Spirituality: Faith and Healthcare Presented by Chaplain Dana Bratton “We are not human beings having a spiritual experience. We are spiritual beings having

Spirituality: Faith and HealthcareSpirituality: Faith and Healthcare

Presented by Chaplain Dana Bratton Presented by Chaplain Dana Bratton

““We are not human beings having a We are not human beings having a spiritual experience. We are spiritual beings spiritual experience. We are spiritual beings having a human experience.”having a human experience.”

--Teilhard de ChardinTeilhard de Chardin

Presentation Outcome GoalsPresentation Outcome GoalsParticipants will be able to:Participants will be able to:

Define spirituality and religion, and have Define spirituality and religion, and have awareness of the benefits of spirituality in the awareness of the benefits of spirituality in the care of patients, especially patients at the end of care of patients, especially patients at the end of life as based on the examination of research.life as based on the examination of research.

Identify what spiritual needs are, and how to Identify what spiritual needs are, and how to respond to spiritual and emotional needs.respond to spiritual and emotional needs.

Recognize that one’s own spirituality might affect Recognize that one’s own spirituality might affect how one might relate to, and provide care to how one might relate to, and provide care to patients. Develop awareness of personal issues patients. Develop awareness of personal issues that might hinder one from providing spiritual that might hinder one from providing spiritual care.care.

Have the ability to assist with the faith of others Have the ability to assist with the faith of others without proselytizing without proselytizing

Have spiritual assessment tools Have spiritual assessment tools Identify chaplain’s role as part of the health care Identify chaplain’s role as part of the health care

team and in the spiritual care of the hospice team and in the spiritual care of the hospice patientpatient

Identify other areas of available support for Identify other areas of available support for spirituality in patient care.spirituality in patient care.

DefinitionsDefinitions1) Spirituality1) Spirituality

SpiritualitySpirituality refers to a belief in a higher power, an refers to a belief in a higher power, an awareness of life and its meaning, the centering of a awareness of life and its meaning, the centering of a person with purpose in life. It involves relationships with person with purpose in life. It involves relationships with a higher being, with self, and with the world around the a higher being, with self, and with the world around the individual.. Spirituality implies living with moral individual.. Spirituality implies living with moral standards.standards.

“ “The spirit of a human is his essence, that part of him or The spirit of a human is his essence, that part of him or her that is not visible. The part that does not die but is her that is not visible. The part that does not die but is immortal. Webster defines spirit as “ a life giving force” immortal. Webster defines spirit as “ a life giving force” and as the “active presence of God in human life.” and as the “active presence of God in human life.”

(National Center of Continuing Education, Inc. Death and Dying, pg. 23)(National Center of Continuing Education, Inc. Death and Dying, pg. 23)

MSOP Report III regarding spiritualityMSOP Report III regarding spirituality

Spirituality is recognized as a factor that contributes to Spirituality is recognized as a factor that contributes to health in many persons. The concept of spirituality is health in many persons. The concept of spirituality is found in all cultures and societies. It is expressed in found in all cultures and societies. It is expressed in an individual’s search for ultimate meaning through an individual’s search for ultimate meaning through participation in religion and / or belief in God, family, participation in religion and / or belief in God, family, naturalism, rationalism, humanism and the arts. All naturalism, rationalism, humanism and the arts. All these factors can influence how patients and health these factors can influence how patients and health care professionals perceive health and illness and care professionals perceive health and illness and how they interact with one another.how they interact with one another.

Christina Puchalski MDChristina Puchalski MD

MSOP Report III. MSOP Report III. Association of American Medical Colleges, Association of American Medical Colleges, 19991999

2) Religion2) Religion

ReligionReligion is an organized and public belief system of is an organized and public belief system of worship and practices that generally has a focus on a worship and practices that generally has a focus on a god or supernatural power. It generally offers an god or supernatural power. It generally offers an arrangement of symbols and rituals that are meaningful arrangement of symbols and rituals that are meaningful and understood by it’s followers.and understood by it’s followers.

“ “Religion is primarily a set of beliefs, a collection of Religion is primarily a set of beliefs, a collection of

prayers, or rituals. Religion is first and foremost a way of prayers, or rituals. Religion is first and foremost a way of seeing. It can’t change the facts about the world we live seeing. It can’t change the facts about the world we live in, but it can change the ways we see those facts, and in, but it can change the ways we see those facts, and that in itself can often make a difference.” (Harold that in itself can often make a difference.” (Harold Kushner)Kushner)

Major World ReligionsMajor World Religions

– ChristianityChristianityCatholic, Lutheran, Presbyterian, Catholic, Lutheran, Presbyterian,

Methodist,Nazarene, Episcopal Methodist,Nazarene, Episcopal Baptist (largest protestant denomination in US)Baptist (largest protestant denomination in US)Non-denominationalNon-denominationalOther Western faithsOther Western faiths

– JudaismJudaismReform, Conservative, and OrthodoxReform, Conservative, and Orthodox

– HinduismHinduism– BuddhismBuddhism– Islam (Muslims)Islam (Muslims) George Ann Daniels MS, RNGeorge Ann Daniels MS, RN

Spirituality Spirituality Spirituality fulfills specific needsSpirituality fulfills specific needs

– Meaning to life, illness, crises, and deathMeaning to life, illness, crises, and death– Sense of security for present and futureSense of security for present and future– Guides daily habitsGuides daily habits– Elicits acceptance or rejection of other peopleElicits acceptance or rejection of other people– Provides psychosocial support in a group of Provides psychosocial support in a group of

like-minded peoplelike-minded people– Strength when facing life’s crisesStrength when facing life’s crises– Healing strength and supportHealing strength and support

George Ann Daniels MS, RNGeorge Ann Daniels MS, RN

Spiritual CareSpiritual Care

• • Practice of compassionate presencePractice of compassionate presence

• • Listening to patient’s fears, hopes, pain, dreamsListening to patient’s fears, hopes, pain, dreams

• • Obtaining a spiritual historyObtaining a spiritual history

• • Attentiveness to all dimensions of the patient Attentiveness to all dimensions of the patient and patient’s family: body, mind and spiritand patient’s family: body, mind and spirit

• • Incorporation of spiritual practices as appropriateIncorporation of spiritual practices as appropriate

• • Involve cInvolve chaplains as members of the haplains as members of the interdisciplinary healthcare teaminterdisciplinary healthcare team


A More Compassionate Model A More Compassionate Model of Careof Care

Focus on The Whole PersonFocus on The Whole Person

PhysicalPhysical

EmotionalEmotional

SocialSocial

SpiritualSpiritual

Christina PChristina Puchalski Muchalski MDD

Bio-Psycho-Social-SpiritualBio-Psycho-Social-Spiritual

Schools of Medicine have been slow to Schools of Medicine have been slow to recognize & appropriate this model of recognize & appropriate this model of whole person care.whole person care.

