“Spiritual Care is Everyone’s Business”...spiritual distress or a possible spiritual crisis...

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MNHPC 29th Annual Conference | April 14–16, 2019 www.mnhpcconference.org

“Spiritual Care is Everyone’s Business”

David Hottinger, Mdiv, HCMC

Amy Cotter, LSW, MA, Our Lady of Peace

Deb Lane, RN, BSN, CHPN, Our Lady of Peace

Eileen O’Shaughnessy, MD, nephrologist, HCMC


David Hottinger, Mdiv, Director of Spiritual Care, HCMC


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• Define spirituality and the role of the Spiritual Care Generalist

• Identify screening tools to elicit spiritual distress in patients and

their families

• Discuss the ethics of spiritual care

Objectives


Amy Cotter, LSW, MA, Our Lady of Peace


World Health Organization (WHO) Definition of Health

“Health is a complete state of physical, mental, and social wellbeing and not merely the absence of disease or infirmity”

-WHO, 1948

Definition of Health

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Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose, and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.

Integration of Spirituality into Health Care Curriculum: Introduction

Minnich, B, Puchalski, C. Interprofessinal Spiritual Care Training Program Held at the Washington DC Veterans Administration

Broad Definition of Spirituality


That care which recognizes and responds to the needs of the human spirit when faced with trauma, ill health or sadness, and can include the need for meaning, for self-worth, to express oneself, for faith support, perhaps for rites or prayer or sacrament, or simply for the sensitive listener. Spiritual care begins with encouraging human contact in compassionate relationship, and moves in whatever direction need requires.

(NHS Education for Scotland, 2009)

Definition: Spiritual Care


Spirituality and spiritual well-being have been studied globally and these studies demonstrate a positive effect of spirituality on several outcomes:

Spiritual well-being has been associated with improved health-related quality of life (Wildes, 2009, Bergman 2011, Zavala, 2009, Jafari, 2014), and general well-being (Lopez-Sierra, 2015; Sherman, 2015).

Spirituality has often been observed as a coping mechanism and patients with a higher spirituality use their spiritual strength to cope with their cancer diagnosis and its treatment. (Garssen, 2015; Vallurupalli, 2012; Asiedu, 2014)

Spiritual patients are more aware of their prognosis (Seyedrasooly , 2015) and are more at-ease with decision- making, and more satisfied with their decisions regarding treatment and cure. (Mollica, 2016; Sterba, 2014)

Studies

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Principle 1 – Whole-of-organization approach A key success factor is the active engagement of those in leadership.

Principle 2 – Relational care Human relationships are central to spirituality.

Principle 3 – Spiritual care is everyone’s business All team members need to have a basic awareness of spirituality and how it affects their role.

Principle 4 – Spiritual care is about growth and flourishing Spirituality is a part of everyday living.

Reference:

Meaningful Ageing Australia, (2016). National Guidelines for Spiritual Care in Aged Care. Meaningful Ageing Australia, Parkville.

Spiritual Care Guidelines


• Impaired ability to experience and integrate meaning and purpose in life.

• Lack of connectedness with self, others, God or Transcendent and to the significant or sacred. (Herdman,

2009; Puchalski, 2014).

• Pain deep in the soul. (Delgado-Guay et al., 2011)

Spiritual Distress


• Ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself that can be strengthened. (NANDA , 2009)

• Occurs through a dynamic and interactive growth process that leads to a realization of the ultimate purpose and meaning of life. (Hungelmann et. al., 1996)

• Spiritual well-being is the affirmation of life in a relationship with God, self, community and environment that nurtures and celebrates wholeness. (NICA, 1975)

Definition: Spiritual Well-Being

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Deb Lane, RN, BSN, CHPN, Our Lady of Peace


Interprofessional Spiritual Care: An Integrated Model


• Everyone on the team addresses patient suffering and provides support (Generalist)

• Clinicians who develop treatment plans screen for spiritual distress as part of a comprehensive assessment and practice compassionate presence and accompaniment

• Certified chaplains or spiritual care professionals (Specialists) are experts in spiritual care in healthcare settings.

ISPEC Module 1:Background and Introduction

Generalist – Specialist Model

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• Address spiritual issues in care

• Screen for spiritual distress and also for spiritual resources of strength

• Incorporate spiritual distress in assessment and treatment or care plan

• Support spiritual resources of strength

• Provide compassionate presence , reflective inquiry

• Implement appropriate treatment, including referrals to spiritual care professionals and/or other treatment modalities, resources, or programs

• Work with trained spiritual care professionals and others on the team

• Follow up on spiritual issues and adjust plan as needed

The Role of the Clinicians in Generalist Spiritual Care


• Compassionate presence is a unique subset of compassionate care.

