DrDr Stanley C. Macaden

Honarary Palliative care Consultant, BBH

National Coordinator, Palliative Care Programme of CMAI

e.mail < stancmac@gmail.com>

Stanley C. Macaden

Ex Director, Bangalore Baptist Hospital

In a multifaith - multicultural environment

Providing Spiritual Care In a multi-faith, multicultural

environment

Bangalore Baptist Hospital (BBH)Est: 1973

Entrance

Emergency

Radiotherapy Unit

BBH Palliative care

•Started in 1995

•Fully integrated service

•Part of services of the hospital

•For all patients – Ca & Non Ca

•Out pt care, in pt care & home care

•Bereavement support

BBH model of palliative care -An integrated approach !

Base Mission Hospital+ Multi Disc PCT

I P - Symptom control O P- Combined--Terminal care - pall / onc cl - Respite care - support groups

Day care / procedures<25kmsHome care Multi-disc

Multi-pronged+ continuity

of care

>25kmsLocal GP/hosp

Remote supervised -- care

Bereavement supportCa prev / behav change

Three essential components of palliative care

Symptom

relief

Teamwork and partnership

Psychosocial

& Spiritual supportEmpowerment

of person & family

to harness their potential

Aim

Communication

PHYSICAL

Other symptoms

Adverse effects of treatment

Insomnia and chronic fatigue

PSYCHOLOGICAL SOCIAL

Anger at delays in diagnosis Worry about family and finances

Anger at therapeutic failure TOTAL Loss of job, prestige and

income

Disfigurement PAIN Loss of social position

Fear of pain and / or death Feelings of abandonment and

Feelings of helplessness isolation

SPIRITUAL

Why has this happened to me ?

Why does God allow me to suffer like this ?

What’s the point of it all?

Is there any meaning or purpose in life ?

How can I be forgiven for past wrongdoing?

Spiritual Pain

•Why has this happened to me ?

•Why does God allow me to suffer like this ?

•What’s the point of it all?

•Is there any meaning or purpose in life ?

•How can I be forgiven for past wrongdoing?

Total pain needs Total care (wholistic)

Spiritual

Psyche

Soma

Social

From- Introducing Palliative Care – Robert Twycross

(EAPC) Task Forceon spiritual care in palliative care (SCPC)

‘Spirituality is the dynamic dimension of human life that relates to the way persons (individual and community) experience, express and/or seek meaning, purpose and transcendence, and the way they connect to the moment, to self, to others, to nature, to the significant and/or the sacred.’• EUROPEAN JOURNAL OF PALLIATIVE CARE, 2011; 18(2)

Spirituality

Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions and practices.

Puchalski, Christina M., et al. “Improving the spiritual dimension of whole person care: Reaching national and international consensus.” Journal of Palliative Medicine 17.6 (2014): 642-656.

Defn: of spirituality

•Pertaining to God - belief

- understanding

- relationship

•Awareness of the transcendent –

‘the beyond in our midst’

•Awareness of something beyond intellectual knowledge or normal sensory experience

Concerned with -

•Meaning of being fully human – whole

•Meaning and purpose in life

• Interconnectedness and harmony with other people, planet Earth & Universe

•Right relationship with God / power or force in the Universe which transcends the present context of reality

Religion

•Shared framework of theistic beliefs & rituals within which spirituality is expressed and nurtured and the meaning of life explored

•Religion & spirituality not same but often intermingled

•Impact of a person’s religion is either life engaging or life escaping

Religion

“a subset of spirituality, encompassing a system of beliefs and practices observed by a community, supported by rituals that acknowledge, worship, communicate with, or approach the Sacred, the Divine, God (in Western cultures), or Ultimate Truth, Reality, or nirvana (in Eastern cultures).”•i, Christina M., et al. “Improving the spiritual

dimension of whole person care: Reaching national and international consensus.” Journal of Palliative Medicine 17.6 (2014): 642-656.

Religion & Spirituality

•Religion – knowing about God

•Spirituality – knowing God

Signs of spiritual distress• Sense of hopelessness, helplessness, meaninglessness

(withdrawn, suicidal)

•Vivid dreams, nightmares

• Intense suffering, isolation

•Remoteness of God

•Anger towards God – why questions

•Undue stoicism

• Sense of guilt / shame

•Bitter & unforgiving of others

Multi-faith environment• Believer

- Belonging to a particular faith

(Hindu, Muslim, Sikh, Christian, Buddhist, Jain, Jew)

- submitted to God’s will

- stuck on miracles

- Faith - established / Lost / increased

- Some belief in a higher being – no religion

• Atheist

An approach for Spiritual care

•Build a relationship of trust

•Asses spiritual needs

•Facilitate meeting them

•Spiritual dialogue

•Specific (focused) interventions

Build a relationship of trust

•Competence – knowledge, skills, communication

•Character & compassion

•Truthfulness

•Prayer

Asses & meet spiritual needs

•Prayer

•Religious activities – rituals

•Visitation

•Communication

Spiritual dialogue•Relationships

- with God- with family- with others- need to be forgiven / forgive

•Values - that are dear to you- that you want to pass on to your family/ friends

Spiritual dialogue•Meaning - what gives you meaning &

purpose in life?- share some meaningful

moments in life• Hope - what is your hope?

