Spiritual Healing: Palliation and Terminal
Care
Physician Update, Winter 2000
Horace
M. DeLisser, MD
Assistant Professor of Medicine,
Pulmonary, Allergy and Critical Care Division,
Department of Medicine, Hospital of the University
of Pennsylvania
Introduction
Life-threatening disease provokes for the patient
questions of existence, meaning, purpose, regret
and destiny. The burden of these spiritual
issues and the need to have answers contribute,
to variable degrees, to the "pain" of
the patient.(1) Ultimately,
resolution of these questions in a personally
acceptable and satisfying manner represents
an important task for the dying patient and
constitutes spiritual healing. Failure of the
patient to address these issues either in whole,
or in part' may contribute to psychological
and emotional distress that results in additional
physical morbidity.
It is important from the outset to distinguish
between spirituality and religiosity. Spirituality
can be defined in a number of ways(2-6) but
here, as alluded to above, it refers to our own
personal understanding about existence, purpose,
meaning and destiny and the personal efforts
we make to define or clarify that understanding.
In contrast, religiosity is an expression of
belief through the practices of a particular
religion and denomination.(3) Thus
one can have a profound sense of the spiritual
without being "religious,” although
clearly many will define and express their spirituality
in a religious or denominational context.
Until recently, attention to the spiritual dimension
of disease has been an aspect of care that was
long neglected by modem western medicine.(4,
7-11) The reluctance (or even refusal) of
physicians to provide spiritual care stems from
several overlapping factors. First, as American
society has become more secular, and more culturally
and ethnically diverse, physicians are now challenged
with discussing issues with their patients for
which we as a society no longer have a common
language or set of commonly held beliefs that
we can frame these conversations. Second, engaging
the spirituality of a patient necessarily involves
private, personal and potentially very sensitive
issues. For many physicians, this level of intimacy
is intimidating. Third, in some instances, the
physician's own negative or absent experience
in things religious may cause him/her to view
spirituality with suspicion or indifference.
And lastly, physician raining (as well as Western
education in general) over the last century has
emphasized natural, mechanistic and scientific
explanations for understanding and approaching
disease. This affinity for an exclusively biological
basis of disease in turn resulted in medical
school curricula that until very recently gave
little or no attention to the spiritual dimension
of disease and the spirituality of patients.(12) Consequently,
physicians are apt to view religion, spirituality
and belief as antithetical to the culture of
science upon which their education was based.
For the physician interested in providing spiritual
care and promoting spiritual healing the following
is suggested:
1. Attend to your spirituality.
Undeniably all of us on some level are continuously,
consciously and unconsciously, addressing our
spirituality; and as caregivers it is impossible
for us to not consider the spiritual issues
raised by the deaths of our patients and our
roles in the dying process. More, however,
is required. The physician in an active, ongoing
and deliberate way needs to tike the time to
think, read, and search and thus engage and
define his/her spirituality. This may ultimately
mean reconnecting with the faith of one's past,
exploring personally held religious beliefs
more deeply, joining a faith community or pursuing
new spiritual experiences. Attending to one's
own spirituality in these and other ways will
allow for greater ease and comfort when discussing
the spiritual concerns of patients and will
enable the physician to better engage patients
in conversation over these issues.
2. Educate yourself on the religious and
spiritual beliefs of your patients.
For many patients, spirituality is defined by
religious affiliation and/or religious practice.
Thus, it is important that we become familiar
with the diversity of religious traditions, particularly
those that are found in our individual patient
populations.
3. Do a spiritual assessment.
A helpful, non-threatening way of approaching
spirituality with patients is to do a spiritual
assessment. Several tools for assessing the
spirituality of patients have been described
in literature(2, 6, 11) including
one developed recently by Christina Puchalski.(13)
Her approach, which can be remembered by the
acronym FICA, involves questions
on - (i) the patient's faith or belief system
(F); (ii) the influence and
importance of those beliefs (I);
(iii) the patient's participation in a spiritual
or religious community (C);
and (iv) how the patient would like the physician
to address his/her spiritual issues and concerns
(A). Completion of this assessment
opens the door for the physician to initiate
further conversation, either immediately or
in the future, on the specific spiritual concerns
of the patient. Although the spiritual assessment
can be done quite quickly, it is important
that sufficient time be allowed for the assessment
and the resulting conversations between the
physician and the patient. One suggested approach
for achieving this is to incorporate the spiritual
inventory into a visit dedicated to advanced
directives and end-of-life planning.
4. Respond based on the information learned
from the spiritual assessment.
The physician's response should be individualized
and based on the information obtained during
the assessment and the subsequent discussions.
Sometimes simply having someone who is genuinely
listening is sufficient to bring some spiritual
peace to the patient(1) and
is all that is required. Other response may include
future visits to continue the discussions of
the issues raised, suggestions for pertinent
readings and/or referral to pastoral care or
spiritual counseling. Or there may be specific
spiritual or religious practices and rites that
the physician can facilitate or accommodate.
5. Encourage reaffirmation or restoration
of relationships that have been or are important
to the patient.
Family and friends can be tremendous sources
of strength and support and may be the means
by which the dying patient acquires the help
and resources to experience spiritual healing.
Where these relationships are strong and vibrant,
the patient should be encouraged to nurture them
and to reaffirm to those involved what they and
the relationship mean to the patient. Some of
the spiritual distress and anguish dying patients
experience are connected to relationships that
have been neglected or dysfunctional. There is
much healing that can occur when individuals
reconnect to those they were once close to or
reconcile with those from they have been estranged.
Clearly there are relationships that can not
[and maybe should not] be salvaged, as well as
circumstances that require the involvement of
a skilled professional. However, many individuals
with the right encouragement and support can
make the effort to restore these relationships
on their own.
6. Periodically reassess the patient's spiritual
needs and concerns.
Although a full spiritual assessment is not required,
as appropriate and where indicated, the physician
should from time to time revisit the issues of
spirituality for the patient. New spiritual challenges
may have arisen or the patient may just simply
welcome the opportunity to share his/her evolving
insights and experiences.
Conclusion
In conclusion, the call to address the spirituality
of dying patients poses a challenge given the
diversity of our society, the nature of these
conversations and the inadequacies of medical
training; and for many physicians constitutes
yet another item on a growing list of things
that must be done for the patient in a healthcare
climate that restricts the time physicians
spend with their patients. Despite these very
real challenges, it is vital we understand
that by helping the patient to achieve spiritual
healing we are doing something just as significant
and just as real, as providing relief for physical
pain. And in the process we will find that
we will grow professionally, as well as spiritually.
References
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3. O'Connor TSJ, Meakes E, McCarroll-Butler
p, Gadowsky S, O'Neill K. Making the Most
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