• Presence refers to the contemplative aspect of our relationship with patients.

• While compassionate care can involve empathy, forming connections, helping patients with issues, being respective being caring, presence calls upon a unique set of skills in which the clinician moves to a more reflective and contemplative space with the patient. (Puchalski, et.al., 2018 )

• Accompaniment is the outgrowth of presence. It is the spiritual work we do. Compassion is spirituality in action.

ISPEC Module 3: Compassionate Presence: A Contemplative Approach

Compassionate Presence


Listening is much more than allowing another to talk while waiting for a chance to respond. Listening is paying full attention to others and welcoming them into our very beings. The beauty of listening is that those who are listened to start feeling accepted, start taking their words more seriously and discovering their true selves. Listening is a form of spiritual hospitality by which you invite strangers to be friends, to get to know their inner selves more fully, and even to dare to be silent with you.

Henri J.M. Nouwen, Bread for the Journey

Compassionate Care – Deep Listening

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• Doing a complete spiritual assessment

• Diagnosis and treatment of spiritual distress

• Developing and implementing and outcomes based treatment plan

• Chart notes from patient interview in the chart and in the treatment plan

• Making recommendations to the clinicians on what they can do to help

the patient with spiritual distress

• Helping patients and their loved ones discover and use their spiritual and

religious resources at this time

• Teach the clinicians about generalist spiritual care

• Model active listening, compassionate presence, cultural humility

• Participate in family meetings

• Lead and or participate in goals of care discussions

Roles of the Spiritual Care Professional/Chaplain


Eileen O’Shaughnessy, MD, nephrologist, HCMC


“What do I need to know about you as a person to give you the best care possible?”

Spiritual Screening/Assessment

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A survey of 339 oncology clinicians found that 74% nurses and 60% of physicians desire to provide spiritual care when caring for patients with a serious illness.

The most frequently endorsed barriers of providing spiritual care include:– lack of time (72%), – inadequate training (61%), – lack of privacy (52%), – Spiritual care better offered by others (50%)

Inadequate training was identified as the strongest predictor of lack spiritual care provision to patients.(Balboni, et.al. 2014)

An integrated structure for spiritual care (multidisciplinary teams inclusive of chaplaincy) may also influence spiritual care delivery. (Steinhauser, et.al. 2017)

Barriers to Spiritual Care Provision


A quick determination of whether a person is experiencing

spiritual distress or a possible spiritual crisis and

whether referral for a more in-depth spiritual

assessment is indicated.

Good models of spiritual/religious screening employ a few,

simple questions, which can be asked by any health care

professional in the course of an overall screening.

(Fitchett & Canada, 2010)

Spiritual/Religious Screening


Trying to solve the patient’s problems or resolve unanswerable questions.

Going beyond the clinician’s expertise and role, or imposing the clinician’sreligious beliefs on the patient.

Providing premature reassurance.

Not working with spiritual care professionals.

Pitfalls in Discussions About Spiritual and Religious Issues

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• C – Care – What do I need to know about you to take better care of you?

• A – Assistance/help – What has helped you most during the course of your illness?

•

• S – Stress – What are the biggest stressors in your life now?

• H – Hopes/fears – What is your biggest fear? What are you hoping for?

Source:

Alesi, E. R., Ford, T. R., Chen, C. J., Fletcher, D. S., Morel, T. D., Bobb, B. T., & Lyckholm, L. J. (2015). Development of the CASH Assessment Tool to Address Existential Concerns in Patients with Serious Illness. Journal of Palliative Medicine, 18(1), 71-75. Doi: 10.1089/jpm.2014.0053

CASH Assessment Tool


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

O: Organized religion

P: Personal spirituality and practices

E: Effects on medical care and End-of-Life issues

The HOPE Questions


We have been discussing your support systems. I was wondering, what is there in your live that gives you internal support?

What do you hold on to during difficult times?

What keeps you going?

For some people, their religious or spiritual beliefs act as a source of comfort and strength in dealing with life’s ups and downs; is this true for you?

Examples of HOPE Questions

H – Source of hope, meaning, comfort

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Do you consider yourself part of an organized religion

How important is this to you?

What aspects of your religion are helpful and not so helpful to you?

Are you part of a religious or spiritual community? Does it help you? How?

Examples of HOPE QuestionsO- Organized Religion


Do you have personal spiritual beliefs that are independent of organized religion? What are they?