The Nursing profession has long The Nursing profession has long recognized the spiritual aspects of patient recognized the spiritual aspects of patient care.care.

Chaplains and clergy have often assisted Chaplains and clergy have often assisted patients with the spiritual aspects of illness patients with the spiritual aspects of illness and the search for meaning & purpose.and the search for meaning & purpose.

George H. Grant,M.Div., PhC.George H. Grant,M.Div., PhC.

Spiritual care definedSpiritual care defined

Spiritual care is recognizing and responding to Spiritual care is recognizing and responding to the multifaceted expressions of spirituality we the multifaceted expressions of spirituality we encounter in our patients and their families. The encounter in our patients and their families. The purpose is to determine the nature of a person’s purpose is to determine the nature of a person’s relationship to God and other people, and to relationship to God and other people, and to give the person the opportunity to accept give the person the opportunity to accept spiritual support. Themes such as the search spiritual support. Themes such as the search for meaning, feelings of connection or isolation, for meaning, feelings of connection or isolation, hope or hopelessness, and fear of dying are all hope or hopelessness, and fear of dying are all clues that a person is struggling with spiritual clues that a person is struggling with spiritual issues. issues.

Chaplain Loyal WardChaplain Loyal Ward

Research in Spirituality and HealthResearch in Spirituality and Health

Medical Compliance: Study of Heart Medical Compliance: Study of Heart Transplant Patients at University of Transplant Patients at University of

PittsburghPittsburgh

• • Those who participated in religious activities and Those who participated in religious activities and said their beliefs were important showed:said their beliefs were important showed:-- better compliance with follow-up treatment better compliance with follow-up treatment-- improved physical functioning at the 12-month improved physical functioning at the 12-month follow-upfollow-up-- higher levels of self-esteem higher levels of self-esteem-- less anxiety and fewer health worries less anxiety and fewer health worries


Hams, RC et.al. Hams, RC et.al. Journal of Religion and HealthJournal of Religion and Health. 1995: 34(1) 17-32. 1995: 34(1) 17-32

Research in Spirituality and HealthResearch in Spirituality and Health

Immune System Functioning: Study of 1,700 older Immune System Functioning: Study of 1,700 older adultsadults

• • Those attending church were half as likely to have elevated levels if IL-6Those attending church were half as likely to have elevated levels if IL-6•• Increased levels of IL-6 associated with increased incidence of diseaseIncreased levels of IL-6 associated with increased incidence of disease•• Hypothesis: religious commitment may improve stress control by:Hypothesis: religious commitment may improve stress control by:

-- better coping mechanisms better coping mechanisms-- richer social support richer social support-- strength of personal values and world-view may be strength of personal values and world-view may be

mechanism for increased mortality observed in other studiesmechanism for increased mortality observed in other studies

Koenig, HG et.al. Koenig, HG et.al. International Journal of Psychiatry in Medicine.International Journal of Psychiatry in Medicine. 1997 27(3) 233-250 1997 27(3) 233-250


Research in Spirituality and HealthResearch in Spirituality and HealthCoping: Pain questionnaire by American Coping: Pain questionnaire by American

Pain Society to hospitalized patientsPain Society to hospitalized patients

• • Personal Prayer is the most commonly used Personal Prayer is the most commonly used non-drug method for pain management:non-drug method for pain management:

-- Pain Pills Pain Pills 82%82%- Prayer- Prayer 76%76%-- Pain IV med Pain IV med 66%66%-- Pain injections Pain injections 62%62%-- Relaxation Relaxation 33%33%-- Touch Touch 19%19%-- Massage Massage 9% 9%

McNeil, JA et al. McNeil, JA et al. J of Pain and Symptom ManagementJ of Pain and Symptom Management. 1998: 16(1) 29-40. 1998: 16(1) 29-40


Research in spirituality and healthResearch in spirituality and healthCoping: BereavementCoping: Bereavement

• • Study of 145 parents of children who died of cancer:Study of 145 parents of children who died of cancer:-- 80% reported receiving comfort from their 80% reported receiving comfort from their

religious beliefs one year after their child’s deathreligious beliefs one year after their child’s death-- those parents had better physiologic and emotional those parents had better physiologic and emotional

adjustmentadjustment- - 40% of those parents reported strengthening of 40% of those parents reported strengthening of

their own religions commitment over the course of their own religions commitment over the course of the year prior to their child’s deaththe year prior to their child’s death

Cook. Cook. J Sci Sudy of ReligionJ Sci Sudy of Religion. 1983: 22:222-238.. 1983: 22:222-238.Christina PChristina Puchalski Muchalski MDD

Research in spirituality and healthResearch in spirituality and healthCoping: Study of 108 women undergoing Coping: Study of 108 women undergoing

treatment for GYN cancerstreatment for GYN cancers

• • When asked what helped them cope with their When asked what helped them cope with their cancer, the patients answered:cancer, the patients answered:-- 93% their spiritual beliefs 93% their spiritual beliefs-- 75% noted their religion had a significant place 75% noted their religion had a significant place in their livesin their lives-- 49% became more spiritual after their diagnosis 49% became more spiritual after their diagnosis

Roberts, JA et.al. Roberts, JA et.al. American Journal of Obstetrics and GynecologyAmerican Journal of Obstetrics and Gynecology . . 1997. 176(1) 166-1721997. 176(1) 166-172


Gallup survey key findingsGallup survey key findings Reassurances that gave comfortReassurances that gave comfort

89% 89% Believing that you will be in the loving Believing that you will be in the loving presence of God or a higher powerpresence of God or a higher power

87% 87% Believing that death is not the end but a Believing that death is not the end but a passagepassage

87% 87% Believing that part of you will live on Believing that part of you will live on through your children and descendantsthrough your children and descendants

85% 85% Feeling that you are reconciled with Feeling that you are reconciled with those you have hurt or who have hurt youthose you have hurt or who have hurt you

George H. Gallup International Institute. George H. Gallup International Institute. ““Spiritual Belief and the Dying Process: Spiritual Belief and the Dying Process:

A Report on a National Survey,” 1997A Report on a National Survey,” 1997..


