Spirituality in Patient Care

Through most of recorded history spiritual beliefs and religious practices have been assumed to play a central role in health. Religious leaders were often also seen as healers, or at least mediums through whom healing might come. The 20th century particularly saw a separation between the practice of medicine and spiritual/religious belies and practices. Harlod G. Koenig’s book  Spirituality In Patient Care: Why, How, When, and What addresses this gap and argues for the inclusion of patient’s religious and spiritual life as an essential element in “patient-centered medicine” (8). He makes use of volumes of research data to demonstrate the value of religiosity to health, and the importance of health professionals addressing this aspect of their patients’ lives.

The book outlines, as the title suggests, the why, how, when and what of including the spirituality of the patient in the treatment conversation and plan. He then proceeds to discuss some risks – i.e. some ways that religious and spiritual beliefs and practices might be problematic, and how do address these. One example is the notion that illness or suffering is somehow “God’s will” which might dispose a patient to resist treatment or might interfere with that patient’s openness and capacity for healing (108). He outlines professional boundaries for health professionals, and then spends a chapter on each of the following disciplines and how they might address spirituality in patient care: Chaplains and Pastoral Care; Nursing; Social Work; Rehabilitation; Mental Health.

His final two main chapters are spent outlining a model curriculum for including religion and spirituality in medical training, followed by an overview of beliefs and practice found in world religions. These chapters are helpful not only for medical schools but particularly for staff development and inservice training in medical facilities. Ongoing conversation is needed to develop the ability of all health practioners to address these issues effectively with patients and their families. The failure to do so can hinder the ability of patients to develop a relationship of trust with their medical team and to make full use of these resources for their progress toward wholeness.

I highly recommend this book for medical practioners as well as clergy and other religious professionals and lay leaders who function in healthcare settings or interact regularly with people in matters of their health. Below are links to chapter summary notes for use in a book club or other study.

Spirituality in Patient Care – Overview & Intro
Spirituality in Patient Care – Chapter 1
Spirituality in Patient Care – Chapter 2
Spirituality in Patient Care – Chapter 3
Spirituality in Patient Care – Chapter 4

(Other notes coming soon)

Hospital Employee Grief and Loss Support Program

The following is a discussion starter for developing a support program among employees as a 40 bed hospital. If you have insights from your own experience, I would appreciate hearing them. And if you would like help thinking through your own situation, I’d be happy to share in that conversation also.

An updated summary version is available here in pdf.

Initial conversation –

In the past few months several of our coworkers have experienced the death of significant person in their lives. Others are entering a new stage of life with parents and others experiencing a decline in physical or mental health. Still others experience stress and grief related to relationship conflicts and disappointments. All of this has prompted a discussion regarding how we as a staff support one another during these difficult seasons.

Some considerations –

Work relationships are important. People spend half of their waking hours at work. We often spend more time interacting with coworkers than any other people. At a place like TCH, because of our size, the potential increases for us to develop a sense of family. In our families we typically know how to respond when someone has a loss, but at work we may be less confident in what we might say or do to support one another.

What happens when a TCH staff member has a loss? Who do they tell, and what happens next? Some possibilities:

  • Employee informs supervisor
  • Supervisor/employee informs HR
  • Supervisor or HR have a sit-down with employee offer support and discuss bereavement leave and EAP
  • Supervisor or HR informs leadership team & Support Team (Psychologist, Chaplain, Social Workers, etc …)
  • Employee’s immediate coworkers are informed, with the permission of the employee
  • Formal acknowledgement of sympathy is sent (card, flowers, memorial, etc)
  • A “Buddy” coworker is tasked with offering intentional and focused support to the employee, with training and backup from the Support Team. Support may include how often to follow up and how – i.e. have lunch weekly for a month, and monthly for a year. Invite conversation, offer permission to share thoughts and feelings, and to normalize the grief process over time.
  • Supervisor or HR follow up periodically, prompted by a reminder in Outlook.
  • Employees have the right to “opt out” saying, “I do not want to receive specific attention for my loss” and to change their minds and “opt back in”.

 How do we as a staff support one another more generally?

  • Normalizing the grief and loss experience:
    • Recognition that loss comes in many different forms – death, divorce, illness or disability of self or significant other, loss of a hope or dream, significant geographic move of self or others, graduation of kids from High School or College,
    • Recognition that grief is expressed in many different ways – sadness, depression, flat affect, anger, lethargy, manic episodes,
    • Recognition that grief does not respect rules or a timeline – it ebbs and flows, sometimes sneaking up on us and taking us very much by surprise.
  • Periodic in-service training and town hall meetings to discuss various topics (quarterly or semiannually?)
  • Monthly book study

What is the difference between “sharing information to enable and encourage support” and “gossip”?

