Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

[Citation: O'Connell, L. Integrating Spirituality into Health Care Near the End of Life. Innovations in End-of-Life Care, 1999;1(6), www.edc.org/lastacts]

At the present moment, "Spirituality and Health Care" is a code phrase for a whole array of concerns and initiatives being undertaken to improve the spiritual health and well-being of patients, particularly near the end of life. The notion of integrating spirituality, usually the domain of pastoral care, theologians, and philosophers, with health care, the domain of biomedically-trained clinicians focused primarily on the physical body and its diseases and injuries, as well as the psychological dimensions of illness, brings with it some tension in modern, Western societies. The history of Western medicine has been one of gradual but virtually complete disengagement from religious or spiritual explanations of and cures for disease, and an almost total embrace of biological explanations for disease and technologically-sophisticated treatments.

Yet, even as health care and spirituality have come to be seen as largely separate domains in many Western countries, life-threatening disease and illness provoke questions that biomedicine and the apparatus and organization of modern health care delivery have failed to address. These questions are articulated most succinctly in the anguish of the dying patient who asks, "why me?" A dying person’s questions concerning the meaning and purpose of one’s life, the meaning of pain and suffering, confront health care providers in secular societies with a dilemma: what role should they play in eliciting and attempting to meet the spiritual needs of their patients? For some patients the sacred is extremely important; others may have no strong sense of the sacred, yet yearn to find meaning for their own life within the stream of all existence. To what extent are these concerns the province of the chaplain and pastoral care providers, or the duty and responsibility of all health care providers, as part of their ordinary interactions with patients and families?

In some modern societies, spirituality and religion may remain more integrated into health care than in the United States because of either a more homogeneous population and culture, as in present-day Poland or Ireland, or where spirituality in general, even though manifested through a multitude of faiths, is more central to all aspects of life, as in India. In such settings, it may be easier and more natural to integrate spiritual care of patients into health care because it is already well-integrated into many aspects of daily life. However, in the United States, where we have a Constitutional separation of church and state and an espoused belief in the respect for differences in religious belief, it has been a challenge to integrate spiritual care into health care, especially when operating within a secular institution. Despite these challenges, the relevance of spiritual concerns across the life span, but particularly as the end of life draws near, has been receiving more attention from health care providers and institutions.

In this issue of Innovations, we present an interview with Dr. Christina Puchalski, who has designed a short spiritual history for physicians and others to access the patient’s perspective on these issues. Dr. Puchalski is working in a larger context where we now see many efforts to develop more sophisticated methods to measure the impact of religiousness/spirituality on physical and mental health. ^1,2

Currently, there are multiple efforts being made to educate clinicians from a variety of disciplines and others about the spiritual aspects of care for patients. These efforts include courses in medical schools and CME opportunities in residency and nursing programs. There are also efforts to educate the larger public. Further research is being undertaken to correlate results of the medical research with the beliefs and practices of believers from different religious perspectives.

Dr. Puchalski’s work exemplifies another area of activity: practical programs and efforts that focus on integrating patients’ spirituality into their medical care. These efforts focus on screening tools, treatment plans, networking with chaplains and congregations, the roles of doctors, nurses, and patients, etc. End-of-life care is a particularly salient area of interest for these efforts to integrate spirituality.

Linked to a renewed interest in the impact of spiritual beliefs on the lives and well-being of patients is the interest in the spirituality of the medical caregivers themselves, i.e., physicians and nurses. Their faith and spirituality is being studied and programs are being developed that focus on the care and nurture of their spiritual well-being. These efforts occur in a larger context of an ongoing effort to promote relationship-centered care that depends on caregivers cultivating self-awareness and self-knowledge as prerequisites to developing therapeutic relationships with patients.³

Faith-based healthcare systems are investigating how to make their organizations "spirituality friendly." In other words, how can the spiritualities of the employees and associates be respected and encouraged? In particular, there is a question about the "spiritual groundedness" of individuals who would be leaders in faith-based healthcare organizations. These efforts include an effort to make clear what "faith-based" care looks like and to increase its presence. At least two different faith-based organizations have ongoing efforts along these lines. Advocate Health Care, an integrated health delivery network of 24,000 associates who work across the continuum from hospice to acute care is in the midst of a research and organizational change effort to explore what "faith-based" means to their practitioners.

Another effort to name and operationalize what it means to be "faith-based" comes from the Daughters of Charity National Health System. Their effort has resulted in Spirit Care, a focus on the delivery of spiritual health for patients, clients, employees, staff and the community that aims to objectify spiritual health care issues and to identify and bring about desired health outcomes.⁴ This effort has resulted in several videotapes, to be used to explore spiritual health care delivery (See Resources and Tools page for more information.) Institution-wide efforts to clarify what a spiritually based institution means by being "faith-based" as it operates in a heterogeneous society address the same tension that I named at the outset. How do we apply our faith to interactions with others who may not share that same faith? What kinds of behaviors, policies, attitudes cross-cut particular sets of beliefs and make room for potentially diverse sets of patient spiritual beliefs in a health care setting?

Finally, there is an interest in spirituality within biomedical and healthcare organizational ethics. There are three aspects to this concern. The first concerns the ethical problems that will come about as healthcare systems attempt to integrate spirituality into patient care. The second concerns the fact that spiritual beliefs and practices enter significantly into the difficult moral decisions people have to make as they face medical realities. The third concerns spirituality as a grounding for "everyday ethics," for the struggle to implement values into the day-in day-out delivery of healthcare.

We invite you to explore these questions of how to integrate spirituality into health care in the current issue of Innovations. Consult with Dr. Puchalski on the on-line discussion and access the Read More and Resources and Tools pages for further readings and resources.

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References

1. Scientific Research on Spirituality and Health: A Consensus Report, National Institute for Healthcare Research.
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2. Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research, John E. Fetzer Institute Publication.
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3. Tresolini CP and the Pew Fetzer Task Force. Health Professions Education and Relationship-centered Care. San Francisco, CA: Pew Health Professions Commission, 1994.
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4. Creating a Culture of Universal Healing. National Focus. Daughters of Charity National Health System- West Central, 1997.
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