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Spirituality in Health Care

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					SPIRITUALITY IN MEDICINE
    AND HEALTH CARE


    Thomas R. McCormick, D.Min.
 Department of Medical History and Ethics
       U.W. School of Medicine
    Health Care in Early Times
      Medicine & Religion
• Few interventions were possible
• Application of herbal medicines
• Religious concepts of cause and effect
  included :
  – punishment for sins
  – indwelling of evil spirits
  – separation of the patient from God
   Ancient medicine & religion
• 3000 BCE, early written documents show
  Egyptian & Mesopotamian healers were
  priests with magico-religious concepts.
• 5th century BCE in Greek medicine,
  Hippocrates begins a more scientific
  approach, including natural causes.
• By the 3rd century BCE, the Romans were
  influenced by the Greek’s cult of Asclepius.
Greece:
The
Temple
of
Asclepius
     Two views of health care
     HYGEIA & ASCLEPIUS
• HYGEIA: health is the natural order of
  things, fostered by prudent choices and wise
  living, the goal is to find balance between a
  sound body, a sane mind, and a calm spirit--
  medicine should discover & teach the
  natural laws, so we might cooperate.
• ASCLEPIUS: the chief role of medicine is
  to treat disease, the heroic intervenor.
Nursing care and natural healing processes
grow from the approach of Hygeia
Interventive medicine has its roots in Aescleplius
   Theoretical Models Emerge
• Biomedical model in the 19th century
• Psychobiological model--after Freud
  – emotional states contribute to illness
  – relaxation response may reverse illness
• 20th century: bio-psycho-social model
  – 1977, George Engel
  – Life events & lifestyles affect health
    Medicine in the Christian era
• Healings were attributed to Jesus, who
  sometimes linked healing with the power to
  forgive sins.
• The Parable of the Good Samaritan became
  a formative influence on medicine.
• By the 5th century AD, virtually all
  physicians were drawn from clergy in the
  monastic communities. (Kuhn, Psychiatric Medicine Vol. 6 No. 2)
           Secular Medicine
• Secular medicine emerged in the late
  middle ages, but was still under control of
  church.
• 1140 AD church granted first medical
  licenses, conditions, & revocations.
• 1789, the French Revolution, marked the
  break down of religious control over
  medicine.
• Cartesian: separation of mind and body
Separation of Medicine from
          Religion
              • As science began to
                discover the etiology
                of diseases, former
                religious explanations
                no longer held.
              • Science and medicine
                began to distance
                themselves from
                religion.
              • “God of the gaps. . .”
      A Current view of health care:
    A BIO-PSHYO-SOC-SPIRITUAL
                MODEL
• Scientific view of pathophysiology
• Respect for the psychological
• Perception of the social environment
• Attention to the spiritual distress and the
  spiritual resources of the patient
• Described by Division of Behavioral
  Medicine at the University of Louisville
  School of Medicine
              The Spiritual
• The patient is not just body and mind, but a
  spiritual being. --P. Tournier
• Spirituality involves the personal quest for
  meaning & purpose in life and relates to the
  inner essence of the self
• Spirituality: the sense of harmonious inter-
  connectedness with self, others, nature and
  an Ultimate Other (the integrating factor)
    Bio-Psycho-Social-Spiritual
• Although Schools of Medicine have been
  slower to recognize & appropriate this
  model,
• The Nursing Profession has long recognized
  the spiritual aspects of patient care,
• Chaplains and clergy have often assisted
  patients with the spiritual aspects of illness
  and the search for meaning & purpose.
Religion is seen by some to be an
    impediment to medicine
• Jehovah’s Witness who refuses a life saving
  blood transfusion;
• Christian Scientist who refuses allopathic
  health care in favor of a Reader;
• Various religions that may decry
  contraception or forbid pregnancy
  termination.
   Great Diversity of Religions
• Especially in the USA, there is a great
  number of religions so that one can hardly
  speak of religion in general, without making
  reference to a particular religion.
• It is too much to expect of a physician that
  s/he be a student of religions, in addition to
  medicine.
• And, what if the physician is non-religious?
   Question: Should physicians
  avoid talking about religion or
    spirituality with patients?
• A. yes, because a physician can not be
  expected to be conversant with all religions.
• B. yes,because the physician may be an
  atheist or non-believer.
• C. yes, that would be an unethical intrusion
  into the privacy of the patient.
• D. no, particularly when there are
  indications of patient interest or need.
       Distinction: Between
      Religion and Spirituality
• Answer: D; no, there are indications. . .
• A particular religion or faith community is
  one road to spiritual awareness and growth.
• Spirituality in this sense, may transcend a
  particular religion, and resides in that
  universal human space where individuals
  seek to understand the meaning & purpose
  of their lives, and what they most value.
