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Whole Person Medicine Meeting the spiritual needs of patients

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Title: Whole Person Medicine Meeting the spiritual needs of patients


1
Whole Person MedicineMeeting the spiritual
needs of patients
  • Dr Michael Sheldon
  • BA, MB, BS, MBCS, FRCGP, MICGP, Dip Theol.

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The Complete GP
  • Country Practice
  • Academic teaching and research
  • Third world primary care development
  • Back to Academe
  • Finally inner city London practice

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Medical Models
  • Which model do we use in most Western countries?
  • Where did this model come from?
  • Whats good about it?
  • Whats wrong with it?
  • What other models are available?

10
Does Medicine have a philosophy?
  • Scientific Humanism
  • Psycho-somatic
  • Psycho-social-somatic
  • Post-modernism
  • Narrative medicine
  • Whole Person?

11
Thats great but what is the art and science of
medicine today?
  • Evidence Based Medicine
  • Is half of the equation
  • The individual patient is the other half
  • Who delivers this treatment and care?
  • The doctor is less than half of the equation
  • An integrated team of professionals
  • Plus the patient and carers as part of the team
  • What is the desired outcome?
  • What is good health?

12
Integrated health care
  • The whole-person approach seeks to integrate the
    best from the bio-medical approach with social
    science, psychology and other appropriate models
    of humanity, including spirituality.
  • Illness disease person

13
The current philosophy affects the treatment given
  • Obviously the illnesses diagnosed and the
    treatments offered depend to a large extent on
    the belief system underlying current medical
    practice.

14
Three key questions for today
  • What are the spiritual health care needs of
    patients?
  • Are these needs to be met within the health-care
    system?
  • If yes, who is going to meet these needs?

15
Anthropology
  • Anthropology is the science of man the study of
    humankind, cultures, beliefs and development.
  • What you believe about humanity lies at the heart
    of your belief system.
  • In Scientific Humanism, humans are regarded as
    highly evolved animals with attitude

16
What is a whole-person?
  • Physical being
  • Physical body
  • Physical needs, reflexes, basic desires
  • Biological level of functioning
  • Rational being
  • Thinking and reasoning
  • Feeling - emotions

17
What is a whole-person?
  • Social Being
  • Made for relationship
  • Spiritual being
  • Moral behaviour
  • Purpose and meaning
  • Belief system
  • Fully human
  • what does it mean to be human?

18
What is the spirit?
  • Old model of body, soul and spirit not helpful as
    leads to dualism
  • New model based on golf ball picture
  • Seamless functioning of the spirit in ALL human
    activity
  • Spirit connects us with God/Spirit World

19
Old Western dualistic picture
SPIRIT
Communion Worship
SOUL
Mind, intellect Emotions Will
BODY
Senses Physical body Sexuality
20
body
spirit
A new model of man - A golf ball
soul
21
I am an indivisible whole person
Will Emotions Desires Relationships
22
No Dualism Please
23
The Three Windows
  • Physical window
  • Normal medical model view of problems,
    translated into a whole-person approach
  • Psychological window
  • Normal psychological counselling viewpoint
    looking at mind, emotions and life events
  • Spiritual window
  • Looking at the spiritual and religious aspects of
    a persons health problems

24
7 stage model of the human spirit
  • 1 Self-image
  • 2 Relationships with others
  • 3 Relating to the world
  • 4 Moral and ethical practice
  • 5 Purpose and meaning in life
  • 6 Decisions, choices and Will
  • 7 Belief and faith

25
1 Self Image
  • Each person is a unique individual
  • View of themselves and self-understanding
  • Realistic view of strengths and weaknesses
  • Ability to love self and then others
  • Ability to grow and mature and acquire wisdom

26
2 Relationships with others
  • Family
  • Friends
  • Strangers
  • Quality of ability to relate, to give and receive
    love, to mend broken relationships and relate
    appropriately in different situations

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3 Relating to the world
  • Locus of control themselves or others?
  • Attitudes to work
  • Social responsibilities
  • Cultural influences
  • Creativity

28
4 Morality and ethical practice
  • Basis of their personal ethics
  • Are they based on external standards
  • Attitude to religious standards of morality
  • How aware are they of their conscience?
  • Attempts to act morally and consequences

29
5 Purpose and meaning
  • What hope do they have for the future?
  • Priorities in life
  • What fulfilments and disappointments have there
    been?
  • What are the desires of their heart?
  • What do they see as the purpose of life?

