

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## Oliver Sachs, M.D.

*clinical professor of neurology, *
*Albert Einstein College of Medicine, *
*adjunct professor of neurology,*
*NYU School of Medicine *
*consultant neurologist to the Little Sisters of the Poor*

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## “Scientific medicine seeks to rectify the faulty mechanism, the ‘It’; existential medicine seeks to inspire the personal, the ‘I.’  These two forms of medicine must be joined, must co-inhere, as body and soul” – Awakenings

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## To rectify and to inspire

- Together define “Health”

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## Health

- “A state of complete physical, mental and social well-being”
- World Health Organization 1946 charter

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## The World Health Organization’s Definition is broad

- But something is missing

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## Spirituality

- That which gives an individual meaning within the context of relationships

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## Spirituality

- Co-inheres rectification and inspiration
- Co-inheres physical, mental, and social well-being

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## Spirituality

- Two parts:
- Individual meaning (mental)
- Relationship embedding (social)

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## An Embedual Spirituality – Individual embedded in relationships

**An Embedual Spirituality – Individual embedded in relationships**

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## Spirituality – The quest for meaning within relationshipsReligion – “an organized system of beliefs, practices, rituals, and symbols” (H. Koenig, M.D.)

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## All humans are spiritualSome humans are religious

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## Spirituality

**The **
**Sacred**

- Islam

- Christianity

- Judaism

- Buddhism

- Hinduism

- Native American

- Religion

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## Generalist spiritual care

- Responsibility of all practitioners
- Not imposing beliefs or practices
- But listening, caring, respectful curiosity, open ended questions

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## When do I bring up spirituality?

- From the beginning of the relationship
- Over time
- Especially when a patient is entering a hospice or palliative care program

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## What do I ask?

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## C. Puchalski, M.D.

- F – What is your faith tradition?
- I – How important is your faith to you?
- C – What is your church or community of faith?
- A – How do your religious and spiritual beliefs apply to your health?
- A – How might I address your spiritual needs?

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## More questions to ask the poor patient?

- Use as needed to understand patient
- Use as process so that one conversation builds on another
- Not simply another part of History and Physical
- Ask only what you can use

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## Speck’s Assessing spiritual needs

- Best done within a caring relationship where it feels safe enough to explore together the experience of the illness in the context of the person’s life journey or story. . .leading to mutual understanding and the identification of possible coping strategies or options for action.  Attentive to:

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## Assessing spiritual needs

- Past regrets, guilt, hurt, resentments in need of healing as well as successful events and happy memories to be celebrated

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## Assessing spiritual needs

- Present anger about present situation, frustration, vulnerability.  There may also be expressions of helplessness, meaninglessness and loss of control.  The carer may also identify current healthy coping strategies and spiritual strength.

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## Assessing spiritual needs

- Future issues around hope – realistic and unrealistic– regarding cure or length of life and expectations.  Fears of dying and death and ‘life after death’ may also indicate the need for spiritual support.

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## Give me an algorithm 

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## Pre-patient encounter

- Interpathy

- Peer to peer

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## First, discover yourself

- Interpathy – the ability to understand your own values and beliefs, then lay them aside in order to listen attentively to the patient

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## Then, talk with someone about yourself

- How do you understand your own spirituality?
- What do you find most easy to share?
- What do you avoid sharing?
- What questions helped you?  What questions seemed too intrusive?

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## Healing yourself and  talking  with someone about yourself should be ongoing, especially for those caregivers dealing with the terminally ill and dying.   

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## Patient encounters

- Proactive

- Over time

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## Start to be proactive, Discover comfortable questions to ask, learn to listen,learn to be vulnerable,learn to empower   

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## “Enabling people to die in social contexts that do not alienate them from the relationships and belief systems that have sustained them in earlier life is an important principle of palliative care” (Nelda Samarel, EdD, SRN)

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## Patient encounters

- Talking with

- Listen and Refer

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## Listening and Referring

- Not talking at – talking with
- “to understand the patient’s beliefs and what role they play in health and illness, without judgment or attempt to modify those beliefs or lack of belief” (H. Koenig, M.D.)