Americans have long recognized the healing Americans have long recognized the healing power of faith and prayer. power of faith and prayer.

82%: believe in the healing power of prayer82%: believe in the healing power of prayer 64%: feel MDs should pray with those patients who request it64%: feel MDs should pray with those patients who request it

63%: want MDs to discuss matters of faith.63%: want MDs to discuss matters of faith. Almost 99% of MDs say religious beliefs can make a Almost 99% of MDs say religious beliefs can make a

positive contribution to the healing process. Yet, until positive contribution to the healing process. Yet, until recently, most medical studies failed to consider the recently, most medical studies failed to consider the impact of spirituality in disease prevention or the healing impact of spirituality in disease prevention or the healing process. Faith was the forgotten factor that was relegated process. Faith was the forgotten factor that was relegated by healthcare providers to the chaplain's office. by healthcare providers to the chaplain's office.

CMDSCMDS

Fortunately, there is change. Fortunately, there is change. Scientists are realizing what people Scientists are realizing what people already know, that a personal already know, that a personal spiritual relationship helps us make spiritual relationship helps us make sense out of illness. It gives hope. sense out of illness. It gives hope. It changes health-related behavior It changes health-related behavior and thus reduces the risk of and thus reduces the risk of disease. disease.

But faith has an even greater But faith has an even greater impact. Studies have revealed that impact. Studies have revealed that faith improves the immune system, faith improves the immune system, enhances healing, reduces enhances healing, reduces complications during major complications during major illnesses and much more. illnesses and much more.

CMDSCMDS

Clinical QuestionsClinical Questions

• • Does spirituality play a role in end-of-life care? Does spirituality play a role in end-of-life care? How?How?

• • Should nurses address spirituality with their Should nurses address spirituality with their patients and how?patients and how?

• • What is the role of the interdisciplinary team with What is the role of the interdisciplinary team with respect to the needs of the patient?respect to the needs of the patient?

• • How does paying attention to patients’ spiritual How does paying attention to patients’ spiritual needs help with delivery of compassionate care?needs help with delivery of compassionate care?

Where does spirituality fit?Where does spirituality fit?

Patients may have Patients may have coping mechanisms coping mechanisms related to their beliefrelated to their belief

May be supported by May be supported by a community of caring a community of caring others.others.

May feel themselves May feel themselves to be in the company to be in the company of God who gives of God who gives them peace and them peace and comfort.comfort.


Spiritual NeedsSpiritual Needs

• • May be dynamic in patient May be dynamic in patient understanding of illnessunderstanding of illness

• • Religious convictions / beliefs may Religious convictions / beliefs may affect healthcare decision-makingaffect healthcare decision-making

• • May be a patient needMay be a patient need

• • May be important in patient copingMay be important in patient coping

• • Integral to whole patient careIntegral to whole patient care


Five basic spiritual needs of every Five basic spiritual needs of every person:person:

A meaningful philosophy of life (values, and A meaningful philosophy of life (values, and moral sense).moral sense).

A sense of the transcendent (outside of self, A sense of the transcendent (outside of self, view of God and something beyond the view of God and something beyond the immediate life, having hope.)immediate life, having hope.)

A trusting relationship with God (faith).A trusting relationship with God (faith).A relatedness to nature and people (friendship). A relatedness to nature and people (friendship).

Experiencing love and forgiveness.Experiencing love and forgiveness.A sense of life meaning.A sense of life meaning.

NeedsNeedsThe need for meaning and purposeThe need for meaning and purpose

The search for meaning is one of the The search for meaning is one of the primary motivators that keeps us going. primary motivators that keeps us going. When a person comes to a place where When a person comes to a place where his or her life makes no sense, and the his or her life makes no sense, and the seems to be no meaning or purpose, seems to be no meaning or purpose, depression and indifference set in.depression and indifference set in.

If the person can find no help for meaning If the person can find no help for meaning and purpose in the future, he or she longs and purpose in the future, he or she longs for death.for death.

National Center of Continuing Education, Inc. Death and Dying, pg. 24National Center of Continuing Education, Inc. Death and Dying, pg. 24

Man’s Search for MeaningMan’s Search for MeaningVictor FranklVictor Frankl

Sometimes external circumstances in our life Sometimes external circumstances in our life situation are beyond our control.situation are beyond our control.

Frankl maintains that the attitude we choose to Frankl maintains that the attitude we choose to take toward our life situation is within our control.take toward our life situation is within our control.

The spiritual journey relates to our inner struggle The spiritual journey relates to our inner struggle to shape our attitude toward illness and even to shape our attitude toward illness and even death itself.death itself.

A relationship with God gives meaning to life.A relationship with God gives meaning to life.


Where do we find hope?Where do we find hope?

Ultimately from our faith or understanding of our Ultimately from our faith or understanding of our relationship to a higher power. relationship to a higher power.

The belief that a higher eternal power is in The belief that a higher eternal power is in control provides meaning and purpose to any control provides meaning and purpose to any situation. situation.

The need for love and relationshipsThe need for love and relationships

We were created with this need. Humans We were created with this need. Humans are social beings.are social beings.

The emotional need for love and The emotional need for love and relationship is met in the context of relationship is met in the context of significant human relationships.significant human relationships.

The spiritual need for love and fellowship The spiritual need for love and fellowship is met only through a personal relationship is met only through a personal relationship with God.with God.


