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SPIRITUALITY IN MEDICINE AND HEALTH CARE

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Title: SPIRITUALITY IN MEDICINE AND HEALTH CARE


1
SPIRITUALITY IN MEDICINE AND HEALTH CARE
  • Thomas R. McCormick, D.Min. Department of Medical
    History and Ethics
  • U.W. School of Medicine

2
Health Care in Early Times Medicine Religion
  • Few interventions were possible
  • Application of herbal medicines
  • Religious concepts of cause and effect included
  • punishment for sins
  • indwelling of evil spirits
  • separation of the patient from God

3
Ancient medicine religion
  • 3000 BCE, early written documents show Egyptian
    Mesopotamian healers were priests with
    magico-religious concepts.
  • 5th century BCE in Greek medicine, Hippocrates
    begins a more scientific approach, including
    natural causes.
  • By the 3rd century BCE, the Romans were
    influenced by the Greeks cult of Asclepius.

4
Greece The Temple of Asclepius
5
Two views of health care HYGEIA ASCLEPIUS
  • HYGEIA health is the natural order of things,
    fostered by prudent choices and wise living, the
    goal is to find balance between a sound body, a
    sane mind, and a calm spirit--medicine should
    discover teach the natural laws, so we might
    cooperate.
  • ASCLEPIUS the chief role of medicine is to treat
    disease, the heroic intervenor.

6
Nursing care and natural healing processes grow
from the approach of Hygeia
7
Interventive medicine has its roots in Aescleplius
8
Theoretical Models Emerge
  • Biomedical model in the 19th century
  • Psychobiological model--after Freud
  • emotional states contribute to illness
  • relaxation response may reverse illness
  • 20th century bio-psycho-social model
  • 1977, George Engel
  • Life events lifestyles affect health

9
Medicine in the Christian era
  • Healings were attributed to Jesus, who sometimes
    linked healing with the power to forgive sins.
  • The Parable of the Good Samaritan became a
    formative influence on medicine.
  • By the 5th century AD, virtually all physicians
    were drawn from clergy in the monastic
    communities. (Kuhn, Psychiatric Medicine Vol. 6
    No. 2)

10
Secular Medicine
  • Secular medicine emerged in the late middle ages,
    but was still under control of church.
  • 1140 AD church granted first medical licenses,
    conditions, revocations.
  • 1789, the French Revolution, marked the break
    down of religious control over medicine.
  • Cartesian separation of mind and body

11
Separation of Medicine from Religion
  • As science began to discover the etiology of
    diseases, former religious explanations no longer
    held.
  • Science and medicine began to distance themselves
    from religion.
  • God of the gaps. . .

12
A Current view of health care A
BIO-PSHYO-SOC-SPIRITUAL MODEL
  • Scientific view of pathophysiology
  • Respect for the psychological
  • Perception of the social environment
  • Attention to the spiritual distress and the
    spiritual resources of the patient
  • Described by Division of Behavioral Medicine at
    the University of Louisville School of Medicine

13
The Spiritual
  • The patient is not just body and mind, but a
    spiritual being. --P. Tournier
  • Spirituality involves the personal quest for
    meaning purpose in life and relates to the
    inner essence of the self
  • Spirituality the sense of harmonious
    inter-connectedness with self, others, nature and
    an Ultimate Other (the integrating factor)

14
Bio-Psycho-Social-Spiritual
  • Although Schools of Medicine have been slower to
    recognize appropriate this model,
  • The Nursing Profession has long recognized the
    spiritual aspects of patient care,
  • Chaplains and clergy have often assisted patients
    with the spiritual aspects of illness and the
    search for meaning purpose.

15
Religion is seen by some to be an impediment to
medicine
  • Jehovahs Witness who refuses a life saving blood
    transfusion
  • Christian Scientist who refuses allopathic health
    care in favor of a Reader
  • Various religions that may decry contraception or
    forbid pregnancy termination.

16
Great Diversity of Religions
  • Especially in the USA, there is a great number of
    religions so that one can hardly speak of
    religion in general, without making reference to
    a particular religion.
  • It is too much to expect of a physician that s/he
    be a student of religions, in addition to
    medicine.
  • And, what if the physician is non-religious?

17
Question Should physicians avoid talking about
religion or spirituality with patients?
  • A. yes, because a physician can not be expected
    to be conversant with all religions.
  • B. yes,because the physician may be an atheist or
    non-believer.
  • C. yes, that would be an unethical intrusion into
    the privacy of the patient.
  • D. no, particularly when there are indications of
    patient interest or need.

18
Distinction Between Religion and Spirituality
  • Answer D no, there are indications. . .
  • A particular religion or faith community is one
    road to spiritual awareness and growth.
  • Spirituality in this sense, may transcend a
    particular religion, and resides in that
    universal human space where individuals seek to
    understand the meaning purpose of their lives,
    and what they most value.
  • Spirituality implies self-conscious living.

