"Psychospiritual elements of Palliative Care: educational and clinical implications"'

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"Psycho-spiritual elements of Palliative Care
educational and clinical implications". 

• Peter Ravenscroft
• Professor of Palliative Care
• University of Newcastle, Australia

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The pain is what the body experiences, but
suffering is the experience of persons Cassell
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Audience

• What do you think psycho-spiritual issues are?
• How do you tackle psycho-spiritual problems that
  patients have in your practice?

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The elements of psycho-spirituality

• Psycho-spirituality comprises two elements
• The psychological component, particularly the
  psychological and emotional stress evident in
  some people who are facing a crisis e.g. Death
• I do not include psychoses in this category
• and
• The Spiritual component is a quality that goes
  beyond religious affiliation, that strives for
  inspiration, reverence, awe, meaning and purpose,
  even in those who do not want to believe in any
  God.

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Holistic Care
Physical symptoms
Cecily Saunders
Pain
Cultural
Total
Suffering
Psychological
Spiritual
Social
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Losses in dying
Loss of control/ Loss of self-worth/ Loss of
value/ Loss of friendships/ Loss of physical
appearance/ Loss of Security/ Loss of
psychological integrity /Loss of sexual
attractiveness/Loss of interest in activities/
Loss of family/ Loss of future/ Loss of
achievements/ Loss of autonomy/ Loss of
independence/ Loss of expression of spirituality/
Loss of role in community
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Losses bring challenges

• To face the ending of physical life
• To complete unfinished business
• To express feeling and emotions
• To find new pleasures in life
• To say goodbyes
• To deal with the issues of spirituality and God
• To heal relationships

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A caveat...

• Dealing with psycho-spiritual problems is part of
  our helping with the suffering of patients
• not
• An outlet for our own needs to share our own
  spiritual or religious views with patients who
  have no interest in them

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Audience

• Discuss the differentiation of psycho-spirituality
  from religion.

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Distinguishing psycho-spirituality from religion
- Religion

• Religion
• Is a system of beliefs, practices and symbols
  designed to bring the believer close to god
• I would say it is a defined expression of
  spirituality

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Religious distress

• Religious suffering occurs in three general types
  of situations
• patients doubt the validity, usefulness of the
  beliefs they held and are no longer comforted or
  feel guilty about their faith, crisis of faith
• patients who have labeled themselves
  non-religious wonder if they could cope better
  if they had a faith system
• patients feel they are being punished for
  religious reasons

Modified after Fleming D. J. Adv. Nursing
1995221120-1127
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Audience

• How frequently do you see psycho-spiritual
  distress in a palliative care situation?
• What personal situations make people (especially
  those who are dying) likely to have
  psycho-spiritual distress?

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Suffering at Mercy Hospice
Terry W. IMJ 200434604-607
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Aspirations vs Reality
Severe
Group C
Group B
Distress
Kawa, M. Support Care Cancer 200311481-490
Group A
Slight
Mild
Severe
Physical Symptoms
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Circumstances for Psycho-spiritual distress

• When meaning has disappeared
• When there is no purpose
• When there is no value or self worth
• When hope is lost

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Reflection can bring transition...
Secular Achievement Money/reward Work/sport Rol
e/position

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Audience

• Give some illustrations of psycho-spiritual
  distress that you have encountered?

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Psycho-spiritual Distress

• Some Psycho-spiritual questions
• Why me?
• Am I guilty?
• Am I being punished?
• What does the future hold for me?

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Distress associated with dying

• Experiencing vulnerability
• Not being in control, ?dignity
• Being a burden on carers
• Dying alone, not with family / friends
• Dying in an institution, not at home

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A Portrait of a Man without a face Norm
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Audience

• Do you regularly undertake a psycho-spiritual
  assessment when seeing a patient?
• Explain how you do it.

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Clinical PracticeThe Hope Questions

• H Sources of hope, meaning comfort, strength,
  love, peace and connection
• O Organised religion
• P Personal spirituality practices
• E Effects of medical care on end-of-life
  decisions

Anandarajah G et al. Amer Family Physician
20016381-89
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Clinical Practice Other screening Questions...

• Another screening tool suggested by Post et al
  (2000)
• Do you consider yourself spiritual or religious?
• How important are these beliefs to you and do
  they influence how you care for yourself?
• Do you belong to a spiritual community?
• How might health providers best address any needs
  in this area?