Three kinds of loveThree kinds of love

Eros -If you satisfy my needs then I will love you. Eros -If you satisfy my needs then I will love you. A physical love. A physical love.

Phileo - a brotherly love, a friendship live. I love Phileo - a brotherly love, a friendship live. I love you because of what you have or who you are. you because of what you have or who you are. This may be conditional love also, because This may be conditional love also, because things might change.things might change.

Agape – God’s kind of love. I love you, in spite Agape – God’s kind of love. I love you, in spite of …, I love you no matter what. Not deserved, of …, I love you no matter what. Not deserved, not earned. Freely given. Unconditional. not earned. Freely given. Unconditional.

Unconditional loveUnconditional love

Important for the dying person because he Important for the dying person because he or she is no longer in a position to earn or she is no longer in a position to earn love. Therefore it is important to love. Therefore it is important to encourage and support the person’s belief encourage and support the person’s belief in and relationship to God who offers in and relationship to God who offers unconditional love. Examples of how a unconditional love. Examples of how a person might experience this might be person might experience this might be through prayer, and the appropriate use of through prayer, and the appropriate use of Scripture.Scripture.


The need for forgivenessThe need for forgiveness

Guilt is one of the biggest burdens in our lives. It Guilt is one of the biggest burdens in our lives. It results from the failure to live up to expectations, results from the failure to live up to expectations, either our own or those of others.either our own or those of others.

True guilt may come as a result of rebelling against True guilt may come as a result of rebelling against the belief in God, and the consequences of that the belief in God, and the consequences of that rebellion.rebellion.

A sense of forgiveness within the context of one’s A sense of forgiveness within the context of one’s faith, often brings a sense of inner peace for that faith, often brings a sense of inner peace for that person in their relationship with God, self, and person in their relationship with God, self, and others.others.


Forgiveness results in:Forgiveness results in:Less anxiety and depressionLess anxiety and depressionBetter health outcomesBetter health outcomes Increased coping with stressIncreased coping with stressCloseness to God and othersCloseness to God and othersResolves guiltResolves guiltRestored relationshipsRestored relationships

““Beware lest anyone resist the grace of God and a root of Beware lest anyone resist the grace of God and a root of bitterness spring up in you and many be defiled” bitterness spring up in you and many be defiled” Hebrews 12:15Hebrews 12:15


Sharing the patient’s faithSharing the patient’s faith

Ask questionsAsk questions. Allow people to discover the truth for . Allow people to discover the truth for themselves by stimulating their thinking through themselves by stimulating their thinking through questions, which is much more powerful than having questions, which is much more powerful than having them simply listen to your thoughts.them simply listen to your thoughts.

Don't react negatively to objectionsDon't react negatively to objections. Realize that . Realize that expressing doubt is actually a good thing because it expressing doubt is actually a good thing because it means that someone is genuinely thinking about an means that someone is genuinely thinking about an issue. Expect emotions such as anger and hostility to issue. Expect emotions such as anger and hostility to surface during an exploration of faith as people wrestle surface during an exploration of faith as people wrestle with the most important issues in life. Don't take with the most important issues in life. Don't take objections personally as people go through this process. objections personally as people go through this process. Express your disagreements with respect, affirming the Express your disagreements with respect, affirming the value of the people with whom you speak and leaving value of the people with whom you speak and leaving the door open for further discussions.the door open for further discussions.

Sharing the patient’s faithSharing the patient’s faith If the patient expresses a need for assist with their If the patient expresses a need for assist with their

spiritual situation, a chaplain should be made available. spiritual situation, a chaplain should be made available. In the effort to assist the patient to understand their faith, In the effort to assist the patient to understand their faith, the chaplain might ask these questions: "Who is God?," the chaplain might ask these questions: "Who is God?," "Who are We?," "Who is Jesus?," "What Did Jesus Do?," "Who are We?," "Who is Jesus?," "What Did Jesus Do?," "What Can We Not Do?," "What Do We Have to Do?," "What Can We Not Do?," "What Do We Have to Do?," and "What Does God Promise to Those Who Believe?.”and "What Does God Promise to Those Who Believe?.”

Don't discount the beliefs or experiences of others. Don't discount the beliefs or experiences of others.

Show respect for them. Simply ask people to evaluate Show respect for them. Simply ask people to evaluate how their current belief system is working in their lives. how their current belief system is working in their lives. Don’t proselytize. When appropriate, sharing your own Don’t proselytize. When appropriate, sharing your own testimony can be powerful. testimony can be powerful.

Question: Should nurses talk about Question: Should nurses talk about religion or spirituality with patients?religion or spirituality with patients?

A. You may say no, because a nurse can not A. You may say no, because a nurse can not be expected to be conversant with all religions.be expected to be conversant with all religions.

B. You may say no, because the nurse may be B. You may say no, because the nurse may be an atheist or non-believer. (Though I’ve met an atheist or non-believer. (Though I’ve met very few nurses who are.)very few nurses who are.)

C. You may say no, that would be an unethical C. You may say no, that would be an unethical intrusion into the privacy of the patient.intrusion into the privacy of the patient.

D. But the answer is yes, particularly when D. But the answer is yes, particularly when there are indications of patient interest or need.there are indications of patient interest or need.

The nurse’s role in spiritualityThe nurse’s role in spirituality

Define your own philosophy of life and death. Define your own philosophy of life and death. What do you believe? What does human life What do you believe? What does human life mean to you? What does death mean? Is there mean to you? What does death mean? Is there life beyond? Is there a God? Is there a Heaven life beyond? Is there a God? Is there a Heaven and a Hell? and a Hell?

You must be comfortable and confident in what You must be comfortable and confident in what you believe in order to help others. Or you will you believe in order to help others. Or you will be threatened and fearful when confronting be threatened and fearful when confronting death and dying in your patients. death and dying in your patients.

Identify your emotional and physical limitations.Identify your emotional and physical limitations.


