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Religious and Spiritual Issues The Palliative Response


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Title: Religious and Spiritual Issues The Palliative Response

Religious and Spiritual Issues The Palliative
  • F. Amos Bailey, M.D.

Religion and Spiritualityat Lifes End
  • Spiritual and religious concerns may develop or
    intensify at Lifes End
  • Many patients are thinking about these issues in
    relationship to their health
  • Many patients welcome an opportunity to talk
    about religious and spiritual issues as they
    relate to their current life experience

Barriers to AddressingReligious and Spiritual
  • Many persons at Lifes End have not expressed
    their existential concerns for fear of upsetting
    families and friends
  • Many physicians feel unskilled, unprepared and
    uncomfortable talking to patients about religious
    and spiritual concerns

Getting Started
  • Ask open ended questions
  • Use a format
  • Listen and respond empathically
  • Be familiar with resources
  • Pastoral Care
  • Social Work and counseling
  • Communities of faith

The FICA Format
  • F Faith
  • I Importance
  • C Community
  • A Address
  • Christina M. Puchalski, M.D., M.S.
  • The George Washington Institute for Spirituality
    and Health

  • Do you consider yourself a spiritual person?
  • Is faith important to you?
  • Most patients can answer this kind of question
  • Include question in social history
  • Normalize discussion of faith as part of routine
    and not a topic indicating that patient is
    imminently dying

  • Is your faith important in your life at this
  • Have you been able to take comfort
  • from your faith?
  • May reveal sources of strength and support
  • May guide physician in assisting patient to
    maintain sources of support

  • Are you part of a spiritual
  • or faith community?
  • May reveal a source of support
  • May reveal that individual has become isolated
    from faith community
  • Frequent occurrence when chronic illness
  • prevents participation in faith community
  • Physician may be able to foster re-connection

  • How can I address and respect
  • these issues in your care?
  • Patient may have important beliefs, practices and
    rituals that are not part of your tradition
  • Understanding patients tradition early on
    allows the physician to be sensitive to needs

Patients Response
  • Many patients
  • Speak openly
  • Are grateful to physician for asking about this
    important part of life
  • Express no specific concerns or needs

When Patient Voices Concern
  • Respond with
  • Open-ended questions
  • Comments to normalize the concern
  • Help me understand what you mean
  • Many people with serious illnesses ask such
  • That sounds scary/troubling to me, too
  • Do you have any thoughts about why this is
    happening to you (your family)?
  • How does this make you feel?

Discussion GuidelineShare vs. Fix
  • Do
  • Share patients wondering and questioning
  • Share in what it is like to be human and to face
    what is at Lifes End
  • Do Not
  • Do not try to resolve (fix) the patients problem
  • Do not try to answer unanswerable questions

Discussion GuidelineFollow vs. Lead
  • Do
  • Stay within physicians role and expertise
  • Be guided by patients own search
  • Do Not
  • Lifes End is not a time to proselytize
  • Lifes End is not a time to try to convert a
    vulnerable individual
  • Lifes End is not a time to impose personal
    religious or spiritual beliefs

Discussion GuidelineSupport vs. Reassure
  • Do
  • Allow time and permission for people to express
  • Develop comfort with tears and range of feelings
  • Do Not
  • Do not offer premature or inappropriate
  • Do not be a phony

Discussion GuidelineQuestions about Physicians
  • Answer simply
  • I would like to keep the focus on you
  • rather than me
  • I am a person of faith
  • Avoid a religious debate
  • Most patients are grateful that physician
  • is interested in this important part of who they

Steps of Palliative Response Assess
  • For patients with life- threatening
  • and life-limiting illness
  • Clarify sources of hope and meaning
  • Identify Goals of Care
  • Maintain hope
  • Honor preferences at Lifes End

Steps of Palliative ResponseSupport
  • Mobilize resources
  • Healthcare team
  • Patients community and community at large
  • Patients spiritual/religious practice
  • Solace
  • Meaning
  • Hope
  • Connection

Steps of Palliative Response Self-Care for the
  • Develop healthy personal responses to
    experiencing the repeated loss of death
  • Self-monitor and seek assistance as needed
  • Depression
  • Substance abuse
  • Burn out

Spiritual Distress The Palliative Response
  • F. Amos Bailey, M.D.