30
6 Decisions, choices and will
  • Making good decisions
  • This means understanding and making good choices
  • Will Power to follow good path
  • Perseverance
  • Facing challenges

31
7 Belief and Faith (Values)
  • What do they put their faith in (faith is belief
    in action)
  • Concentrate of health and healing rather than
    everything in life
  • Beliefs which were handed down to them
  • What do they actually believe in ?
  • How do they put their faith into practice?

32
Bio-medical model of medicine
  • Biological basis of body
  • Mind is dependent on brain activity
  • No dualism
  • Physical not metaphysical
  • Disease categories based on pathology
  • Laboratory results take precedence
  • Therapy usually physically based
  • Physicians responsibility

33
A post-modern wholistic model
  • Patients experience of illness
  • Importance of understanding health
  • Patient choices
  • Co-operation rather than paternalism
  • Doctor as advocate and support
  • Team work

34
Is spirituality part of a medical model?
  • Three responses
  • 1 Not at all, it may be important, but like the
    need for sewers and clean water, not part of a
    medical model. (Dualism)
  • 2 Yes it is an important part of the delivery of
    health care, involving equality, respect of
    patients beliefs, compassion etc.

35
The third option
  • The spirit plays an important part in both
    becoming ill and then in overcoming sickness, so
    it is an integral part of any successful model of
    care.
  • BUT this presents 3 big challenges
  • What is spirit and how does it act in health?
  • How do we assess spiritual illness?
  • When we understand more, how do we treat
    spiritual ill health?

36
Evidence that spirituality affects health
  • 1 NHS Policy about spiritual needs
  • 2 Proven benefits in health care
  • 3 Spiritual needs distinct from religious needs
  • 4 NICE guidelines on Palliative Care

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NHS Policy some examples
  • HSG (92)2, 1992
  • Meeting the spiritual needs of patients and
    staff
  • National Service Framework for Mental Health. DOH
    1999
  • NICE guidance on Palliative Care 2004 Spiritual
    Support Services
  • NSF for long term conditions. DOH 2005
  • Chief Nursing Officer Review of Mental Health
    Nursing DOH 2006

38
Publications
  • Handbook of religion and health Koening, HK et
    al 2001
  • Most studies in USA focussing on prayer and
    religion rather than spiritual needs.
  • Most research conducted in Palliative Medicine

39
Spiritual well-being end-of-life
  • McClain, Rosenfeld Breitbart. Effect of
    spiritual well-being on end-of-life despair in
    terminally-ill cancer patients. Lancet vol 361
    2003 pp 1603-1607.
  • Chibnall et al. Psycho-social-spiritual
    correlates of death distress in patients with
    life-threatening medical conditions. Palliative
    Medicine. 2003 16(4) 331-338.
  • McIllmurray et al. Psycho-social needs in cancer
    patients related to religious belief. Palliative
    Medicine. 2003. 17(1) 49-54.

40
Spiritual well-being end-of-life
  • Murray SA, Kendall et al Exploring the spiritual
    needs of people dying of lung cancer or heart
    failure a prospective qualitative interview
    study of patients and their carers. Palliative
    Medicine 2004 18 39-45
  • Hirai K, Morita T et al. Professionally perceived
    effectiveness of psychosocial interventions for
    existential suffering of terminally ill cancer
    patients. Palliative Medicine 2003 17 688-694

41
Spirituality End of Life
  • Therefore important to assess spiritual need
    provide adequate personal support and
    re-assurance to
  • patients
  • families
  • and staff
  • This can be demanding and we may need to
  • be clear about our beliefs and agendas

42
Spirituality End of Life
  • BUT
  • Spirituality can also be potentially damaging if
  • unsustained or unrealistic hope / loss of
    expectations
  • perceived punishment / lack of forgiveness
  • unresolved religious problems or imposed
    religious agenda
  • Important to assess existential need provide
    adequate personal support and re-assurance.
  • as per NICE guidance for supportive care .