19
Spirituality
  • Thousands of alcoholic patients who found little
    help from traditional medicine were able to
    become sober and remain abstinent by relying on
    a power greater than themselves and through the
    support of a twelve step program.

20
A Shift of focus from the biomedical to the
psycho-social-spiritual
  • For many patients facing serious illness or the
    end of life, the focus shifts from the biomedical
    to the spiritual.
  • When symptom management and pain control are
    appropriately provided, patients are set free to
    address their final agenda.
  • This may be seen as the last chapter in ones
    spiritual journey. (Mary Levine)

21
(No Transcript)
22
R.M. Mack, MD Occasional notes Lessons learned
from living with cancer. NEJM 3111642, 1984
  • Simply accepting this prognosis was completely
    intolerable for me. I felt I was not yet ready to
    be finished. I still had not seen and done and
    shared with the people I love. . . I could sit
    back and let my disease and my treatment take
    their course, or I could pause and look at my
    life and ask, What are my priorities?

23
Dr. Mack, a Seattle surgeons reflections. . .
  • How do I want to spend the time that is left? I
    began to focus on choosing to do things every day
    that promote laughter, joy, and satisfaction. . .
    I began to make choices to do the things that
    felt good to me.
  • One person, opening to the meaning of life in the
    face of imminent death. . .

24
What do patients nearing the end of life say?
  • fear of uncontrolled pain neg. symptoms
  • worry about becoming a burden on family
  • concern about financial costs of care
  • uncertainty about the dying process
  • anxious anticipation of surrendering the known
    for the unknown
  • Concern for the unfinished business of life

25
Patients raise spiritual questions
  • Who am I, now that I am sick or dying?
  • What is the meaning of my life when I am no
    longer productive and independent?
  • Where am I connected to others who value me and
    see me as a person of worth?
  • What is my relationship to the Ultimate?
  • What do I now value most in the time that is left
    to me?

26
Epictetus a question of meaning
  • It is not as important what happens to a person,
    as to the meaning that the person gives to what
    has happened.
  • Assignment of meaning is a spiritual function.

27
Lipowski how we view illness
  • Illness a challenge
  • Illness as enemy
  • Illness as punishment
  • Illness as weakness
  • Illness as relief
  • Illness as strategy
  • Illness as having value

28
Meaning is related to purpose, therefore
questions might be
  • Why do you think you have become ill now
  • Has this illness changed any attitudes you might
    have about the future?
  • Is there anything more important to you than
    regaining your health?
  • How does this illness interfere with your goals
    in life?
  • What purpose is served in regaining health?

29
Where does spirituality fit?
  • Patients may have coping mechanisms related to
    their belief
  • May be supported by a community of caring others.
  • May feel themselves to be in the company of the
    Divine.

30
Mans Search for Meaning Victor Frankl
  • Sometimes external circumstances in our life
    situation are beyond our control.
  • Frankl maintains that the attitude we choose to
    take toward our life situation is within our
    control.
  • The spiritual journey relates to our inner
    struggle to shape our attitude toward illness and
    even death itself.

31
Frankl the will to meaning. . .
  • Aesthetic one may find meaning in the beauty of
    the sunrise, the sunset, the symphony. . .
  • Relational one may find meaning in
    relationships, be they family or friends
  • Creative one may find meaning in creative
    activity, work, profession, homemaking
  • Attitudinal one may find meaning in shaping the
    attitude taken toward illness or death.

32
What Primary Care Physicians Claim
  • 50-75 of primary care patients present with
    psychosomatic problems or problems related to the
    stresses of life, for which there is no medical
    answer.
  • Problems of somatization complaints or symptoms
    without a precipitating medical or organic
    cause.
  • Problems of depression and anxiety.
  • Spiritual issues arise in primary care!

33
A Spiritual Inventory might include questions
about
  • patients perception of what is going on
  • what gives meaning and purpose to life
  • how, or whether belief and faith enter in
  • love by whom do you feel loved-accepted?
  • forgiveness--need it? grant it to others?
  • prayer--for what do you pray?
  • quiet and meditation--what is off center?
  • worship--what restores you to center?

34
Taking a spiritual history. . .
  • S Spiritual Belief System
  • P Personal Spirituality
  • I Integration in a Spiritual Community
  • R Ritualized Practices and Restrictions
  • I Implications for Health Care
  • T Terminal Events Planning (advance directives,
    DNR wishes, DPOA etc..)

35
S Spiritual Belief System
  • How would you describe your spiritual belief
    system?
  • Do you find comfort in this current illness from
    your beliefs and practices?
  • What in particular is helpful to you?
  • Internal private belief system
  • External participant in a community

36
P Personal Spirituality
  • What are your most important personal beliefs?
  • The professional need not believe what the
    patient believes, but must acknowledge that the
    patients beliefs are important.
  • An individual may have a profound spirituality,
    but may not be overtly religious.

37
I Integration in a Spiritual Community
  • National Institute for Healthcare Research report
    studies claiming
  • regular church attenders live longer.
  • risk of diastolic hypertension ranked 40 lower
    among people who actively participate in
    spiritual practices.
  • 93 female cancer patients said their beliefs
    helped them sustain hope.

