Title: "Psychospiritual elements of Palliative Care: educational and clinical implications"'
1"Psycho-spiritual elements of Palliative Care
educational and clinical implications".Â
- Peter Ravenscroft
- Professor of Palliative Care
- University of Newcastle, Australia
2The pain is what the body experiences, but
suffering is the experience of persons Cassell
3Audience
- What do you think psycho-spiritual issues are?
- How do you tackle psycho-spiritual problems that
patients have in your practice?
4The 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.
5Holistic Care
Physical symptoms
Cecily Saunders
Pain
Cultural
Total
Suffering
Psychological
Spiritual
Social
6Losses 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
7Losses 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
8A 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
9Audience
- Discuss the differentiation of psycho-spirituality
from religion.
10Distinguishing 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
11Religious 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
12Audience
- 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?
13Suffering at Mercy Hospice
Terry W. IMJ 200434604-607
14Aspirations vs Reality
Severe
Group C
Group B
Distress
Kawa, M. Support Care Cancer 200311481-490
Group A
Slight
Mild
Severe
Physical Symptoms
15Circumstances 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
16Reflection can bring transition...
Secular Achievement Money/reward Work/sport Rol
e/position
17Audience
- Give some illustrations of psycho-spiritual
distress that you have encountered?
18Psycho-spiritual Distress
- Some Psycho-spiritual questions
- Why me?
- Am I guilty?
- Am I being punished?
- What does the future hold for me?
19Distress 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
20A Portrait of a Man without a face Norm
21Audience
- Do you regularly undertake a psycho-spiritual
assessment when seeing a patient? - Explain how you do it.
22Clinical 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
23Clinical 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
24Psycho-spirituality the University
René Descartes
1596-1650
- Dualism
- Soma (body)
- Psyche Brain
- Mind
25Psycho-Spirituality and the Medical School
Curriculum
Started to lobby in 1994, Pilot project 2000,
Teaching commenced 2001
?
26Organisation 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
27Reflective 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
28Reflective 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...
29Reflective 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
30Reflective 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. .
31Reflective 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....
32Reflective 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.
33Audience
- What would you include in your care plan for a
patient with psycho-spiritual distress? - In a palliative care setting?
- In a general practice?
34Implementing 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
35Roles 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... -
36Some thoughts gathered along the way
37- A unique life lived is a work of art
Eric Cassell
38The 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)
40Thank YouDiscussion?
41McClain-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
42Belief 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
43Belief 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
44The 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