43
Questions to consider
  • What distinction is important between
    spirituality and Religion?
  • Is spiritual care distinct from psychotherapy?
  • Should spiritual care be within the medical
    model?

44
Part 2 Spirituality and health care
  • How can the health care service meet patients
    spiritual needs?
  • Distinguish between spiritual and religious
    needs.
  • Is there a problem?

45
Assessment in whole-person care
46
An integrated assessment - physical
  • Physical window
  • Listening in a relaxed manner to the patients
    story
  • Build up a trusting relationship
  • Concentrate on the medical aspects
  • Picking up on verbal and non-verbal clues to
    explore further
  • Exploring their health beliefs
  • Appropriate examination and investigations

47
Taking a herstory
Traditional Present complaint Past
history Direct questioning Add on social to aid
discharge home
Whole-person Open up to patients
story Listen Observe patients belief
system Patient - led
48
Psycho/social assessment
  • Done by a counsellor
  • Usually takes 2 to 3 sessions
  • Patient gives permission to share findings with
    other team members
  • Report is integrated with the other physical and
    spiritual findings.
  • This assessment can be combined with the
    spiritual one

49
Counselling
  • Two basic tools
  • Life-lines
  • Significant people/support networks
  • Additional questionnaires and counselling tools
  • Well developed counselling skills
  • Broad theoretical base with knowledge of
  • A number of models of counselling (Person
    centred, TA, Gestalt, REBT)
  • Personality developmental models

50
Life-line
  • Timeline starting from birth.
  • Key episodes in their lives are represented by
    peaks and troughs, symbols, words and numbers.
  • Tell their story as they go along.


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Significant people / support networks
  • Patient draws a circle representing themselves.
  • Other circles are drawn at varying distances to
    represent significant people(ve and ve)

52
Summarising the information
  • Report
  • Engagement with the process
  • Strong emotions and goals
  • Significant issues and events
  • Significant beliefs and attitudes
  • Relationships
  • Self-perception
  • General conclusions and actions

53
Spiritual Assessment
  • About the human spirit and not just religious
    experience
  • Varies according to known beliefs of the person
  • Assessment and not therapy at this stage
  • Start with explanation of what the spirit is and
    does

54
Spiritual Assessment
  • Best undertaken by a chaplain or pastoral
    counsellor
  • Usually takes one or two sessions
  • Based on the 7 stage model
  • Exploring patients understandings, beliefs and
    actions.
  • Highlight problems in self image,
    relationships, world-view, ethical practice,
    hope, purpose, meaning, will and beliefs

55
What would whole-person care look like?
  • Major differences would be
  • 1 Integrated team includes patient
  • 2 Full assessment of person through three
    windows
  • 3 Diagnosis made in whole person terms
  • 4 Continuing assessment is dynamic
  • 5 Therapy will be multi-disciplinary but
    integrated

56
Principles of whole-person health
  • 1 Patient is central
  • 2 Importance of narrative
  • 3 The true story of the patients health
  • 4 Man whole greater than the sum of the parts
  • 5 Making a diagnosis
  • 6 Definition of health
  • 7 An integrated health care team
  • 8 Self-help by patient is encouraged
  • 9 Outcomes to be achieved
  • 10 Growth, development and maturity

57
1 Patient is central
  • Illness is the patients experience (distinguish
    from disease and sickness).
  • Each person is unique in physical and personal
    make-up.
  • Patient has great needs during illness to
    understand, to adapt, to cope and to survive in a
    positive way.
  • Its their health problem, they needs to help
    themselves, to help make decisions, to adapt
    their beliefs, fears and behaviour.

