Whole Person Medicine Meeting the spiritual needs of patients

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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?

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Does Medicine have a philosophy?

• Scientific Humanism
• Psycho-somatic
• Psycho-social-somatic
• Post-modernism
• Narrative medicine
• Whole Person?

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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?

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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

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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.

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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?

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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

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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

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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?

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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

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Old Western dualistic picture
SPIRIT
Communion Worship
SOUL
Mind, intellect Emotions Will
BODY
Senses Physical body Sexuality
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body
spirit
A new model of man - A golf ball
soul
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I am an indivisible whole person
Will Emotions Desires Relationships
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No Dualism Please
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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

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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

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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

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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

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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

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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?

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6 Decisions, choices and will

• Making good decisions
• This means understanding and making good choices
• Will Power to follow good path
• Perseverance
• Facing challenges

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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?

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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

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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

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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.

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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?

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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

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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

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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.

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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

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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

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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 .

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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?

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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?

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Assessment in whole-person care
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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

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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
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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

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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

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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)

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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

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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

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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

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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

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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

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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.

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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.

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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

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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.

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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9 Outcomes to be achieved (3)

• Spiritual
• Personal growth
• Increasing compassion and relationships
• Peace at heart (relief from anxieties)
• Hope for the future

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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

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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?

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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

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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.

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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)

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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

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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.

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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
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Ross Bryson

• GPs at Karis in Birmingham
• Spiritual needs in General Practice
• http//www.wphtrust.com/spirit02.html

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Spirituality the new Religion

• Rob Merchant at Stafford University
• http//www.wphtrust.com/spirit03.html

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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.

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Guiding principles

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

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3 simple rules

• Be patient centred
• Be integrated
• Be committed

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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

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Internet Resources

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