Ethics & professional boundariesEthics & professional boundaries

Spiritual History: patient-centered Spiritual History: patient-centered Recognition of pastoral care professionals as Recognition of pastoral care professionals as

expertsexpertsMore in-depth spiritual counseling should be under More in-depth spiritual counseling should be under

the direction of chaplains and other spiritual the direction of chaplains and other spiritual leadersleaders

Praying with patients:Praying with patients:You can, if the patient requests, or make aYou can, if the patient requests, or make areferral to pastoral care for chaplain led prayer.referral to pastoral care for chaplain led prayer.

9 dimensions9 dimensionsof patient assessmentof patient assessment

1.1. Illness / treatment Illness / treatment summarysummary

2.2. Physical Physical

3.3. Psychological Psychological

4.4. Decision making Decision making

5.5. Communication Communication

6.6. Social Social

7.7. Spiritual Spiritual

8.8. Practical Practical

9.9. Anticipatory planning Anticipatory planning for deathfor death

EPEC- AMAEPEC- AMA

Approach toApproach tospiritual assessmentspiritual assessment

Suspect spiritual painSuspect spiritual painEstablish a conducive Establish a conducive

atmosphereatmosphereExpress interest, ask specific Express interest, ask specific

questionsquestionsListen for broader meaningsListen for broader meaningsBe aware of your own beliefs Be aware of your own beliefs

and biasesand biases

EPEC- AMAEPEC- AMA

A Spiritual Inventory might A Spiritual Inventory might include questions about:include questions about:

The patient’s perception of what is going on.The patient’s perception of what is going on.What gives meaning and purpose to life?What gives meaning and purpose to life?How, or whether belief and faith enter in.How, or whether belief and faith enter in.Love: By whom do you feel loved-accepted?Love: By whom do you feel loved-accepted?Forgiveness--need it? Do you need to grant it to Forgiveness--need it? Do you need to grant it to

others?others?Prayer--What do you pray for?Prayer--What do you pray for?Quiet and meditation--What helps get you on Quiet and meditation--What helps get you on

center?center?


Spiritual assessmentSpiritual assessment

Meaning, value – personal, of the illnessMeaning, value – personal, of the illness– burden, control, independence, dignityburden, control, independence, dignity

FaithFaithReligious life, spiritual lifeReligious life, spiritual lifeIdentify areas of spiritual crises. Would Identify areas of spiritual crises. Would

pastoral intervention be needed or desired pastoral intervention be needed or desired – their own pastor or the hospital or – their own pastor or the hospital or hospice chaplain?hospice chaplain?

EPEC- AMAEPEC- AMA

Spiritual assessmentSpiritual assessment

Spiritual assessment should, at a Spiritual assessment should, at a minimum, determine the patient’s minimum, determine the patient’s denomination, beliefs, and what spiritual denomination, beliefs, and what spiritual practices are important to the patient.practices are important to the patient.

This information assists in determining the This information assists in determining the impact of spirituality, on the care and impact of spirituality, on the care and services being provide, and will identify if services being provide, and will identify if further assessment or services are further assessment or services are needed.needed.


Spiritual Assessment Spiritual Assessment

An integral part of a patient’s initial assessment An integral part of a patient’s initial assessment should include data about the patient’s spiritual should include data about the patient’s spiritual and religious beliefs.and religious beliefs.

Several tools exist for spiritual assessment.Several tools exist for spiritual assessment.Spiritual care needs to be individualized, with Spiritual care needs to be individualized, with

the patient given the opportunity to participate the patient given the opportunity to participate


Open ended questions that are specific Open ended questions that are specific regarding beliefs can be helpful. A formal regarding beliefs can be helpful. A formal assessment guide can provide a review of assessment guide can provide a review of the strength and meaning of person’s the strength and meaning of person’s religious practices that can open the door religious practices that can open the door to helping the person establish a to helping the person establish a meaningful relationship with their higher meaningful relationship with their higher power.power.


Spiritual HistorySpiritual History

• • Taken at initial visit as part of the social Taken at initial visit as part of the social history, and at follow-up visits as appropriatehistory, and at follow-up visits as appropriate

• • Recognition of cases to refer to chaplainsRecognition of cases to refer to chaplains• • Opens the door to conversation about values Opens the door to conversation about values

and beliefsand beliefs• • Uncovers coping mechanism and support Uncovers coping mechanism and support

systemssystems• • Reveals positive and negative spiritual coping Reveals positive and negative spiritual coping • • Opportunity for compassionate careOpportunity for compassionate care


Taking a spiritual history. . .Taking a spiritual history. . .

S Spiritual Belief SystemS Spiritual Belief SystemP Personal SpiritualityP Personal SpiritualityI Integration in a Spiritual CommunityI Integration in a Spiritual CommunityR Ritualized Practices and RestrictionsR Ritualized Practices and RestrictionsI Implications for Health CareI Implications for Health CareT Terminal Events Planning (advance T Terminal Events Planning (advance

directives, DNR wishes, DPOA etc..)directives, DNR wishes, DPOA etc..)


Assess for spiritual activitiesAssess for spiritual activities

Religious denomination (past or present) Religious denomination (past or present) Where do you go to church when you are Where do you go to church when you are able? able?

Activity level Do you go all the time? Activity level Do you go all the time? Prayer / scriptural resources Do you read Prayer / scriptural resources Do you read

your Bible? Do you pray much? your Bible? Do you pray much?

Assess for spiritual crises Assess for spiritual crises

Search for meaning or purpose in one’s life.Search for meaning or purpose in one’s life.Loss of a sense of connection with people or Loss of a sense of connection with people or

God.God.Feelings of guilt or unworthinessFeelings of guilt or unworthinessNo relationship with GodNo relationship with GodAnger, denial, and bitterness expressed toward Anger, denial, and bitterness expressed toward

self, others, or God. Questioning of faithself, others, or God. Questioning of faithDesire for forgivenessDesire for forgivenessSense of abandonment by GodSense of abandonment by God

Spiritual Assessment ToolsSpiritual Assessment Tools

SPIRIT SPIRIT FICA (Pulchalski 1999)FICA (Pulchalski 1999)LET GO (Storey and Knight 1997)LET GO (Storey and Knight 1997)Nurses and MDs should know the patient’s Nurses and MDs should know the patient’s

personal values and wishes. The patients personal values and wishes. The patients religion is specified in the medical record. religion is specified in the medical record.