58
2 Importance of narrative
  • Life is a story
  • Do we know what our story is?
  • Can we change our story?
  • Narrative medicine helps the patient to make
    sense of their pain and suffering so that they
    can cope with it. It gives them the power to
    change their story to a healthier one.

59
Telling the story
  • Telling their story increases a persons
    understanding of their health.
  • Importance of language verbal, non-verbal and
    emotional.
  • The more times the story is told the nearer it
    can come to the truth.
  • The story is told within the context of a
    trusting relationship

60
3 Seeking the truth
  • As the person increases in their understanding of
    the truth about their health issues so they have
    the power to become healthier
  • They can then better adapt, cope, make
    allowances, take action, seek appropriate help,
    make better decisions etc.

61
Discovering the health story
  • The health story in adults is complicated.
  • You only discover your story as you tell it.
  • A story is told within the context of a
    relationship so different stories may be told to
    different people
  • The story will develop over time as it is
    re-told.
  • Assessing the truth of the story needs the
    combination of objective and subjective
    listening.
  • Accepting your health story is the first step
    towards changing it for a healthier one.
  • Healing and Health comes through walking in the
    truth

62
4 Model of a whole-person
  • We have a model of man as
  • Physical being
  • Social being
  • Rational being
  • Spiritual being
  • The whole is greater than the sum of the parts
  • You cannot separate off the different parts of a
    person and treat them separately.

63
5 Making a diagnosis
  • Bio-medical model
  • Diagnosis made in patho-physiological terms
  • Patient-centred model
  • Diagnosis made in terms of problems
  • Whole-person model
  • Diagnosis is layered on three levels

64
Whole-person diagnosis
  • Bio-Physical level
  • Signs and symptoms which are the end result of
    multiple internal and external factors
  • Causation level
  • Multi-factorial causations of the physical
    end-points of symptoms and signs
  • Patho-physiological
  • Psycho-somatic
  • Life events
  • Attitudes and beliefs
  • Person level

65
6 Definition of Health
  • A new definition of health is needed.
  • Health is a statement about the present moment
    which mainly indicates the functional ability of
    the person.
  • Health has as many multiple facets as the person
    does

66
NOT the definition of Health
  • NOT the absence of disease we all have diseases
  • NOT the absence of symptoms we all experience
    pain and suffering
  • NOT complete happiness and fulfilment

67
The real definition of Health
  • Strength to be human to live and die
  • Minimising morbidity and then -
  • Adapting to residual pathology
  • Coping with pain and suffering
  • Growing through difficulties
  • Learning compassion and kindness
  • Coming closer to inner peace - Shalom

68
The strength to be human
  • To be human
  • In relationship with self
  • In relationship with others
  • Free to mature and grow
  • Fulfil the purpose of our life
  • Health is not a state but a journey
  • Health is relative and not absolute
  • We become the people we are through our
    relationships with others

69
7 The health care team is integrated
  • The individual doctor being responsible for all
    of a patients health needs is no longer
    appropriate
  • BUT a collection of arrogant health care
    professionals, all fighting to guard their
    territory, and telling the patient different
    things
  • is worse than useless its dangerous

70
An integrated health care team
  • The patient needs to be at the centre of the team
  • An integrated team has
  • Skill mix
  • Respect for one another
  • Awareness of own limits of competence
  • Cooperate and support one another
  • Teach each other
  • This implies time to meet together, and good
    communications

71
8 Self-help by the patient is encouraged
  • Health is a life-long affair
  • The patient is the best person to conduct the
    orchestra BUT needs to be able to hand over the
    baton when too ill.
  • This requires
  • Courage and confidence
  • Knowledge and understanding
  • Good health seeking behaviour

72
9 Outcomes to be achieved (1)
  • Physical
  • Limitation of harmful effects of diseases
  • Cure wherever possible
  • Limitation of consequences of diseases
  • Maximise physical functioning
  • Reduce morbidity
  • Prolong life and a good quality of life
  • Psycho-social
  • Spiritual