What are the boundaries between being friendly, collegial, supportive, and being intrusive? How do we invite/encourage each person to state their need and be able to speak when their need changes?

What other questions/considerations need to be raised that are not identified here?

DEATH AND DYING, A CONVERSATION AMONG MEDICAL PROFESSIONALS

Understanding our own mortality

Elizabeth Kubler-Ross (1975) states that “We cannot give loving and caring support to dying persons and their loved ones until we have faced our own death and mortality within the depths of our being.” (Miriam Jacik 1989, 257) See “A look at death and dying” questionnaire.

Addressing our personal beliefs and experiences of loss and death.

  • What losses have you experienced in your life? (a pet, a friend moving away, loss of extended family, loss of family of origin member, loss of present family, loss of significant job, loss of home, divorce, loss of physical functioning, etc.)

What were you taught about death as a child? Was death something to be feared? Was it a secret not to be spoken of? How were the dead spoken of? Was fear connected with death?

“A person’s faith and religious belief system are often a strong source of support during illness and in the face of death. It behooves the [medical professional] to honor this reality not only in his or her own personal life but also in the patient’s life. One does not have to share the same religious affiliation to be able to understand and accept another’s spiritual orientation.” (Jacik 262)

  • How then, are we to have this conversation? Recognizing that we have already been called to consider our own thoughts and feelings regarding death, our own and more generally, how do we engage with others?

“It is important to believe that one person can help another die well, much as one would have helped another to live well….human life is temporary… human beings are mortal… the journey through life is transient.” (Jacik 263)

A statement that describes what motivates the ministry that I do.

“Healthcare professionals, being part of a society that fears, avoids, and denies death, share the same fears and attitudes about death as those they are called to serve. Overcoming such negative attitudes about death requires a personal struggle with the issues of our own mortality, reflection on our personal fears of dying, and being in touch with or formulating our personal philosophy of life. The latter entails the topics of introspection that all people face: the meaning and purpose of life, the meaning of suffering and death, personal beliefs about God or some higher being, the place of God in one’s life, the hereafter, the forms of religious expression one uses, and one’s religious belief system.” (Jacik 257)

Jacik, Miriam. “Spiritual Care of the Dying Adult.” In Carson, Verna Benner. Spiritual Dimensions of Nursing Practice (Philadelphia: W.B. Saunders 1989)

Consider also the work of

Dr. Ira Byock, MD, Chair, Palliative Medicine, Dartmouth Medical School  – www.dyingwell.org

Meaning and Grief

Grief is an emotional response to loss – real or perceived, past, present or anticipated.

Humans seek meaning. One of a child’s earliest questions is, “Why?” She wants to know the meaning behind an event, the reason for a direction. “Why is the sky blue?” She is not asking a scientific question about how light is reflected and refracted and how the atmosphere becomes a filter for the dark void of space, which we then perceive as blue. You will loose her if you try to ‘explain’ in response to her ‘why’ question. She is asking what it means that the sky is blue. Similarly, when a child asks, “Where do babies come from?” he is not asking a biology question, but a meaning question, an existential, ontological inquiry into the origin of life.

We need for our lives to mean something, and that meaning usually (always?) derives from our relationships – with ‘the other’ and with self. When a person’s sense of self is disturbed, when important relationships are fractured, then life ‘loses its meaning’. Depression sets in coincident with this loss of meaning drawn from relationships. The loss may only be perceived by the depressed person, while all around still experience and value the relationship. Even when depression has a chemical component, there is typically experienced some psychological component of loss. Part of what is lost is meaning, and grief follows. If meaning cannot be restored, or new meaning found, then depression may set in.

Our ability to ‘do something’ in the world, to make or produce something, to ‘be a productive member of society’ is also about relationships – with self, others and the world. It’s about our ability to contribute, to ‘be useful’ to the other, to be needed. When men, in particular, retire, they often experience a loss of meaning, as their self-identity, and how they understood themselves in relation to others, was derived from work. Part of the ‘grief process’ in this instance will be to choose new ways of framing meaning. The joy one derives even from caring for a pet or tending a small garden, these are expressions of relationship which when lost will be missed – not only the act, but the meaning the act represented.

Of particular significance is the series of losses that come with aging – losses of ability, contribution, and independence. When a mother can no longer cook for her children or care for her grandchildren, she may experience grief. When a father can no longer provide, no longer ‘help out’ with projects around the house, he too may grieve. Next comes the time when they cannot do these things even for themselves, and roles reverse so that the caregiver becomes the receiver of care. This includes a loss of role, of identity, of independence, and perhaps even of dignity, modesty and self-respect. With each of these losses come a unique kind of grief.

