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


1
"Psycho-spiritual elements of Palliative Care
educational and clinical implications". 
  • Peter Ravenscroft
  • Professor of Palliative Care
  • University of Newcastle, Australia

2
The pain is what the body experiences, but
suffering is the experience of persons Cassell
3
Audience
  • What do you think psycho-spiritual issues are?
  • How do you tackle psycho-spiritual problems that
    patients have in your practice?

4
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.

5
Holistic Care
Physical symptoms
Cecily Saunders
Pain
Cultural
Total
Suffering
Psychological
Spiritual
Social
6
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
7
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

8
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

9
Audience
  • Discuss the differentiation of psycho-spirituality
    from religion.

10
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

11
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
12
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?

13
Suffering at Mercy Hospice
Terry W. IMJ 200434604-607
14
Aspirations vs Reality
Severe
Group C
Group B
Distress
Kawa, M. Support Care Cancer 200311481-490
Group A
Slight
Mild
Severe
Physical Symptoms
15
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

16
Reflection can bring transition...
Secular Achievement Money/reward Work/sport Rol
e/position

17
Audience
  • Give some illustrations of psycho-spiritual
    distress that you have encountered?

18
Psycho-spiritual Distress
  • Some Psycho-spiritual questions
  • Why me?
  • Am I guilty?
  • Am I being punished?
  • What does the future hold for me?

19
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

20
A Portrait of a Man without a face Norm
21
Audience
  • Do you regularly undertake a psycho-spiritual
    assessment when seeing a patient?
  • Explain how you do it.

22
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
23
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
24
Psycho-spirituality the University
René Descartes
1596-1650
  • Dualism
  • Soma (body)
  • Psyche Brain
  • Mind

25
Psycho-Spirituality and the Medical School
Curriculum
Started to lobby in 1994, Pilot project 2000,
Teaching commenced 2001
?
26
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
27
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

28
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...

29
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

30
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. .

31
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....

32
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.

33
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?

34
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

35
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...

36
Some thoughts gathered along the way
37
  • A unique life lived is a work of art

Eric Cassell
38
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
39
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)
40
Thank YouDiscussion?
41
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
42
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
43
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
44
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
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