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## Listening and Referring

- Counsel and refer “when complicated or complex issues are present” (Koenig) or when spiritual care requires more time
- Pray only if both you and patient are comfortable, and you have either talked to the chaplain or the chaplain is unavailable

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## How can chaplains help?

- Chaplains focus on the patient as spiritual
- Chaplains present the patient’s spirituality to other caregivers; they are the “specialists in spirituality”
- Chaplains have the expertise to facilitate spiritual reconstruction.

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## How can chaplains help?

- Chaplains can offer reconciliation and give hope
- Chaplains can be available to patients, bringing no preconceived agenda to the discussion.
- Chaplains can validate expressions of frustration, anger, sadness, and loss

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## How can chaplains help?

- Chaplains integrate theological training with expertise in various understandings of health and illness
-  Chaplains can represent God or the patient’s community of faith
- Chaplains listen, attend, pray, and provide ritual expression to a person’s spirituality

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## How can chaplains help?

- Chaplains can be  the team’s liaison to the patient’s local spiritual care provider and spiritual care community.
- Chaplains can offer bereavement counseling and post-death remembrances

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## How can chaplains help?

- Chaplains can be available to caregivers feeling the loss of the patients they have treated.
- Chaplains can counsel caregivers on their spirituality

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## Summary

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## If health is indeed a “state of complete physical, mental, and social well-being,” then can a person die “healed,” out of physical pain, reconciled to God and others, at peace?

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## And if a person can die “healed,” should that not be the goal of all our labors with those who are in the dying process?

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## And if a person can die “healed,” shouldn’t caregivers work as a team to provide physical, mental, social, and spiritual healing?

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## How might one die healed?

- Relieved of physical pain and distress
- At peace with the past
- Surrounded by meaningful relationships
- Touched and cared for
- Reconciled with God/ Higher Power
- Looking forward while letting go

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## Within each of our perspectives, each of us can give patients hope and a future 

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## The beauty of good hospice and palliative care is that it empowers the patient to take control of his life. 

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## Caregivers are the coaches, the trainers, and the rehabilitation specialists.  

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- The patient is the expert, the chief actor, the quarterback

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## For the patient to make sense of terminal illness, and make meaning through it, requires discussion and reflection 

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## Spiritual care can facilitate such discussion and reflection 

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## I close with two quotations that illustrate good spiritual care 

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## Lori Arviso Alvord, M.D.

*First Navajo woman surgeon*
*Associate Dean, Dartmouth Medical School*
*Autobiography:*
***The Scalpel and the Silver Bear***
*(1999)*

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## “Navajo people have a concept called Walking in Beauty, but it isn’t the beauty most people think of.  Beauty to Navajos means living in balance and harmony with yourself and the world.   

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## It means caring for yourself– mind, body, and spirit– and having the right relationships with your family, community, the animal world, the environment– earth, air, and water– our planet and our universe.   

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## If a person respects and honors all these relationships then they will be walking in beauty”

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## Philip Simmons, Ph.D.

*Taught literature and creative writing*
*Lake Forest College*
*1993 learned he had ALS *
*(Lou Gehrig’s Disease)*
***Learning to Fall ****(2000)*
*Died 27 July 2002*

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## “We are all – all of us– falling. We are all, now, this moment, in the midst of that descent, fallen from heights that may now seem only a dimly remembered dream, falling toward a depth we can only imagine, glimpsed beneath the water’s surface shimmer   

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## And so let us pray that if we are falling from grace, dear God let us also fall with grace, to grace.  If we are falling toward pain and weakness, let us also fall toward sweetness and strength.     

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## If we are falling toward death, let us also fall toward life”

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