Do you believe in God? What kind of relationship do you have with God?

What aspects of your spirituality or spiritual practices do you find most helpful to you personally? (e.g. prayer, meditation, readings, hiking, communing with nature)

Examples of HOPE QuestionsP- Personal spirituality/practices


Has being sick (or your current situation) affected your ability to do the things that usually help you spiritually?

As a doctor, is there anything I can do to help you access the resources that usually help you?

Are you worried about any conflicts between your beliefs and your medical situation/care/decisions?

Are there any specific practices or restrictions I should know about in providing your medical care? (e.g., dietary restrictions, use of blood products)

Examples of HOPE QuestionsE – Effects on medical care and End-of-Life issues

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“What do I need to know about you as a person to give

you the best care possible? ”


David Hottinger, Mdiv, Director of Spiritual Care, HCMC


“My patient wants me to pray. What do I do?”

Ethical & Cultural Challenges in Spirituality

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Spiritual Countertransference

Cultural Competency

Praying with patients

Ethical Challenges in Spirituality and Health


It is the ethical responsibility of all health care providers to attend to all dimensions of a person including the spiritual dimension. (Polzer & Engebretson, 2012)

Barriers for clinicians addressing spiritual issues with patients include

– discomfort in dealing with spiritual issues,

– lack of training, or

– perceived lack of time. (Balboni, et.al. 2014)

Ethical Challenges in Spirituality and Health


Intimacy with formality

Power differential between patient and clinician.

Context: what is the reason the patient is being seen and what is appropriate to address for the context?

Training of the different members in spiritual care, or lack of training

Levels of expertise in spiritual care

Relationship Between Clinician & Patient

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Ms. Casey is a 32-year-old patient, who comes into her primary care doctor’s office for depressed feelings. While taking the spiritual history, Dr. Alexander learns that the patient is not spiritual, has no meaning in life and is searching. Ms. Casey did grow up Catholic and used to like the church but has not been there since her early 20s. Dr. Alexander is Catholic and knows some great Catholic Churches that have active young adult groups and activities. He feels this information would help his patient.



Ms. Casey:

Doctor, I have no meaning in life. I feel like I am wandering and need to find a spiritual home. I used to be Catholic, am not sure I believe in any of that. Do you have any advice?


Dr. Alexander:

I know some great Catholic churches

that have interesting activities, social

justice groups etc. Sometimes you can

have a bad experience with one church

and find another that is good. Would

you be interested in that?

What do you think of Dr. Alexander’s response?

What do you think are better responses?

What was the spiritual countertransference issue in this case?


Tell me more about not having any meaning in your life?

Is there anyone or anything that give you meaning?

If you can imagine a spiritual home—what would it be

like for you?

Referral to Chaplains

Better Responses

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Cultural competence has been defined as “a set of skills and practices that lead to culturally appropriate services that respect patients’ ethno-cultural beliefs, values, attitudes, and conventions.”

(Bhui, et.al., 2007)

Cultural Competence


Religious and spiritual beliefs are often integrated as part of cultural competency (Whitley, 2012)

Attention to spiritual beliefs and values of the patients can aid in the development of culturally competent and accessible services and increase satisfaction with care (Whitley, 2012)

Religion and spirituality as part of cultural competence


I am a Muslim woman from Pakistan taking care of a

Jewish man from Russia.

I am a Hindu man from India taking care of a Lutheran

woman from South Minneapolis.

I am an Asian Atheist taking care of a Native American

healer.

What am I supposed to do?

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“Be curious”


Clinicians should first inquire whether there are religious and spiritual practices that patients and families would like to engage in and try to find out what spiritual practices are important to the patient.

Clinicians should consider working with chaplains who are trained in creating rituals that are appropriate for the patient.

Hospitals should attempt to provide space and opportunity for patient religious, cultural or spiritual rituals if possible.

Cultural Competence How do we help patients and families with their

religious and spiritual needs in our programs?

Be curious

Call the Chaplains

Find the space, make it happen


Patient spiritual domains and their relationship to patient-centered health care outcomes. Quality-of-life focusedend-of-life medical care, for example, receipt of hospice care and lack of heroic, aggressive measures at the end of life, forexample, resuscitation, ventilation, and death in an intensive care unit. Notably, this does not take into account patient goals of end-of-life care, also a key, inter-related outcome for patients. EOL : end of life; QOL: quality of life.

(Steinhauser, et.al., 2017)

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• Praying with a patient can aid in creating and maintaining a relationship that is trusting and provides a healing environment for the patient.