Post SG et al. Ann Int Med 2000132578-583
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Psycho-spirituality the University
René Descartes
1596-1650

• Dualism
• Soma (body)
• Psyche Brain
• Mind

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Psycho-Spirituality and the Medical School
Curriculum
Started to lobby in 1994, Pilot project 2000,
Teaching commenced 2001
?
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Organisation of 3rd Year attachment

• Introductory Lectures
• Assignment of students
• History and Examination (including
  psycho-spiritual history)
• Literature review
• Debriefing
• Reflective diary

Attachment to the family of a palliative care
patient for 7 weeks in groups of 3
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Reflective diaries Results

• ..N was a member of the Baptist Church and V was
  a Roman Catholic. N told us their (marriage)
  vows were said in the priests private rooms and
  not in front of the alter. This had upset them
  both and still made them feel angry and
  uncomfortable at not being married in front of
  Godthey brought up their children as Anglicans.
  N and V said they strongly believed in God and in
  some form of life after death. ...I was
  surprised that he seemed to have come to terms
  with this impending demise

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Reflective diaries Results

• When I was 16 my Nanna suicided (euthanasia
  really...) Although I understand why she made the
  decision at the time, she was 86 and in chronic
  pain (dam(n) it, I am crying as (I) write this)
  and she knew the end was coming and wanted to be
  in control of it (maybe).
• I just really strongly feel now that if she had
  had good palliative care, then maybe she wouldnt
  have made that decision...

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Reflective Diary Results

• Attending a funeral was an interesting
  experience for me, on many levels. Firstly,
  never having really attended one before, I didnt
  know how Id react. The only (funeral) Id
  attended was as a child with a distant relative,
  but as it was a Muslim funeral/wake, females were
  not able to see what was going on. So up to this
  point I havent had to be confronted with death

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Reflective diaries Results

• Today we discussed Ks spirituality. She
  believed in reincarnation, spirits and ghosts.
  She believed that after she died, she would come
  back to be with her family. This gave her
  comfort and hope. .

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Reflective diaries Results

• Today we discussed (with the patient) some of
  the psycho-spiritual issues involved. I am
  amazed at how important Es faith is to him, and
  how vital it is to his strength at this time. It
  seems to be what keeps him going through
  everything....

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Reflective Diary

• Secondly, the mass/service was a Roman Catholic
  one. I found, that, being a Protestant
  Christian, that I am ignorant of many of the
  traditions and rituals that took place, and in
  particular, what they symbolise. ...However,
  throughout the mass, this issue was dealt with by
  the fact that, and by the remembrance, that we
  are all still worshipping the same GodOverall it
  was a good reminder of my own faith, as well as a
  celebration of Ds life.

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Audience

• What would you include in your care plan for a
  patient with psycho-spiritual distress?
• In a palliative care setting?
• In a general practice?

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Implementing the process...

• Admission or GP assessment should include
  psycho-spiritual questions. Establish a base
  line on everyone coming onto the programme
• Junior medical staff and medical students are
  familiarised with psycho-spiritual questions
• Psycho-spiritual issues are discussed at team
  meetings. All staff are aware
• Pastoral care and chaplaincy are consulted
• Psycho-oncology/psychiatry consults may be
  required

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Roles for each of us should include

• Remaining open and receptive, not distancing
• Confronting issues for the good of the patient
• Not controlling, but serving people
• Realizing that we do not need to own problems
  ourselves
• Taking opportunities for debriefing, supervision,
  fun, recreation etc...

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Some thoughts gathered along the way
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• A unique life lived is a work of art

Eric Cassell
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The Music is always more important than the
words. Some people can never put sorrow into
words, but they can almost always tell a story.

Ed Cassem
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Gifts At core, what have we been given?We
have been given transience, freedom and
attachment.Perfect equation!Our response shapes
life.Balfour Mount, 2003
(For people involved in palliative care)
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Thank YouDiscussion?
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McClain-Jacobson Study Results

• 276 patients (C66.3, Female 57.2, )
• Comfort68.4, no comfort20.4, unsure 11.3
• Belief in afterlife - Catholic72,
  Protestant64, Jewish46
• Believers vs non-believers find comfort (plt0.001)

McClain-Jacobson C et al Gen. Hosp. Psychiatry
200426484-486
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Belief in Afterlife vs Distress
SWBFunctional Assessment of Chronic Illness
Therapy-Spiritual Well-being Scale HADSHospital
Anxiety and Depression Scale HDRSHamilton
Depression Rating Scale
McClain-Jacobson C et al. Gen. Hosp. Psychiatry
200426484-486
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Belief in Afterlife vs Despair
BHSBeck Hopelessness Scale SAHDSchedule of
Attitudes toward a Hastened Death SISuicidal
ideation
McClain-Jacobson C et al. Gen. Hosp. Psychiatry
200426484-486
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The relationship of spirituality to existential
distress...

• For some, spiritual or religious issues are
  embedded in existential themes eg
• Spirituality ? transcendence, control
• Spirituality ? meaning, identity
• Spirituality ? intimacy, alienation, positive
  for relationships