Chapter 37: Spirituality in patient care – looking at the bigger picture
|"The possession of knowledge does not kill the sense of wonder and mystery. There is always more mystery."|
- Anais Nin.
While doctors are usually very good at taking care of a patient’s physical needs , we usually neglect to minister to our patient’s desire for spiritual comfort. This is a deficiency we urgently need to rectify, because a patient’s spiritual health can have a significant impact on how they cope with their illness. The idea that spirituality can help to heal is very old, and traditional cultures have always relied on medicine men, witch doctors and shamans to use spiritual interventions in order to cure illnesses, often with remarkable results. After all, it is through both the channels of medicine and religion that humans have grappled with the common issues of suffering, despair, and death , when confronted with an illness.
Since the topic is so unfamiliar for most doctors , let’s first start with some definitions. Unfortunately, even defining spirituality is difficult, because it is such a nebulous and intangible topic, and has a different meaning for everyone. While all of us are spiritual beings, many doctors are uncomfortable talking about spirituality because they consider it to be too unscientific, and often confuse it with religion. The word spirituality comes from the Latin root spiritus, which means "breath"--referring to the breath of life. Since a "hard” definition is impossible, let’s settle for a "soft” one– spirituality is the way you find meaning, hope, comfort and inner peace in your life. Spirituality involves opening our hearts, connecting with others, and cultivating our capacity to experience awe, reverence and gratitude. Many people experience spirituality through religion and each religion attempts to help ask and answer mankinds spiritual questions. Each religion has developed a specific set of beliefs, teachings and practices, but in contrast to religion that is organized and communal, spirituality is highly individual and intensely personal, and it is possible to be spiritual with out being religious or even believing in God . Spiritual distress occurs when individuals are unable to find sources of meaning, hope, love, peace and comfort in life ; and illness can often trigger spiritual distress in patients and family members. Spiritual care consists of relieving this distress, and involves compassion, listening and the encouragement of realistic hope; and need not involve any discussion of God or religion.
Addressing the patient’s spirituality should be a routine part of health care for many reasons. (1) Religious beliefs and spiritual needs are common among patients, and many patients would like their doctors to address these issues (2) Religious beliefs influence medical decision making (3) There is a relationship between spirituality and health.
(4) Supporting a patient’s spirituality can enrich the patient-physician relationship.
However, there are a number of barriers doctors encounter when talking about spirituality. Clinicians practice in the bio-medical model and pride themselves on being hard-headed rational scientists, so that many feel that nebulous concepts such as spirituality are unimportant and irrelevant. After all, you can palpate an enlarged liver and auscultate the heart, but how do you examine the soul ? Second, few physicians are religious or spiritual themselves, which is why they often fail to realise the importance of spiritual matters to their patients. Since the effect of spirituality on health is often not taught during medical training, many never consider this area at all. Other doctors feel that the spiritual concerns of patients are private and that physicians should not inquire about them; and they are worried that they may offend patients who have differing religious beliefs. The simplest solution is to avoid discussing religious or spiritual matters, which is what most doctors end up doing, but this is often not desirable.
It is difficult for physicians to ignore or avoid patient spirituality , especially in India . Rather than shy away from such discussions, you need to develop a technique to become comfortable dealing with these issues. This is why the American Psychiatric Association recommends that physicians inquire about the religious and spiritual orientation of patients "so that they may properly attend to them in the course of treatment.” This is simple common sense – after all , patient care is much more than disease management; and involves addressing the needs of the whole person. Spiritual care can play a complementary role to medical care, especially in dealing with critically ill patients or the dying.
Physicians can easily incorporate spirituality into their practice by assessing the patients spirituality in order to diagnose spiritual distress; and by providing therapeutic interventions to alleviate this distress. For assessment and diagnosis, the key is to learn to take a spiritual history , to help you define the spiritual needs of your patients. In fact, taking a spiritual history can actually provide basic spiritual care for many patients, in that it allows patients to voice their spiritual doubts, needs and concerns, and allows physicians to comfort them, if they need this. More advanced spiritual treatment can be provided by referring patients to sources of spiritual care such as priests; temples, churches and mosques; family and friends; and community resources (eg, satsangs and similar support groups). Thus, many hospitals have chapels, temples and prayer rooms today, and patients should be encouraged to use these services.
Since the concept of taking a spiritual history is so new for most doctors , the HOPE questions designed by Gowri Anandarajah can prove to be very helpful, because they allow for an open-ended exploration of an individuals spiritual resources and concerns . A useful way to introduce these questions is by asking: "For some people, their spiritual beliefs act as a source of comfort and strength in dealing with lifes ups and downs. Is this true for you?"
H: Sources of hope . What are their sources of hope, strength, comfort and peace ? This helps to define their basic spiritual resources.
O: Organized religion. Are they a member of a religious group ? How active are they ?
P: Personal spirituality and practices. What specific aspects do they find most helpful in their own life ? Prayer ? Meditation ? Music ?
E: Effects on medical care issues ( for example, dietary restrictions for Jains). This can help focus the discussion back onto clinical management
Following the spiritual assessment, you have many management options.
1. Take no further action. Spiritual concerns often have no clear solutions, and experienced physicians know that in many cases there is little they can offer to their patients in the way of medical solutions. Often the best therapeutic intervention you can provide is your presence, understanding, and compassion, which is in itself a spiritual response.
2. Include spirituality in adjuvant care. You can help patients identify spiritual measures that can be useful to them in conjunction with standard medical treatment. For example, a patient may choose to have a picture of their guru in their room, or listen to the Gita during dialysis , or read the Bible before surgery.
3. Modify the treatment plan. Modifications can be made based on a better understanding of your patients spiritual needs. This can include measures such as stopping chemotherapy in a patient with terminal cancer; referring a patient in spiritual crisis to a priest; using community cultural resources; and teaching meditation techniques to patients with chronic pain or insomnia.
Before you can begin to address your patient’s spiritual needs, you first need to understand your own spiritual beliefs . One way to promote self-understanding is to perform a formal spiritual self-assessment by taking a spiritual history on yourself ! Spiritual self-care is integral to serving your patients and self-care can take the form of reconnecting with family and friends, time alone (for meditation, playing a sport, recreational reading, nature watching, etc.), community service, or religious practice, such as praying.
Learning about spirituality will help you become a better physician. It will help you find meaning in your daily work as you appreciate the importance of your primary role – to serve your patients. It will also help you become more compassionate, and teach you the importance of hope , and why you need to support your patient’s spiritual needs . Finally, it will help to keep you humble, because it will teach you to realize there is so much about the human body we do not understand and cannot control – and that the human spirit can perform miracles modern medicine still cannot comprehend.
Finally, you should pay more attention to spirituality for purely selfish reasons ! Spirituality is key to self-growth, and allows us to continually be amazed at the miracle of human life. By virtue of being doctors , we are privileged to have a ring-side view of life’s most exciting battles , right from birth to death , but many of us get jaded with time. Spiritual awareness allows us to appreciate the wonders of life, so we can continually rejuvenate ourselves and look on each day as a brand new adventure, and lead a more meaningful life. Spirituality allows you to get in touch with your own humanity – the ultimate reward !