This is the second in a series of posts based on my presentation called “The Sweet Spot: Ethical Interdisciplinary Spiritual Care” (c)2014. This work is copyrighted and all rights are reserved, however, please feel free to share it electronically or even in print with proper credit provided. I want this material to reach as far as possible to help professionals, and the field, as much as possible.–Carla
For Week 1 of the Sweet Spot series (click here to read), I wrote about the importance of all members of the healthcare team being prepared to screen for and respond to spiritual distress in the moment, when necessary.
I then shared my own ways of administering, or asking the questions for, Puchalski’s FICA screening tool.
I also spoke of the importance of referring to the trained, clinical spiritual care counselor (aka, “chaplain”) to perform the clinical spiritual assessment, develop the spiritual plan of care, and perform interventions to respond long-term to that spiritual distress.
Last week’s post was the “How”, but some may not yet be clear about the “Why”, and wonder what in the heck makes spiritual care so vital to competent, patient-centered care. Others may fully believe that impeccable spiritual care is crucial, but are not quite able to articulate the “Why”.
So here goes…
Episode 2 of the Sweet Spot series–the “Why” of Ethical Interdisciplinary Spiritual Care
My first point in making the case for ethical spiritual care is, well, the ethical one! I believe all persons deserve access to the benefits spiritual/existential care may provide without fear of judgment, abandonment, or coercion.
I speak about this regularly and wrote about it recently in a post on Hospice Times called, “Manifesto for Competent Spiritual Care: 7 Things That Matter” (click the title to give it a quick read. It’s fairly short!) So, I won’t belabor that point here.
My second point in the case for exquisite spiritual/existential care is based on empirical data and best practices, which I’ll discuss below. Research into spiritual care in healthcare is sorely lacking. Operationalizing the ethereal, making the aesthetic more concrete, can be more than a challenge.
Religion, spirituality, existentialism–these are weighty and heady issues shrouded in much mystery that often feel simply overwhelming to address. For some, this mystery is comforting and peaceful; for others, it can be a mild headache or even grounds for an all out post-traumatic involuntary eye–twitch.
Thankfully, we’re slowly getting more comfortable with the topic of spirituality in healthcare and are developing the empirical data to back it up!
But great strides have been made in recent years thanks to grants from the Templeton Foundation, the work of the Healthcare Chaplaincy Network, publications by Christina Puchalski and Betty Ferrell (one of which I referenced last week), and numerous others.
Even the National Consensus Project for Quality Palliative Care, which lists the 8 Domains necessary for competent palliative care, gave Spiritual, Religious, and Existential Aspects of Care its own whole domain (Domain 5). Instead of being just a paragraph or text box blurb in the midst of some other domain, it got it’s own place in the show and it’s even cross-referenced across multiple other domains in the document (“Clinical Practice Guidelines for Quality Palliative Care, Third Edition”, 2013, https://www.hpna.org/multimedia/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf
We are making tremendous progress in understanding the importance of quality, professional spiritual care in healthcare, but we have a long way to go.
What we’ve learned is that spiritual pain, described as “a pain deep in your soul (being) that is not physical” (Mako, Galek, & Poppito, 2006) appears to be common in healthcare patients and is significantly associated with lower self-perceptions of spiritual quality of life (Delgado-Guay, Hui, et al, 2011).
As I stated last week, the data indicates patients want to talk to their providers about their religious and spiritual concerns, but most often do not get to (Williams, 2011).
When we fail to respond adequately to patients’ spiritual distress, we find depressed mood and a decline in quality of life with persons beginning to wonder whether, for instance, God has abandoned them or even still loves them (Pargament, et al, 2001, 2004).
I call this failure on our part spiritual neglect, one extreme of what I call spiritual malpractice. When I first used this term with a dear and respected friend, who is an M.D., she said, “Don’t use that term in the medical community! It’s a big word that will turn us off an shut us down.”
But I argued that the goal isn’t to incite fear, it’s to make clear that not tending to persons’ religious, spiritual, and/or existential needs is a VERY big deal and one to which we must pay serious attention. An here’s more of “Why”.
When we DO address spiritual distress, we find higher patient and family satisfaction (Astrow, et al, 2007; Daaleman, et al, 2008; Wall, et al 2007), lower rates of hospital deaths (Flannelly, et al, 2012), higher rates of hospice enrollments and patients being less likely to pursue unnecessarily aggressive treatments (Balboni, et al, 2010; Balboni, et al, 2011; Flannelly, et al, 2012).
All of this means that when we tend to their spiritual distress, persons are more likely to die exactly where all the surveys say we want to die–at home surrounded by our things and pets and loved ones with familiar sights and sounds and smells and NOT connected to tubes and wires and beeping machines.
Now, don’t get me wrong…tubes and wires and beeping machines sometimes save our lives. I’m not against them, at all. In fact, I’m a left-handed red-headed Aries, so I know a thing or two about hanging on stubbornly and fighting against the odds. But sometimes we fight far too long and far too much to our detriment, in terms of our dignity and quality of life and the wear and tear it puts on our bodies and our families and our resources.
Surveys also consistently find that our greatest fear isn’t death, it is how we will die that scares the snot out of us. We do not want to be in pain, lose our dignity, or be a burden to our families. I’ll refer you to the amazing work of Dr. Monica Williams-Murphy and her book “It’s OK to Die” for more on this topic, lest this rabbit run too far off the trail.
This whole issue brings me to a point I mentioned last week, and promised to circle back to and address. It can be easy to assume that if a person declares a religious faith and connection (to a church, synagogue, sangha, mosque, etc.) that spiritual care from the healthcare team is redundant and therefore not necessary.