““The secret in the care of the patient is in The secret in the care of the patient is in caring for the patient.”caring for the patient.”

Francis PeabodyFrancis Peabody

FICA assessment toolFICA assessment tool

FF Faith, Belief, MeaningFaith, Belief, Meaning

II Importance and InfluenceImportance and Influence

CC CommunityCommunity

AA AddressAddress


The HOPE QuestionsThe HOPE Questions

H:H: Sources of Sources of hhope, meaning, ope, meaning, comfort, strength, peace, love comfort, strength, peace, love and connection and connection

O: OO: Organized religion rganized religion P: PP: Personal spirituality and ersonal spirituality and

ppractices ractices E: EE: Effects on medical care and ffects on medical care and

eend-of-life issues nd-of-life issues

LET GOLET GO

LListening to the patient’s storyistening to the patient’s storyEEncouraging the search for meaningncouraging the search for meaningTTelling of your concern and acknowledging the elling of your concern and acknowledging the

pain of losspain of lossGGenerating hope whenever possibleenerating hope whenever possibleOOwning your limitationswning your limitations

Spiritual HistorySpiritual History

FF Do you have a spiritual belief? Do you have a spiritual belief? FaithFaith? Do ? Do you have spiritual beliefs that help you cope with you have spiritual beliefs that help you cope with stress? What gives your life meaning?stress? What gives your life meaning?

II Are these beliefs Are these beliefs importantimportant to you? How to you? How do do they they influenceinfluence you in how you care for you in how you care for

yourself?yourself?

CC Are you part of a spiritual or religious Are you part of a spiritual or religious communitycommunity??

AA How would you like your healthcare How would you like your healthcare provider provider to to addressaddress these issues with you? these issues with you?


Ritualized Practices and Ritualized Practices and RestrictionsRestrictions

Patients may Patients may especially value the especially value the rituals of their faith rituals of their faith community:community:

Anointing (last rites) Anointing (last rites) of a dying personof a dying person

ScriptureScripturePrayerPrayerCommunion Communion


Spiritual needs neglectedSpiritual needs neglectedWhy? Many people have not recognized their Why? Many people have not recognized their

own spiritual needs, and thus are uncomfortable own spiritual needs, and thus are uncomfortable in assessing them in others.in assessing them in others.

Religion is often considered a private matter and Religion is often considered a private matter and one not to be discussed.one not to be discussed.

It is important in medicine to assess a person’s It is important in medicine to assess a person’s physical situation related to his bowel physical situation related to his bowel movements or his or her sex life. Aren’t these movements or his or her sex life. Aren’t these private matters as well? private matters as well?

Should a nurse be interested in spiritual needs Should a nurse be interested in spiritual needs in their patients? Yes. in their patients? Yes.


Patient care is done by a team of Patient care is done by a team of interfacing disciplinesinterfacing disciplines

Medical specialtiesMedical specialtiesNursing and allied health professionsNursing and allied health professionsPsychologyPsychologyPastoral care/health chaplaincyPastoral care/health chaplaincyPhilosophy: bioethicsPhilosophy: bioethicsCommunity services: faith or need based service Community services: faith or need based service

groupsgroupsHospice and parish nursingHospice and parish nursingEach discipline contributes a special perspective Each discipline contributes a special perspective

on human experience, which when taken on human experience, which when taken together, can lead to a general understanding of together, can lead to a general understanding of the healing process.the healing process.


Four resourcesFour resources The therapeutic use of yourself. We affirm to The therapeutic use of yourself. We affirm to

each patient that he or she is worthy of our each patient that he or she is worthy of our time and involvement, relating in a supportive time and involvement, relating in a supportive caring way.caring way.

The use of prayer when appropriate. Dialogue The use of prayer when appropriate. Dialogue within the context of your own religious beliefs within the context of your own religious beliefs about your concerns for the patient. about your concerns for the patient.

When appropriate, the use of Scripture. They When appropriate, the use of Scripture. They are God’s communication to us. Teaching to are God’s communication to us. Teaching to live in harmony with God, ourselves, and live in harmony with God, ourselves, and others.others.

Referrals to clergy and chaplainsReferrals to clergy and chaplains

National Center of Continuing Education, Inc. Death and Dying, pg. 27-28National Center of Continuing Education, Inc. Death and Dying, pg. 27-28

A meaningful lifeA meaningful lifeA peaceful, dignified deathA peaceful, dignified death

““There is a time for everything, and a There is a time for everything, and a season for every activity under season for every activity under heaven: a time to be born and a heaven: a time to be born and a time to die….”time to die….”

Ecclesiastes 3:1-2Ecclesiastes 3:1-2

Life GoalsLife Goals

Questions asked by dying and Questions asked by dying and chronically ill patientschronically ill patients

• • Why is this happening to me now?Why is this happening to me now?

• • What will happen to me after I die?What will happen to me after I die?

• • Will my family survive my loss?Will my family survive my loss?

• • Will I be missed? Will I be remembered?Will I be missed? Will I be remembered?

• • Is there a God? If so, will He be there for Is there a God? If so, will He be there for me?me?

• • Will I have time to finish my life’s work?Will I have time to finish my life’s work?


““The uncertainty is not the dying, it’s The uncertainty is not the dying, it’s the preparation. We need to know how to the preparation. We need to know how to deal with the inevitable deaths of loved ones deal with the inevitable deaths of loved ones and friends and patients.and friends and patients.

Death is the last enemy, but one that Death is the last enemy, but one that need not be feared.”need not be feared.”

Billy Graham Billy Graham Death and the Life AfterDeath and the Life After

Conspiracy of silenceConspiracy of silence

Reluctance to discuss death and dyingReluctance to discuss death and dyingCultural practices regarding truth tellingCultural practices regarding truth tellingMD and patient each wait for the other to initiate MD and patient each wait for the other to initiate

discussion. Even more so in the case of family discussion. Even more so in the case of family members. members.