• Some barriers to praying with patients include:

– Not being comfortable asking questions about prayer

– Not being confident enough to pray with patients

– Not having enough time to pray with patients

– Cultural concerns

Prayer at the Bedside


Jerry has pancreatic cancer. Dr. Smith just told him of his diagnosis and poor prognosis. Jerry has been a patient of Dr. Smith’s for 30 years. They attend the same church. Jerry says to Dr. Smith, “Can you pray with me?”

Prayer: Scenario 1


Should Dr. Smith pray with Jerry?

Does it make a difference that the patient and the physician attend the same church? Why or why not?

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What if Jerry’s nurse was Ms. Martinez?

Jerry is a religious man and Ms. Martìnez considers herself an agnostic. They have not discussed spiritual issues before. Nurse Martìnez feels uncomfortable praying with patients. During their visit, Jerry asks Nurse Martìnez to pray with him. What are options for Nurse Martìnez?

Prayer: Scenario 2


It depends on their own religious and spiritual beliefs, the congruence of their beliefs with those of the patient and family, and their relationship with the patient.

Many physicians may be willing to be present and stand silently while the patient prays, or to ask a chaplain to led the prayer and be present during that time if the patient wishes and if the clinician is comfortable with that.

(Lo, et.al. 2003)

How should healthcare professionals respond when such patients or their families ask them to pray for them or with them?


• Explain to patient that you are not comfortable leading a prayer but that you will sit with the patient and listen to his prayer.

• You could also say you will find a chaplain to lead the prayer and stay in the room but not participate so the patient does not feel abandoned.

• You can invite the patient to lead the prayer and participate in whatever way you are comfortable with. Its best to ask the patient to lead the prayer as most clinicians are not trained on how to lead prayers.

Ethics and Praying with Patients

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• Proselytizing is not acceptable in the physician-patient relationship.

• Conversation about spiritual needs is about a relationship of mutuality and freedom.

• If the clinician coerces a spiritual awakening, even subtly, it will not be a conversion based on the free assent of the patient or marked by the mutuality.

• The clinician might avoid discussion of spirituality because of the fear that their inquiries might be misinterpreted as proselytizing. By doing this appropriately it won’t be construed that way.

• Spiritual inquiry should be made politely and without presuppositions about the patient's response. (Sulmasy, 2009)

• Praying with patients ─ controversial area, general guidelines that hold respect for patient as primary, and being mindful that patients’ needs come before healthcare professional’s needs. (Lo, et.al. 2002, Post, et.al. 2000)

Ethics and Professional Boundaries


Mr. T is an 80 year old gentleman in the MICU with multi-organ failure and a poor prognosis. He is on the ventilator and CRRT without the expectation that he will improve. There is a family meeting to discuss this.

The patient is Russian Orthodox and so is his family. There religion has been very important to them. A Russian interpreter is used for the meeting. The interpreter knows the patient and family well and may overly involved.

Shortly after the meeting has begun, the son asks for people to raise their hands if they believe in Jesus Christ.

Later, the family states they believe the patient will get better if Dr. Prekker goes to the bedside and prays that his kidneys will be healed.

Case Scenario


44 year old African American Baptist man is admitted to

hospice after an out of hospital arrest. He was

resuscitated, but appears to have significant ongoing

cardiac issues. His kidneys are failing and he has

evidence of severe anoxic injury.

The wife says she needs a couple more days to handle all

this. She is appreciative of the hospice care, but asks for

one more intervention. She wonders if the hospice staff

will pray for her husband on admission and ongoing.

Case Scenario

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Ms. Williams has cirrhosis and a poor prognosis. Nurse Roberts included a spiritual assessment in his first meeting with Mrs. Williams.

Ms. Williams is a faithful Pentecostal and Nurse Roberts is a practicing Buddhist. During her second meeting Ms. Williams talks about her fears about dying and her intense despair that her life is ending. She has deep regrets about her alcoholism.

She has young children and desperately wants to live longer for them. Nurse Roberts was clearly affected in the visit by Ms. Williams’ despair. Nurse Roberts was a teenager when his mother died of cancer.

As Ms. Williams talks about her deep pain with this she pauses for a moment and looks up at Nurse Roberts and asks if he believes in the healing power of Jesus Christ.

What are options for his response?

Case Scenario


“Everything you do is spiritual work…”Bishop Desmond Tutu

“Spiritual Care is Everyone’s Business”...spiritual distress or a possible spiritual crisis...

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Transcript of “Spiritual Care is Everyone’s Business”...spiritual distress or a possible spiritual crisis...