But one critical finding in the research indicates this is not only false, but a possibly dangerous proposition. In the cancer studies performed by Balboni and colleagues listed above, the findings initially showed that those patients who identified as highly religious were MORE likely to pursue aggressive end of life treatments.
That made us all stop for more than a moment. One would expect that those who are highly religious would have hope and comfort in this life and even some form of comfort or hope about an afterlife of some form that comes from their religious faith. We tend to equate those who fight longer and harder, unless they are young and/or otherwise healthy, with those who are afraid or have unresolved issues or grief that leave them not yet ready to let go of this life and face death.
So we were all quite confused.
Then, in the follow-up studies, what Balboni began to tease out from the data is that if persons only receive spiritual support from their faith community, which usually does not understand medical processes and the impact of grief on acceptance of a diagnosis, for example, the patient is more likely to pursue unnecessarily aggressive treatments at the end of life.
But if the healthcare team is ALSO involved in providing spiritual care, that comes with education and grief counseling and knowledgeable support, it appears that effect is mediated–meaning highly religious persons become no more likely to pursue aggressive treatment than other less religious patients.
A well-meaning, well-intentioned faith community may push a patient and family to fight the good fight and trust in G_d’s help if they do not have a seasoned medical team joining them in a way that helps to educate everyone involved and support them through their grief.
So the next time you hear someone on the team say, “Oh, they have their own minister…” pull this out and borrow my soap box to make the case that we cannot leave them without professional, clinical, spiritual care counselors or spiritual support from the medical team!
The next time you hear another discipline say, “The chaplains can handle a bigger case-load…it’s not like they do that much”, avoid the initial visceral reaction toward snatching them nekid and burning their clothes. Instead, point them to the research and best practices listed here, or any of the growing literature that demonstrates the importance of good spiritual care.
It can be easy to sit distraught on the sidelines, claiming the other disciplines won’t let us play at the big kid’s table on the healthcare team, but that helps no one and gives away our power. We can equip ourselves with the data that backs up, and even gives us the language for, why what we do in spiritual care is so important. We can then demonstrate the importance with the way we practice our care…but that’s for another post, later in the series!
For now, I hope this information has been helpful, and I hope you’ll tune in next week as I take the information above and make the third point, that good spiritual care can tremendously impact an organization’s financial bottom line.
After next week’s post, I’m hoping that the next time you hear an administrator say, “We just can’t devote the budget to a stronger spiritual care program”, you’ll just smile and say, “Hang on a second. Let me show you something…”
So stay tuned!
Astrow, A., Wexler, A., Texeira, K., He, M., Sulmasy, D. (2007). Is failure to meet spiritual needs associated with cancer patients’ perceptions of quality of care and their satisfaction with care? Journal of Clinical Oncology, Vol. 25, pp 5753-5757.
Balboni, T., Balboni, M., Paulk, M., et al (2011). Support of cancer patients’ spiritual needs and associations with medical care costs at the end of life. Cancer, V 117, pp. 5383-5391.
Balboni, T., Paulk, M., Balboni, M., et al (2010). Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. Journal of Clinical Oncology, Vol. 28, pp. 445-452.
Daaleman, T., Williams, C., Hamilton, V., Zimmerman, S. (2008). Spiritual care at the end of life in long-term care. Medical Care, Vol. 46, pp 85-91.
Delgago-Guay, M., Hui, D., Parsons, H., Govan, K., De la Cruz, M., & Thorney, S. (2011). Spirituality, Religiosity, and Spiritual Pain in Advanced Cancer Patients. Journal of Pain and Symptom Management, 41:6, pp. 986-994.
Flannelly, K., Emanuel, L., Handzo, G., Galek, K., Silton, N., & Carlson, M.(2012). A national study of chaplaincy services and end of life outcomes. BMC Palliative Care, 11:10.
Mako, C, Galek K, & Poppito, SR. (2006). Spiritual pain among patients with advanced cancer in palliative care. Journal of Palliative Medicine, 9, pp 1106-1113.
Pargament, K., Koenig, H., Tarakeswar, N., & Hahn, J. (2001). Religious struggle as a predictor of mortality among medically ill elderly patients: A two-year longitudinal study. Archives of Internal Medicine, 161, pp 1881-1885.
Pargament, K. I., Koenig, H. G., Tarakeshwar, N., & Hahn, J. (2004). Religious coping methods as predictors of outcomes of psychological, physical, and spiritual outcomes among medically ill elderly patients: A two-year longitudinal study. Journal of Health Psychology, 9, pp. 713-730.
Wall, R., Engelberg, R., Gries, C., Glavan, B., Curtis, J. (2007). Spiritual care of families in the intensive care unit. Critical Care Medicine, Vol. 35, pp.1084-1090.
Williams, J., Meltzer, D., Arora, V., Chung, G., & Curlin, F. (2011). Attention to Inpatients’ Religious and Spiritual Concerns: Predictors and Association with Patient Satisfaction. Journal of General Internal Medicine. DOI:10.1007/s11606-011-1781-y
About Rev. Dr. Carla Cheatham:
After a career in social services, with an MA in Psychology and certification in crisis counseling, Carla received her MDiv. and PhD. in Health & Kinesiology and began serving faith communities. For almost a decade, she has worked as a spiritual counselor in healthcare, primarily for hospice.
After realizing many lacked supportive education in multi-faith spiritual care, Carla and her colleagues created the SCIE (“sky”) curriculum, which expanded to include boundary training and presentations in a multitude of areas. She provides training for all healthcare staff both via webinar and live presentations.
Carla has taken stories from the curriculum and published them as a book of stories called Hospice Whispers: Stories of Life, available here or through Amazon. The Grief Companion Guide to Hospice Whispers designed for both individuals and groups, is set to publish later this Spring. She is also writing her second book on the art of presence with those who are suffering.