73
9 Outcomes to be achieved (2)
  • Psycho-social
  • Relief from psychological pain
  • Improved relationships
  • Greater understanding of own health
  • Ability to take preventative action
  • Ability to adapt to a healthier life-style

74
9 Outcomes to be achieved (3)
  • Spiritual
  • Personal growth
  • Increasing compassion and relationships
  • Peace at heart (relief from anxieties)
  • Hope for the future

75
10 Maturing and developing
  • To be healthy is to have greater control over
    health related decisions
  • We can learn and so mature in our health
  • In different stages of our lives different
    aspects of health become more important.
  • A healthy life ends in a healthy death

76
So how can we be part of the answer?
  • What do we do?
  • Medical practice
  • Counselling
  • Pastoring/Chaplaincy
  • Social work
  • Do we just acknowledge each other and make
    referrals?
  • What does it mean to become integrated, whole
    person therapists?

77
Part 3 Who provides spiritual care?
  • Up to now, any spiritual needs have been met by a
    chaplain.
  • Is there a problem with this?
  • Christian denominations
  • Other religions
  • Non-religious
  • Distinguish between spiritual and religious needs

78
Religious needs
  • Chaplaincy will continue to provide these both
    within and outside health care.
  • Instead of Anglican chaplains, most will need to
    be Muslims or Pentecostal pastors.

79
Core spiritual needs
  • Going back to our model of the human spirit
    everything apart from formal religious activity
  • Much of this enters into everyday medical
    practice.
  • There is a place for specialist providers (as in
    counselling)

80
7 stage model of the human spirit
  • 1 Self-image
  • 2 Relationships with others
  • 3 Relating to the world
  • 4 Moral and ethical practice
  • 5 Purpose and meaning in life
  • 6 Decisions, choices and Will
  • 7 Belief and faith

81
Spiritual Care Advisors (SCA)
  • To provide a core level of Spiritual Care
    provision, integrated with other health care
    professionals, and able to refer on to a wide
    variety of religious chaplains as required.

82
Karis Medical Centre
My job description states that my purpose is to
provide spiritual care for patients and staff.
Anyone may be referred, regardless of faith, and
are referred by GPs, consultants, nurses, or
self-referral. The reasons for referral vary and
include working with the bereaved and dying,
patients coming to terms with change, illness,
trauma, and difficult decisions. Some come with
spiritual issues guilt, forgiveness, wanting
to find God, or looking for meaning. Patients of
different faiths, who already have a faith
structure, are often open to receiving strength
from God in different ways. I have listened and
prayed with Muslims, Sikhs, Buddhists, Hindus,
and people of other faiths, and no faith. Annie
Hughes (Chaplain now SCA) http//www.wphtrust.c
om/spirit04.html
83
Ross Bryson
  • GPs at Karis in Birmingham
  • Spiritual needs in General Practice
  • http//www.wphtrust.com/spirit02.html

84
Spirituality the new Religion
  • Rob Merchant at Stafford University
  • http//www.wphtrust.com/spirit03.html

85
BUT
  • All of us need to be Whole Person Doctors and
    practitioners.
  • How much does the doctor do, and how much is
    referred?
  • I believe it is the same as with counselling.

86
Guiding principles
  • Give love
  • Provide hope
  • Exercise faith
  • Within an integrated team
  • Having a practical theology
  • Practiced with humility
  • Available to all

87
3 simple rules
  • Be patient centred
  • Be integrated
  • Be committed

88
A good doctor
  1. Knows the science (and art) of medicine
  2. Knowledge
  3. Understanding
  4. Wisdom
  5. Respects the patient
  6. Care, concern
  7. Seeks to apply best practice
  8. Practices in a whole person model of medical
    care

89
Internet Resources
  • Whole Person Health Trust
  • www.wphtrust.com
  • WholeCare
  • www.wholecare.org
  • Mike Sheldon
  • www.drmikesheldon.com
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