• Spirituality implies self-conscious living.
               Spirituality
• Thousands of alcoholic patients who found
  little help from traditional medicine were
  able to become sober and remain abstinent
  by relying on “a power greater than
  themselves” and through the support of a
  twelve step program.
          A Shift of focus:
        from the biomedical
   to the psycho-social-spiritual
• For many patients facing serious illness or
  the end of life, the focus shifts from the
  biomedical to the spiritual.
• When symptom management and pain
  control are appropriately provided, patients
  are set free to address their “final agenda.”
• This may be seen as the last chapter in one’s
  spiritual journey. (Mary Levine)
R.M. Mack, MD “Occasional notes: Lessons learned
  from living with cancer.” NEJM 311:1642, 1984

• “Simply accepting this prognosis was
  completely intolerable for me. I felt I was
  not yet ready to be finished. I still had not
  seen and done and shared with the people I
  love. . . I could sit back and let my disease
  and my treatment take their course, or I
  could pause and look at my life and ask,
  What are my priorities?
  Dr. Mack, a Seattle surgeon’s
         reflections. . .
• How do I want to spend the time that is left?
  I began to focus on choosing to do things
  every day that promote laughter, joy, and
  satisfaction. . . I began to make choices to
  do the things that felt good to me.”
• One person, opening to the meaning of life
  in the face of imminent death. . .
What do patients nearing the end
         of life say?
• fear of uncontrolled pain & neg. symptoms
• worry about becoming a burden on family
• concern about financial costs of care
• uncertainty about the dying process
• anxious anticipation of surrendering the
  known for the unknown
• Concern for the “unfinished business of
  life”
 Patients raise spiritual questions
• Who am I, now that I am sick or dying?
• What is the meaning of my life when I am
  no longer productive and independent?
• Where am I connected to others who value
  me and see me as a person of worth?
• What is my relationship to the Ultimate?
• What do I now value most in the time that is
  left to me?
Epictetus: a question of meaning
• “It is not as important
  what happens to a
  person, as to the
  meaning that the
  person gives to what
  has happened.”
• Assignment of
  meaning is a spiritual
  function.
    Lipowski: how we view illness
•   Illness a challenge
•   Illness as enemy
•   Illness as punishment
•   Illness as weakness
•   Illness as relief
•   Illness as strategy
•   Illness as having value
  Meaning is related to purpose,
  therefore questions might be:
• Why do you think you have become ill now
• Has this illness changed any attitudes you
  might have about the future?
• Is there anything more important to you
  than regaining your health?
• How does this illness interfere with your
  goals in life?
• What purpose is served in regaining health?
     Where does spirituality fit?
• Patients may have
  coping mechanisms
  related to their belief
• May be supported by a
  community of caring
  others.
• May feel themselves
  to be in the company
  of the Divine.
    Man’s Search for Meaning
         Victor Frankl
• Sometimes external circumstances in our
  life situation are beyond our control.
• Frankl maintains that the attitude we choose
  to take toward our life situation is within
  our control.
• The spiritual journey relates to our inner
  struggle to shape our attitude toward illness
  and even death itself.
   Frankl: the will to meaning. . .
• Aesthetic: one may find meaning in the beauty
  of the sunrise, the sunset, the symphony. . .
• Relational: one may find meaning in
  relationships, be they family or friends
• Creative: one may find meaning in creative
  activity, work, profession, homemaking
• Attitudinal: one may find meaning in shaping
  the attitude taken toward illness or death.
     A Spiritual Inventory might
      include questions about:
•   patient’s perception of what is going on
•   what gives meaning and purpose to life
•   how, or whether belief and faith enter in
•   love: by whom do you feel loved-accepted?
•   forgiveness--need it? grant it to others?
•   prayer--for what do you pray?
•   quiet and meditation--what is off center?
•   worship--what restores you to center?
     Taking a spiritual history. . .
•   S Spiritual Belief System
•   P Personal Spirituality
•   I Integration in a Spiritual Community
•   R Ritualized Practices and Restrictions
•   I Implications for Health Care
•   T Terminal Events Planning (advance
    directives, DNR wishes, DPOA etc..)
     S Spiritual Belief System
• How would you describe your spiritual
  belief system?
• Do you find comfort in this current illness
  from your beliefs and practices?
• What in particular is helpful to you?
  – Internal: private belief system
  – External: participant in a community
      P Personal Spirituality
• What are your most important personal
  beliefs?
• The professional need not believe what the
  patient believes, but must acknowledge that
  the patient’s beliefs are important.
• An individual may have a profound
  spirituality, but may not be overtly
  religious.
