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Monthly Archives: June 2014

Illness and Reconciliation

In a previous blog post, I discussed the crucial role that relationships and community play in human flourishing. Indeed, our need to connect with each is so profound that conflict in our most important relationships can be a source of great distress. This is particularly true when we endure illness. As Daniel Sulmasy writes,

“As their bodies bend and break, dying patients are somehow reminded of the brokenness in their relationships with others and of their deep need for the healing of reconciliation.”[1]

In David Schenek’s book Healers, a physician tells the story of

“a mid-80s lady admitted to our inpatient unit with advanced GI cancer. There was no treatment, and she didn’t want it anyway. She progressed as expected, and she had stopped taking food or liquids. And then she lapsed into an actively dying phase.”

 

The physician explained that

“I had a very frank talk with the son and grandson, and they wanted to be at the bedside when she takes her last breath. So two, three days passed—four days come, five days passed. . . This went on a week, a week and a half, then two weeks. Defying physiology. We were at a month of not having so much as a drop of water, and yet her heart was beating, barely. No palpable blood pressure. But if watched, every fifteen seconds her chest rose. She was still breathing. . . . Then a friend of the family came in. She nudged me and said, ‘What’s going on?’ I said ‘I don’t know. She won’t die. Maybe you can help.’ She said, ‘You know she has a daughter. They parted 25 years ago. They’d had some disagreements, and then parted, and it wasn’t at all favorable.’ I wondered whether they could resolve it, even though they have not spoken to each other in 25 years, and I said. ‘Do you have any way of getting ahold of her?’ She replied, ‘I haven’t had any contact with her in maybe 10 years, but here is the number I have.’ So I walked in the room, and I called from the bedside phone. A lady answered the phone. I said, ‘This is the doctor from hospice. Is this so-and-so?’ ‘Yes.” ‘I am so glad to be able to get you. I just want you to know that I have been taking care of you mom. He developed cancer some months ago, and she has been declining every since. She is very close to the end of her life now. I just found out that you two had parted some years ago, perhaps not on the best of terms. I know in those circumstances some things can get left unsaid. Some things you might want to tell her and talk to her about.’ She said, ‘Well, yeah.’ I said, ‘You need to understand that she is very close to the end of life. She is not responsive at all. But I am going to put the phone up to her ear to give you a chance just to say whatever you think you might want to say to her. I don’t know if she can physically hear you. But I think she will know you are here.’ So I put the phone down by the patient’s ear. I can hear chattering—kind of wanted a speaker phone. What do you say to somebody after twenty-five years? . . After about five minutes, I see tears rolling down this lady’s face. It was a very powerful moment—because logically, where is the substrate for this? She has no water in her body. . . . So the tears were streaming down her face. I heard the chattering stop, and I took the phone back and described to her daughter what I just saw. ‘I want you to know that she heard what you said, and that her tears flowed. This is a very healing process for her. I thank you very much.’ I hung up the phone—and five minutes later she was dead.”[2]

The physician concluded that “clearly there something she needed to complete in her journey toward health. She was not going to die until that was done.”

 

[1] Sulmasy, D. Spiritual Issues in the Care of Dying Patients, JAMA, Sept. 20, 2006—Vol 296, No 11

[2] Schenek, David and Larry Churchill. (2012) Healers, Oxford University Press

 
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Posted by on June 20, 2014 in Uncategorized

 

How Should Physicians Address Spiritual Issues?

In my previous blog post, I argued that physicians and other practitioners have an ethical imperative to address patients’ spirituality. This raises the question of how they are to do so. It is to this topic that I will now turn.

 

An initial question is the nature of the practitioner’s role in addressing patients’ spiritual needs. Dr. Harold Koenig, a leading authority of the subject of spirituality and health care, states the practitioner’s role is to take a spiritual history and orchestrate resources to meet those needs.[1]

 

In a spiritual history, practitioners ask patients about their spirituality and their spiritual needs. Koenig writes that “taking a brief spiritual history if necessary in order to 1) understand the role that spiritual beliefs play in the patient’s coping with illness, 2) understand how spiritual beliefs may be a source of stress or distress for patients, 3) become familiar with the patient’s religious beliefs as they relate to decisions about medical care, 4) become aware of how much those medical decisions are likely to receive from the patient’s social network (which is often their faith community), and 5) identify spiritual needs that could affect the patient’s health outcomes or use of health services.” He also writes that taking a spiritual history “sends a message that this aspect of the patient’s identity is recognized and respected by the health practitioner and that the patient is valued as a whole person.” [2]

 

Koenig suggest the best times to take a spiritual history are “1) when taking the medical history during a new patient evaluation, 2) when taking the medical history while admitting a patient to the hospital, nursing home, hospice, or palliative care setting, 3) when doing a health maintenance visit as part of a well-person evaluation, and 4) whenever the medical situation calls for it.”[3]

 

In clinical situations that are rushed, Koenig suggest the following question: “Do you have any spiritual needs or concerns related to your health?” This acknowledges to the patient that this is an area that the heath practitioner is concerned about and opens the door to future conversations.[4] Christina Puchalski has developed an instrument called FICA to facilitate taking a more in-depth spiritual history.[5] F stand for faith and belief.This includes questions such as, “Do you consider yourself spiritual? What gives your life meaning? Do you have spiritual beliefs that help you cope with stress?” I stands for importance of the person’s spirituality. This can be assessed this by asking questions such as”What importance does your spirituality or your beliefs have in our life? Have your beliefs influenced how you take care of yourself in this illness? C stands for the patient’s community support. To assess this, practitioners can ask: “Are you part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love or who are important to you?” A stands for how practitioners can address the patient’s spirituality.Puchalski recommends a question such as “How would you like me, your healthcare provider, to address these spirituality issues in your healthcare?”

 

After taking a spiritual history, a clinician’s second role can be to orchestrate spiritual resources for the patient.   This includes, most importantly, referring patients to spiritual care professionals such as chaplains and clergy. In addition, based on the patient’s wishes, practitioners can work with spiritual professionals to provide helpful spiritual support such as inspiring music and reading, meditation, and support groups

 

When taking a spiritual history, it is important that practitioners know their limits and be clear about certain boundaries. First, they must respect patients’ privacy. If they don’t want to talk about their spirituality, practitioners need to honor that. Secondly, practitioners must be vigilant about not imposing their beliefs on patients since doing so would be abusing their authority in an especially vulnerable time in patients’ lives. Finally, a spiritual history is not the same as an in-depth spiritual assessment. For intensive spiritual counseling and spiritual crisis, practitioners should refer patients to chaplains who have skills and training in this realm.

 

[1] Koenig, Harold. (2013) Spirituality in Patient Care: Why, How, When, and What. Templeton Press

[2] Koenig, Harold. (2013) Spirituality in Patient Care: Why, How, When, and What. , Templeton Press

[3] Koenig, Harold. (2013) Spirituality in Patient Care: Why, How, When, and What. , Templeton Press

[4] Koenig, Harold. (2013) Spirituality in Patient Care: Why, How, When, and What. , Templeton Press

[5] Puchalski, C. Taking a Spiritual History Allows Clinicians to Understand Patients More Fully. Journal of Palliative Medicine 3 (2000): 129-37

 
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Posted by on June 11, 2014 in Uncategorized

 
 
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