Avoidance: “I’m healthy. I’m busy. No time. My Avoidance: “I’m healthy. I’m busy. No time. My family will take care of it.” family will take care of it.”

Discussing specific treatments and procedures Discussing specific treatments and procedures instead of confronting the issue of impending instead of confronting the issue of impending deathdeath

Medical team’s responsibilitiesMedical team’s responsibilities

Initiate discussion of end-of-life issuesInitiate discussion of end-of-life issuesHelp patients articulate their goals for careHelp patients articulate their goals for care

– Clarify treatment preferencesClarify treatment preferences– Uncover personal valuesUncover personal values

Establish and maintain caring, trusting Establish and maintain caring, trusting relationshiprelationship

Acknowledge importance of spiritual Acknowledge importance of spiritual dimension in the dying processdimension in the dying process

End-of life discussions: howEnd-of life discussions: how

Establish rapport and a caring relationshipEstablish rapport and a caring relationshipAsk about death-related beliefs and concernsAsk about death-related beliefs and concernsTake time to listen Take time to listen Communicate empathy and respectCommunicate empathy and respectBe nonjudgmentalBe nonjudgmental

““Put your house in order because you are going to die; you will not recover.”; you will not recover.”

2 Kings 20:12 Kings 20:1

End-of life discussions-how End-of life discussions-how

Become aware of patient’s cultural, ethnic, Become aware of patient’s cultural, ethnic, religious backgroundreligious background

Be honest and compassionate Be honest and compassionate Silence is a powerful tool Silence is a powerful tool Any person on the team- doctor, nurse, Any person on the team- doctor, nurse,

social worker, may recommend and refer to social worker, may recommend and refer to chaplains or other clergy or other team chaplains or other clergy or other team members.members.

End-of-life discussions - End-of-life discussions - when?when?

Urgently :Urgently :– Imminent deathImminent death– Patient talks about dyingPatient talks about dying– Questions about hospice or palliative careQuestions about hospice or palliative care– Recent admission for severe, progressive illnessRecent admission for severe, progressive illness– Severe suffering and poor prognosisSevere suffering and poor prognosis– Initial assessment when coming on hospiceInitial assessment when coming on hospice

Quill 2000. JAMA 284:2502Quill 2000. JAMA 284:2502

Initiating end-of-life Initiating end-of-life discussions - when?discussions - when?

Routinely when:Routinely when:– Discussing prognosisDiscussing prognosis– Discussing treatment with low probability of Discussing treatment with low probability of

successsuccess– Discussing hopes and fearsDiscussing hopes and fears– MD would not be surprised if patient died in 6-12 MD would not be surprised if patient died in 6-12

monthsmonths

Quill 2000. JAMA 284:2502Quill 2000. JAMA 284:2502

A Shift of focus:A Shift of focus:from the biomedical from the biomedical

to the psycho-social-spiritualto the psycho-social-spiritualFor many patients facing serious illness or For many patients facing serious illness or

the end of life, the focus shifts from the the end of life, the focus shifts from the biomedical to the spiritual.biomedical to the spiritual.

When symptom management and pain When symptom management and pain control are appropriately provided, patients control are appropriately provided, patients are set free to address their “final agenda.”are set free to address their “final agenda.”

This may be seen as the last chapter in This may be seen as the last chapter in one’s spiritual journey. (Mary Levine)one’s spiritual journey. (Mary Levine)


Spiritual IssuesSpiritual Issues

SufferingSufferingMeaning and PurposeMeaning and PurposeLoss or AbandonmentLoss or AbandonmentGuilt or ShameGuilt or ShameTrustTrustReconciliationReconciliationHopeHope


The struggle with serious illness is ultimately The struggle with serious illness is ultimately a spiritual struggle.a spiritual struggle.

Spiritual Identifiers in Dying PatientsSpiritual Identifiers in Dying Patients•• Is there purpose or value to their life?Is there purpose or value to their life?•• Are they able to transcend their suffering?Are they able to transcend their suffering?•• Are they at peace with themselves and others?Are they at peace with themselves and others?•• Are they hopeful, or are they despairing?Are they hopeful, or are they despairing?• • What nourishes their personal sense of value: What nourishes their personal sense of value:

prayer, religious commitment, personal faith, prayer, religious commitment, personal faith, relationship with others?relationship with others?

•• Do their beliefs help them cope with their anxiety Do their beliefs help them cope with their anxiety about death and with their pain, and do they aid about death and with their pain, and do they aid them in attaining peace?them in attaining peace?

Patients raise spiritual questionsPatients raise spiritual questionsWho am I, now that I am sick or dying?Who am I, now that I am sick or dying?What is the meaning of my life when I am no What is the meaning of my life when I am no

longer productive and independent?longer productive and independent?Where am I connected to others who value me Where am I connected to others who value me

and see me as a person of worth?and see me as a person of worth?What is my relationship to God and am I going to What is my relationship to God and am I going to

Heaven?Heaven?What do I now value most in the time that is left What do I now value most in the time that is left

to me?to me?


Unresolved issues and fearsUnresolved issues and fears

Old feuds or broken relationsOld feuds or broken relationsLast visits, seeing people for the last timeLast visits, seeing people for the last timeLifetime project Lifetime project Unfinished businessUnfinished businessFuneral plans Funeral plans Financial plansFinancial plansNeed to forgive or be forgivenNeed to forgive or be forgivenLoss of control and dignityLoss of control and dignityLoss of relationshipsLoss of relationshipsBeing a burdenBeing a burdenPhysical sufferingPhysical suffering

Spiritual CopingSpiritual Coping

• • Hope: for cure, for healing, for finishing Hope: for cure, for healing, for finishing important goals, for a peaceful deathimportant goals, for a peaceful death

• • Sense of controlSense of control

• • Acceptance of situationAcceptance of situation

• • Strength to deal with situationStrength to deal with situation

• • Meaning and purpose: in life in midst of Meaning and purpose: in life in midst of sufferingsuffering


Spiritual Care for the dyingSpiritual Care for the dying

• • Practice of compassionate presencePractice of compassionate presence

• • Listening to patient’s fears, hopes, pain, dreamsListening to patient’s fears, hopes, pain, dreams