    I Integration in a Spiritual
           Community
• National Institute for Healthcare Research
  report studies claiming:
• regular church attenders live longer.
• risk of diastolic hypertension ranked 40%
  lower among people who actively
  participate in spiritual practices.
• 93% female cancer patients said their
  beliefs helped them sustain hope.
   R Ritualized Practices and
         Restrictions
• Patients may especially value the rituals of
  their faith community:
• Baptism for a critically ill newborn
• Anointing (last rites) of a dying person
• Scripture
• Prayer
• Communion, or Eucharist Service
 I    Implications for Health Care
• What does the patient understand about
  his/her medical condition & prognosis?
• What are the patient’s beliefs about
  suffering, about pain control?
• Does the patient understand the principle of
  double effect?
• What are the patient’s goals in the time that
  is left?
    T Terminal Events Planning
•   Does the patient have an advance directive?
•   Attorney in fact: Durable Power of Atty.?
•   Curative - Palliative -Comfort Care?
•   How does the patient view dying?
    – Is it the final end?
    – Is it the beginning of life eternal?
    – What is the patient’s final agenda?
Mentoring, and teaching by example, is
perhaps the most effective approach.
UWSOM is
featured for
teaching end
of life care to
medical students
Students in
preceptorships
or RUOP’s in
                   Hospice Student
the pre-clinical
years, or in
the clerkships,
may gain a
deeper
appreciation of
the spiritual
needs
and resources
of
patients.
Different
cultures
may have
ceremonies
and rituals of
special
importance in
coping with
illness or
preparing for
death.(Navaho)
       Choice in Dying Study
• Education in spirituality should be
  interdisciplinary (med/nrsng/pastoral),
  expose students to dying patients, and to
  caregiver mentors who model ideal
  knowledge, skills and attitudes.
• Preclinical years: patient interview,
  hospice elective, preceptorships
• Clinical years: Clerkships, Hospice rotation,
  Simulated Patient Interviews, Patient care.
 Persons with major illness or
debilitating disease find strength
 and support from religious or
        spiritual sources.
• Measures of religious coping can predict
  outcomes of life crises, vs. non-religious.
• Use of religious coping skills by older
  patients is associated with diminished risk
  of depression, or of recovery from depr.
• Spiritual intervention needs a (CPT) code.
Recent surveys by NIHR find:
• 43% of physicians pray for their patients,
• 90% of doctors at the American Academy
  of Family Physicians 1996 meeting agreed
  that “a patient’s spiritual beliefs can be
  helpful in his or her medical treatment”
• 58% have actively pursued information on
  spirituality and healing.
5 requirements for physicians to
meet the spiritual needs of patient
•   Be trustworthy,
•   treat the patient as a person,
•   be kind,
•   maintain hope,
•   assist the patient in determining what it
    means to live.
    Foster,DW in Religion and Medicine: the physician’s
    perspective. Fortress Press, 1982
        American Psychiatric
           Association
• Physicians should maintain respect for their
  patient’s beliefs. It is useful for physicians
  to obtain information on the religious or
  ideologic orientation and beliefs of their
  patients. . .
• Physicians should not impose their own
  religious, anti-religious, or ideologic
  systems of belief on their patients. . .
Spirituality in Medicine (1 credit)
     UW School of Medicine
• A multidisciplinary med school elective
• Provides a framework for students to
  communicate with patients about the
  patient’s spiritual connections
• Allows each student to make visitations
  with a hospital chaplain--seeing patients
  with serious illness or life threatening
  illness
        Goals of this Course:
• Heighten awareness and enhance the role
  of spirituality in our own lives;
• Foster respect and appreciation for the
  diversity of patient beliefs and values;
• Strengthen commitment to relationship-
  centered approach to health care;
• Develop a better understanding of the role
  of the hospital chaplain and clergy as
  partners in caring for patients.
Spirituality Education at the UW
• Year 1: ICM, Human Behavior
• Year 2: ICM II, “Terminal Illness Seminar”
• Electives:
  –   SPIRITUALITY IN HEALTH CARE
  –   HOSPICE ELECTIVE
  –   ETHICAL ISSUES SURROUNDING DYING
  –   PRECEPTORSHIPS & RUOP
  –   INDEPENDENT RESEARCH PROJECTS
          Contact Information
• Dr. Thomas R. McCormick
• email: mccormic@u.washington.edu
• http://eduserv.hscer.washingnton.edu/bioethics/
•   Box 357120
•   School of Medicine
•   University of Washington
•   Seattle, WA 98195
Case examples of spiritual issues:
•   a disturbing visit from the daughter
•   the professor’s inoperable cancer
•   medical student with an astrocytoma
•   what will my dying be like?
•   a patient’s lament, “please help my parents”

				
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posted:5/3/2012
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