Multiple griefs can pile up, much like other kinds of stress. Stress is a condition or feeling experienced when a person perceives that “demands exceed the personal and social resources the individual is able to mobilize.”  (Richard S. Lazarus)  The Holmes-Rahe Stress Scale is a useful tool for understanding the compounding effect of stresses over time. Loss and Grief function in similar ways, and often include specific stress elements in them, emotionally, mentally, and physically.

At a time of loss, people often ask questions of meaning – usually they begin with ‘why?’ or ‘how?’.

Why did this happen?  OR more pointedly – Why did God let this happen?

How will I go on?

What do you do when loss comes into your life? Take a moment to list a few of the losses that you have experienced at any time in your life, and then specifically in the last two years.

And it matters whether the loss was sudden and surprising, or known and a long time in developing.

An extended period of loss – such as a slow death from a debilitating disease – offers special significance to our grief. We this time can allow all involved opportunities to grieve slowly over time, to ‘adjust’ to ideas of a new reality and think things through. In this way, they may have more peace about the loss, and grow to a place of understanding with their questions. At the same time, this long, drawn-out process also may prompt some to experience greater suffering. A deep sadness comes with prolonged suffering, as one perhaps wishes ‘for it all to be over.’ Added to that is the fatigue that comes with suffering, caring, and grieving for weeks and months on end.

In his groundbreaking work on Logo Therapy entitled Man’s Search for Meaning, Viktor Frankl processes his experience in the Nazi concentration camps during WWII. What Frankl observed, very simply, is that those who found some reason to survive, did. In other words, those for whom life continued to have meaning. The meaning could be tied to family and friends, to life itself, to ‘resistance’, or even to work left undone, as it was for Frankl. Many human beings (there are always exceptions) want life to make sense, to have some kind of reason behind it. People say this about their periods of depression: “I needed a reason to get out of bed in the morning.” Don’t we all need such a reason, in some form or another? The challenge for people is that those things which used to provide meaning are 1) no longer effective, or 2) no longer there. The second is the case with grief and loss.

So, as we enter into caring relationships with others, we need to be aware of our own losses, their meaning for us and effect on us. We then need to be sure that these are able to illumine our interactions without infecting them. My grief gives me understanding and empathy for others, but must not be laid or projected onto the other and their experiences.

We also want to listen for expressions of grief and loss, giving the other opportunity to express these, and explore questions of meaning if they so choose. If we are anxious about our own loss and grief, then we will not have the capacity for calm presence as we listen to the other. Indeed, one of the ways our own loss and grief gains new meaning is when it is redeemed by enabling us to be present with/for the other in their times of need without our own needs controlling the interaction. We can not give meaning to the grief and loss of others. We CAN and should give them permission to explore and seek meaning in the midst of their own journey.

A reflection from faith

As we enter into this process, we bring our own understandings of God and God’s place in the world. The Christian tradition is one which has multiple expressions of how loss and grief can become opportunities for deeper meaning in life, in opposition to cultural presumptions that loss leads to a destruction of meaning.

Paul articulates that:

1 Therefore, since we are justified by faith, we have peace with God through our Lord Jesus Christ, 2 through whom we have obtained access to this grace in which we stand; and we boast in our hope of sharing the glory of God. 3 And not only that, but we also boast in our sufferings, knowing that suffering produces endurance, 4 and endurance produces character, and character produces hope, 5 and hope does not disappoint us, because God’s love has been poured into our hearts through the Holy Spirit that has been given to us. 6 For while we were still weak, at the right time Christ died for the ungodly. 7 Indeed, rarely will anyone die for a righteous person—though perhaps for a good person someone might actually dare to die. 8 But God proves his love for us in that while we still were sinners Christ died for us. (Romans 5)

This passage makes several points: 1) the suffering and loss experienced in the death of Jesus became redemptive because of God’s grace at work in and through those events, and 2) our own experiences of suffering (grief and loss) become an opportunity for us to grow toward hope. These two ideas are central to the Christian understanding of life in this world.

Additionally, we believe/understand that losses in this world are only temporary, and that an experience of life awaits us where there is no loss, grief, sorrow, tears or pain (Revelation 21:3-4). We need to be very careful in the midst of another’s grief. Proclaiming these truths to someone who does not already believe them rings very hollow. Rather, let our faith in them bring us comfort and assurance as we enter into the sufferings of others so that we are able to ‘not let our hearts be troubled, neither be afraid’, but rather provide a calm, steady, safe place in which others may explore their own deep questions and the meaning they may find in and after their experiences of loss and grief.

When the Well-Meaning Become the Grief Police    By Sara Perry