Spiritual QuestioningAt Lifes End
  • Common
  • Most patients have been thinking about spiritual
    issues and are open to discussion with physician
  • Can be a major source of distress
  • Existential
  • Why things happen
  • Not answered by science and medicine, which
    address how things happen
  • Extends beyond formal religious beliefs

Fostering Transcendence
  • Transcendence is a state of meaning and hope
    providing connection with family and others
  • across life-changing events
  • ultimately across even death itself
  • Individuals at Lifes End often struggle
  • to maintain connections
  • to achieve a sense of transcendence

Examples of Transcendence
  • If a member of your family has died
  • do you still consider this person a part of
  • your family?
  • If so, you have achieved some degree of
    transcendence over death, since you are
    maintaining a connection with the person
  • who has died

Life as Defined by Meaning
  • Examples of things that give life meaning
  • Family
  • Children
  • Religious faith
  • Career
  • Patriotism and country
  • Friends and community

Life as Defined by Meaning
  • The list continues
  • Material possessions
  • Pets
  • Hobbies
  • Causes, civic clubs, party affiliations
  • The arts - music, literature, visual arts
  • Nature

Lifes End Often Threatens Our Sources of Meaning
  • Everyone wants to go to heaven,
  • but no one wants to die
  • to get there.
  • - H.L. Mencken

Changing Relationship to Sources of Meaning
  • The Patients Struggle
  • To find meaning when can no longer maintain roles
    that gave life meaning
  • May attempt to maintain meaningful roles beyond
    ability to perform them
  • The Palliative Response
  • Reframe and explore sources of meaning
  • Strengthen, maintain, develop connections

Suffering withLoss of Sources of Meaning
  • Suffering
  • The state of severe distress
  • associated with events
  • that threaten the intactness
  • of a person
  • - E. Cassell, 1991

Spiritual/Existential Distress The Palliative
  • Ask and Listen
  • Accept and normalize
  • Acknowledge spiritual distress
  • Confirm distress as part of suffering at Lifes
  • Explore
  • Be willing and available to discuss spiritual
  • Help patient incorporate this aspect of
    personhood into current life and illness

Rx for Spiritual Distress Tell the Truth
  • Offer honest assessment of probable prognosis and
    course of illness
  • Helps patient/family plan and prioritize
  • Attempting to shield people from harsh reality
    may result in their inability to accomplish
    important work of Lifes End

Rx for Spiritual Distress Help Patient Prioritize
  • Which is more important?
  • Staying in town to take chemotherapy for stage IV
    lung cancer?
  • or
  • Visiting a daughter in another state who has
    just delivered a new grandchild?
  • Tuesdays with Morrie shows how an individual may
    actively live at Lifes End

Rx for Spiritual Distress Respond to All Suffering
  • Excellent Symptom Control
  • Frees time and energy to work out issues
  • Community Resources
  • Assistance to maintain efficacy at Lifes End
    (e.g., hospice)
  • Pastoral Counseling
  • Refer to Pastoral Care and/or faith community as
    appropriate for each individual

Rx for Spiritual DistressReframe Helping
  • Help as Support
  • Support with truth and honesty
  • Support to live life fully
  • Support to live with joy, expectation, hope

Rx for Spiritual DistressReframe Helping
  • Help as Support Vs. Fix
  • Not within our power resolve spiritual issues for
  • Must support people to find their way

RX for Spiritual DistressHelp Patient Leave
  • Write letters and make videos
  • (especially for children too young to remember)
  • Tell and write stories
  • Make scrapbooks
  • Distribute personal belongings, mementos or

RX for Spiritual DistressHelp Patient Make
  • Celebrate birthdays and holidays
  • out of season
  • Family reunions and get-togethers
  • Physician can assist with time off from work for

Spiritual DistressThe Palliative Response
  • Support process of finding meaning and achieving
    transcendence at Lifes End
  • Process is unique for each patient and family
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