Spiritual aspects of palliative care

CHARMAINE BLANCHARD, MPhil Pall Med, MB BCh, BSc (Hons) Palliative Medicine

Senior Lecturer, Centre for Palliative Care, Chris Hani Baragwanth Hospital, Johannesburg

Correspondence to: C Blanchard (vervet@iafrica.com) 

There is a growing recognition of the importance of spiritual care in providing quality care to patients with life-threatening illnesses. Subsequently, attention to spiritual issues is increasingly being expected of the health professional.1 The WHO definition of palliative care includes spiritual care as an aspect of improving the quality of life of patients facing death. Medical doctors are skilled in and comfortable with providing physical care. Psychosocial issues are recognised with appropriate referral to a social worker. However, spiritual care is not easily addressed.2

Spiritual support has been shown to positively affect the quality of life of patients with cancer as they near death.2 As patients have to cope with declining health and function, their spiritual focus is increased. As the inevitability of death approaches, the person may express the need for spiritual reflection and review.3 Unmet spiritual needs often escalate into distress which is expressed physically or emotionally, resulting in increased utilisation of health services.3

Concept of total pain

Pain is not just a physical experience. Dame Cecily Saunders introduced the concept of total pain – physical, emotional and spiritual – when describing the complex nature of suffering of patients with advanced illness.4 The perception of pain is intensified by spiritual suffering. While physical pain may be treated with a range of analgesics, these are not effective in treating emotional or spiritual pain. Addressing the non-physical dimensions of pain may reduce the treatment required to control total pain. Patients who express emotional distress related to spiritual issues may be prescribed anxiolytics or antidepressants or may even be sedated, whereas they actually need spiritual care.4 Most patients find that their spiritual beliefs are a source of comfort to them; however, for some their beliefs may become a source of distress as they review the meaning of their illness and life.2 As doctors who offer palliative care for our patients, we have a responsibility to address the spiritual suffering as much as the physical suffering as the former contributes to the total pain.

Spirituality and spiritual care

There is no single definition that adequately describes spirituality. Robert Twycross describes spirituality as an awareness of the transcendent, something beyond the ordinary human experience, and something of wonder.5 Other definitions include attention to meaning, purpose in life, values, and relationships with self, others and God/higher presence as part of the spiritual experience.3 While many may use religion and spirituality interchangeably, religion is only one of many forms of spiritual expression. Spirituality is therefore multidimensional and has a different meaning for each individual, including the patient and the doctor. In offering patient-centred care, the doctor needs to be sensitive to this difference in perception of spirituality and be clear about the meaning and intention of spiritual care.1

Just as spirituality defies any attempt at a single definition, it is difficult to expediently offer spiritual care in the same way as we diagnose and treat illness. A review of the literature shows that spiritual care is considered as a spectrum of care ranging from the way the patient is treated by health care professionals so that they do not feel depersonalised, staff giving time and being present, to specific assessment and intervention in cases of spiritual distress.3

Spiritual assessment tools such as FICA, HOPE and SPIRIT have been developed to identify patients’ beliefs and sources of support in spiritual aspects of their life.6 While these tools are very useful, care must be taken that they are not used to ‘tick boxes’, thereby not identifying or addressing any real spiritual issues. An attentive, experienced doctor may recognise references to spiritual distress from the dialogue or from questions the patient asks. Once a doctor has recognised spiritual suffering, it is necessary to refer the patient to an appropriate specialist, such as a chaplain or pastoral carer. Spiritual care based on a patient-centred approach is best provided by a multidisciplinary team.5

Conclusion

Doctors often feel unqualified to do a spiritual enquiry; however, education is not the only pre-requisite for good spiritual care. A willingness to connect at a human level, to listen attentively, to be reflective and to be spiritually aware enhances the delivery of skilled care. It is important for a doctor to be willing to listen, recognise spiritual distress and refer as necessary. ‘Palliative care informed by spiritual attentiveness allows both the patient and provider to give up illusions of therapeutic entitlement to cure and at the same time honour the privilege of intentional and reverent care of the dying.’4

References available at www.cmej.org.za