- belief in afterlife?•Peace - what gives you peace?

- do you have peace?

Specific interventions only with permission

•Share your personal feelings, stories, testimony – to bring glory to God

•Share Scripture verses as appropriate

•Pray with their permission

Tools for Spiritual Care1. History & needs assessment

•SPIRIT: FICA: FAITH: HOPE: FACT: SNAP:

2. Evaluation – Quality indicators

•Quality of Spiritual Care scale (QSC)

•Evidence-based quality indicators for Spiritual Care:

Tools for Spiritual Care1. History & needs assessment

• SPIRIT (T. A. Maugans, “The SPIRITual history,” Archives of Family Medicine 5 (1997): 11-16; B. Ambuel and D. E. Weissman, “Discussing spiritual issues and maintaining hope,” in eds., D. E. Weissman and B. Ambuel, Improving End-of-life Care: A Resource Guide for Physician Education, 2nd ed. (Milwaukee, WI: Medical College of Wisconsin, 1999)

• FICA (C. M. Puchalski and A. L. Romer, “Taking a spiritual history allows clinicians to understand patients more fully,” Journal of Palliative Medicine 3 (2000): 129-37.)

Tools for Spiritual Care1. History & needs assessment

• HOPE (G. Anandarajah and E. Hight, “Spirituality and medical practice: Using the HOPE questions as a practical tool for spiritual assessment,” American Family Practice 63 (2001): 81-88.)

• FAITH (D. E. King, “Spirituality and medicine,” in eds. M. B. Mengel, W. L. Holleman and S. A. Fields, Fundamentals of Clinical Practice: A Text Book on the Patient, Doctor and Society (New York, NY: Plenum, 2002): 651-69.)

Tools for Spiritual Care1. History & needs assessment

• FACT (LaRocca-Pitts, A Chaplain’s Tool for Assessing Spiritual Needs in an Acute Care Setting Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 28 Number 1 • Spring/Summer 2012 (AJPCH 2009)

• SNAP (The Spiritual Needs Assessment for Patients)

Rashmi K. Sharma, Alan B. Astrow, MD, Kenneth Texeira, PhD, Daniel P. Sulmasy, MD, PhD

http://dx.doi.org/10.1016/j.jpainsymman.2011.07.008

Tools for Spiritual CareEvaluation – Quality Indicators

• Quality of Spiritual Care scale (QSC) - a scale measuring quality of spiritual care at end of life that was tested on family members of deceased long-term care residents http://www.jpsmjournal.com/article/S0885-3924(13)00389-8/fulltext – 2014

• Evidence-based quality indicators for Spiritual Care: Healthcare Chaplaincy Network - 2016 (www.healthcarechaplaincy.org/research )

FICA: Spiritual AssessmentSpiritual History-Christina M Puchalski

•F – Faith, Belief, Meaning• I – Importance and Influence•C – Community•A – Address / Action in Care

(www.gwish.org)

Spiritual care: Quality Indicators (18)

•1. Structural indicators - 5

•2. Process indicators - 7

•3. Outcomes - 6

Important

•Listen to their experience•Share your experience in love (not forcing)•Never argue, force or compel•Sometimes ‘being’ there more important than ‘doing’ or talking•Providing neat answers unlikely to be helpful•Encourage finding own answers – meaning in their suffering

Remember

•God’s Spirit ministers to the spirit of the person

•We are only instruments in His hands

•What we may see

- is acceptance

- submission

- peace

Counseling

Prayer

Comments by families

•Godly, compassionate, timely, excellent, Angelic support•Team gave courage to my mother and helped me handle the situation•Team became like our family members•Never seen such caring health professionals•We pray for strength to the team to take care of more people

Best poster award-14th International IAPC Conf – TATA MH Mumbai Feb 2007

Feed back to Question -

Was our spiritual support through discussion and prayer

- comforting? (76%)- acceptable? (24%)- upsetting? ( 0%)- unacceptable? (0%)

Conclusion

•Spiritual care must be provided•Can be done sensitively•Must be done in love•We can never fully understand a person’s spiritual pain•We are only partners with God in His healing ministry•Does help in accepting the situation and in obtaining peace.

Our motivation & guidance• Lord Jesus said in His sermon on the mount (Matthew

5:13,14)

“You are the salt of the earth”

“You are the light of the world”

Light to expel the darkness of death by the light of the world - -JESUS! By lifting up JESUS! By giving them JESUS!

• Jesus’ love compels us to be competent, compassionate and committed in serving the suffering and dying and allowing them to die peacefully with dignity and HOPE

Thank You

Definitions

•Transcendence: exceeding/surpassing usual limits : extending or lying beyond the limits of ordinary experience (MW)•Existence or experience beyond the normal or physical level.(Ox)•Existential: relating to, or affirming existence (living) (MW)