38
R Ritualized Practices and Restrictions
  • Patients may especially value the rituals of
    their faith community
  • Baptism for a critically ill newborn
  • Anointing (last rites) of a dying person
  • Scripture
  • Prayer
  • Communion, or Eucharist Service

39
I Implications for Health Care
  • What does the patient understand about his/her
    medical condition prognosis?
  • What are the patients beliefs about suffering,
    about pain control?
  • Does the patient understand the principle of
    double effect?
  • What are the patients goals in the time that is
    left?

40
T Terminal Events Planning
  • Does the patient have an advance directive?
  • Attorney in fact Durable Power of Atty.?
  • Curative - Palliative -Comfort Care?
  • How does the patient view dying?
  • Is it the final end?
  • Is it the beginning of life eternal?
  • What is the patients final agenda?

41
Mentoring, and teaching by example, is perhaps
the most effective approach.
42
UWSOM is featured for teaching end of life care
to medical students
43
Students in preceptorships or RUOPs in the
pre-clinical years, or in the clerkships, may
gain a deeper appreciation of the spiritual
needs and resources of patients.
Hospice Student
44
Different cultures may have ceremonies and
rituals of special importance in coping with
illness or preparing for death.(Navaho)
45
Choice in Dying Study
  • Education in spirituality should be
    interdisciplinary (med/nrsng/pastoral), expose
    students to dying patients, and to caregiver
    mentors who model ideal knowledge, skills and
    attitudes.
  • Preclinical years patient interview, hospice
    elective, preceptorships
  • Clinical years Clerkships, Hospice rotation,
    Simulated Patient Interviews, Patient care.

46
Persons with major illness or debilitating
disease find strength and support from religious
or spiritual sources.
  • Measures of religious coping can predict outcomes
    of life crises, vs. non-religious.
  • Use of religious coping skills by older patients
    is associated with diminished risk of depression,
    or of recovery from depr.
  • Spiritual intervention needs a (CPT) code.

47
Recent surveys by NIHR find
  • 43 of physicians pray for their patients,
  • 90 of doctors at the American Academy of Family
    Physicians 1996 meeting agreed that a patients
    spiritual beliefs can be helpful in his or her
    medical treatment
  • 58 have actively pursued information on
    spirituality and healing.

48
5 requirements for physicians to meet the
spiritual needs of patient
  • Be trustworthy,
  • treat the patient as a person,
  • be kind,
  • maintain hope,
  • assist the patient in determining what it means
    to live. Foster,DW in Religion and Medicine the
    physicians perspective. Fortress Press, 1982

49
American Psychiatric Association
  • Physicians should maintain respect for their
    patients beliefs. It is useful for physicians
    to obtain information on the religious or
    ideologic orientation and beliefs of their
    patients. . .
  • Physicians should not impose their own religious,
    anti-religious, or ideologic systems of belief on
    their patients. . .

50
Spirituality in Medicine (1 credit) UW School of
Medicine
  • A multidisciplinary med school elective
  • Provides a framework for students to communicate
    with patients about the patients spiritual
    connections
  • Allows each student to make visitations with a
    hospital chaplain--seeing patients with serious
    illness or life threatening illness

51
Goals of this Course
  • Heighten awareness and enhance the role of
    spirituality in our own lives
  • Foster respect and appreciation for the diversity
    of patient beliefs and values
  • Strengthen commitment to relationship- centered
    approach to health care
  • Develop a better understanding of the role of the
    hospital chaplain and clergy as partners in
    caring for patients.

52
Spirituality Education at the UW
  • Year 1 ICM, Human Behavior
  • Year 2 ICM II, Terminal Illness Seminar
  • Electives
  • SPIRITUALITY IN HEALTH CARE
  • HOSPICE ELECTIVE
  • ETHICAL ISSUES SURROUNDING DYING
  • PRECEPTORSHIPS RUOP
  • INDEPENDENT RESEARCH PROJECTS

53
Contact Information
  • Dr. Thomas R. McCormick
  • email mccormic_at_u.washington.edu
  • http//eduserv.hscer.washingnton.edu/bioethics/
  • Box 357120
  • School of Medicine
  • University of Washington
  • Seattle, WA 98195

54
(No Transcript)
55
End of Life Consensus Coalition
  • GOALS
  • Improve spirituality death education in the
    training of professionals
  • Improve access to Hospice care for dying
    patients
  • Provide community education, empowering patients
    and their families to make good choices as the
    end of life approaches

56
Curricular Suggestions
  • Create an end of life education theme committee
  • Discover what is being taught now
  • And what is missing in the curriculum
  • Utilize PBL (Problem Based Learning)
  • Use OSCEs
  • Videotaped Review Sessions on EOL care

57
Case examples of spiritual issues
  • a disturbing visit from the daughter
  • the professors inoperable cancer
  • medical student with an astrocytoma
  • what will my dying be like?
  • a patients lament, please help my parents
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