• • Obtaining a spiritual historyObtaining a spiritual history

• • Attentiveness to all dimensions of the patient Attentiveness to all dimensions of the patient and patient’s family: body, mind and spiritand patient’s family: body, mind and spirit

• • Incorporation of spiritual practices as appropriateIncorporation of spiritual practices as appropriate

• • Involve cInvolve chaplains as members of the haplains as members of the interdisciplinary healthcare teaminterdisciplinary healthcare team


Community supportCommunity support

Sources of assistanceSources of assistanceChurchChurchDisease support groups Disease support groups Hospice Hospice Social groupsSocial groupsFriends, neighbors, and employment Friends, neighbors, and employment

peerspeers

Nurses must be compassionate and Nurses must be compassionate and empathic in caring for patients… In all empathic in caring for patients… In all of their interactions with patients they of their interactions with patients they must seek to understand the meaning must seek to understand the meaning of the patients’ stories in the context of of the patients’ stories in the context of the patients’ beliefs and family and the patients’ beliefs and family and cultural values…. They must continue cultural values…. They must continue to care for dying patients even when to care for dying patients even when disease-specific therapy is no longer disease-specific therapy is no longer available or desired.available or desired.

MSOP Report I, MSOP Report I,

Association of American Medical colleges, 1998Association of American Medical colleges, 1998Christina Puchalski MDChristina Puchalski MD

GriefGrief

An emotion or complex of emotions we An emotion or complex of emotions we experience when we lose someone or experience when we lose someone or something we value.something we value.


Assessment of the Meeting of Assessment of the Meeting of Spiritual NeedsSpiritual Needs

•• Does the health care provider listen to their Does the health care provider listen to their beliefs, faith, pain, hope or despair?beliefs, faith, pain, hope or despair?

•• Are patients able to express their spirituality Are patients able to express their spirituality through prayer, art, writing, reflections, through prayer, art, writing, reflections, guided imagery, religious or spiritual reading, guided imagery, religious or spiritual reading, ritual, or connection to others of God?ritual, or connection to others of God?

•• Are referrals made to chaplains, counselors, Are referrals made to chaplains, counselors, or spiritual directors when appropriate?or spiritual directors when appropriate?


Case 1: Clarifying religious statements Case 1: Clarifying religious statements by patientsby patients

Mr. R is a 77 year-old, white, retired mechanic whoMr. R is a 77 year-old, white, retired mechanic whohas class II congestive heart failure and coronaryhas class II congestive heart failure and coronaryartery disease that cannot be revascularized. After anartery disease that cannot be revascularized. After anemergency department visit for an exacerbation ofemergency department visit for an exacerbation ofcongestive heart failure, his physician raises the issue of congestive heart failure, his physician raises the issue of a DNR order. The following conversation occurs:a DNR order. The following conversation occurs:

Physician: “In your situation, CPR is very unlikely to Physician: “In your situation, CPR is very unlikely to succeed. What do you think about what I have said?”succeed. What do you think about what I have said?”

Mr. R: “Well, I want you to do what you can. I trust that Mr. R: “Well, I want you to do what you can. I trust that God will decide when it’s my time.”God will decide when it’s my time.”

Case 2: Case 2: Responding to religious reasons for Responding to religious reasons for rejecting the physician’s medical rejecting the physician’s medical

recommendationsrecommendationsMrs. M is a 72 year-old black woman with chronic Mrs. M is a 72 year-old black woman with chronic obstructive pulmonary disease who has been receiving obstructive pulmonary disease who has been receiving mechanical ventilation for 2 months because of acute mechanical ventilation for 2 months because of acute respiratory distress syndrome and multiorgan failure. respiratory distress syndrome and multiorgan failure. Believing that Mrs. M now has only a 1% chance of being Believing that Mrs. M now has only a 1% chance of being successfully extubated, her physicians begin to discuss successfully extubated, her physicians begin to discuss limiting life-sustaining interventions. Mrs. M is unable to limiting life-sustaining interventions. Mrs. M is unable to participate in these discussions. She had previously participate in these discussions. She had previously indicated that her husband should act as her surrogate indicated that her husband should act as her surrogate but did not provide specific directives for her care. Mr. M but did not provide specific directives for her care. Mr. M and their 2 children insist that mechanical ventilation be and their 2 children insist that mechanical ventilation be continued, believing that God will answer their prayers continued, believing that God will answer their prayers and work a miracle.and work a miracle.

General RecommendationsGeneral RecommendationsConsider spirituality as a potentially Consider spirituality as a potentially important component of every patient’s important component of every patient’s physical well-being and mental health. physical well-being and mental health. Address spirituality in your initial Address spirituality in your initial assessment; continue addressing it at assessment; continue addressing it at follow-up visits if appropriate. In patient follow-up visits if appropriate. In patient care, spirituality is an ongoing issue. care, spirituality is an ongoing issue. Respect patient’s privacy regarding Respect patient’s privacy regarding spiritual beliefs; don’t impose your beliefs spiritual beliefs; don’t impose your beliefs on others.on others.


General Recommendations, General Recommendations, cont…cont…

• • Make referrals to chaplains, spiritual Make referrals to chaplains, spiritual directors, or community resources as directors, or community resources as appropriateappropriate

• • Awareness of your own spirituality will not Awareness of your own spirituality will not only help you personally, but will also only help you personally, but will also overflow in your encounters with those for overflow in your encounters with those for whom you care.whom you care.


Religious Beliefs Related to Religious Beliefs Related to Health CareHealth Care

What are the health related beliefs of these What are the health related beliefs of these major religions? major religions? – BuddhismBuddhism– ChristianityChristianity– HinduismHinduism– JudaismJudaism– IslamIslam– Atheism Atheism

That’s your homework. Thanks and may God bless That’s your homework. Thanks and may God bless your ministry in caring for people.your ministry in caring for people.

Documents

Spirituality: Faith and Healthcare Presented by Chaplain Dana Bratton “We are not human beings having a spiritual experience. We are spiritual beings having