MDs perspective on EOL spiritual care
MDs perspective on EOL spiritual care
Meshing spiritual with science
In addressing spiritual care for their patients at the end of life, physicians often face the challenge of how to mesh the spiritual concerns with objective science, which is a challenge that sometimes results in a "significant disconnect" with patients, said Rabbi Barry M. Kinzbrunner, MD.
Kinzbrunner, who is senior vice president and chief medical officer of Vitas Innovative Hospice Care in Miami, was a speaker at the recent 11th Clinical Team Conference and Pediatric Intensive sponsored by the National Hospice and Palliative Care Organization.
Because pain can be psychosocial, spiritual, as well as physical, to illustrate all the contributors to "total pain," Kinzbrunner, who is trained as an oncologist, offered The Portenoy Model, published in 1988 in the CA: A Cancer Journal for Clinicians.1 One of the major contributors to suffering at the end of life, according to that model, is fear of death, along with other contributors, such as loss of work, physician disabilities, and financial concerns.
The word "spiritual," he noted, is derived from the Latin "spiritus," meaning breath. However, trying to define spiritual care can be difficult. For example, he said, a literature review uncovered 92 definitions of spirituality, with seven "definitional themes," including:
"relationship to a higher power or reality greater than self;
"not of the self;
"transcendence or connectedness unrelated to belief in a higher being;
"not of the material world;
"meaning and purpose in life;
"life force of the person; integrating aspects of the person;
"summative definitions that combined multiple themes."2
In other definitions of spirituality, he noted that religion is seen, in some sense, as a subset of spirituality.
He explained that in the guidelines on chaplaincy and spiritual care in the National Health Service Scotland that "spiritual care is not necessarily religious. Religious care, at its best, should always be spiritual."3
"One does not necessarily exclude the other," Kinzbrunner says.
In a study of palliative care physicians and spirituality by Seccareccia and Brown, the study found, according to Kinzbrunner's presentation, that "physicians described spirituality as a multidimensional construct that may involve:
a search for meaning and purpose;
a sense of connectedness;
a relations to a higher being or power;
The study also found that "spirituality is different than religion," he said, with the study suggesting that "religious patients often were described as experiencing distress related to what they perceived as punishment from God."
Another finding, according to the presentation, was that "the authors conclude that the impact of a physician's personal spirituality on practice and practice on spirituality were inextricably woven together."4
What makes this work?
The message from this study's findings, according to Kinzbrunner, is that "physicians have to be spiritual, as well, to make this work; if there is no spirituality by the [physician], then it's very hard for the patient to express" spiritual/religious concerns.
Kinzbrunner also noted that the latest Pew research showed that 90% of Americans believe in and pray to a higher power. However, in one study by Curlin et al, 66% of physicians say that in treating patients, they do not consider "what would God want me to do."5
In a 2009 study by Fitchett et al on physician's experience and satisfaction with chaplains, of the 1,102 physicians surveyed, the respondents identified themselves as 59% Christian; 16% Jewish; 14% other; and 10% no religious affiliation. However, 41% of respondents agreed with the statement, "My whole approach to life is based on my religion." Also, 50% of respondents believed it was appropriate to pray with patients, Kinzbrunner notes.6
Kinzbrunner explained that in a 1999 study by Ehman et al, 51% of 177 respondent patients in a pulmonary outpatient clinic identified themselves as "religious," while 90% responded that they believed that prayer may sometimes influence recovery from an illness.7
In a 2008 study by Jacobs et al, it was found that "57.4% of the public and 19.5% of the professionals believe that divine intervention could save a person when physicians believe treatment is futile."8
"More than half of the public believes in a miracle," according to that study, Kinzbrunner noted. "The public is more often looking for a miracle than the people taking care of them, and that, to me, speaks volumes."
A 2007 study by Balboni et al found that 88% of 230 patients "considered religion to be at least somewhat important," according to Kinzbrunner's presentation.9 Also, "spiritual support by religious communities or the medical system was significantly associated with patient quality of life," with 47% reporting "spiritual needs minimally or not met by [the] religious community"; while 72% reporting "spiritual needs minimally or not met by [the] medical community." Another finding of the Balboni study was that "religiousness was significantly associated with wanting all measures to extend life."
Americans are "much more tolerant of cultural diversity than religious diversity," Kinzbrunner suggested. "I think what's beginning to happen in this country is that if you're religious, what you want must be wrong," he said. He also noted that just as we tend to think outside the box on how to provide patient care to those with cultural diversity, we should try to do the same for those with religious diversity.
Another study by Balboni et al on the impact of spiritual care on the perception of the quality of medical care and quality of life near death "shows you how important spiritual care is," Kinzbrunner said.10 So, even for people who are not religious, spiritual care is important at the end of life, and it requires the participation of the entire health care team, including physicians, he said.
1. Portenoy R. Practical aspects of pain control in the patient with cancer. CA Cancer J Clin. 1998;38:332.
2. Unruh AM, et al. Spirituality unplugged: A review of commonalities and contentions, and a resolution. Can J Occup Ther 2002;69:5-19.
3. Guidelines on Chaplaincy and Spiritual Care in the NHS in Scotland SEHD, October 2002.
4. Seccareccia D, Brown JB. Impact of spirituality on palliative care physicians: Personally and professionally. J Pall Med 2009; 12:805-809.
5. Curlin FA, et al. Religious characteristics of U.S. physicians: A national survey. J Gen Intern Med 2005;20:629-634.
6. Fitchett G, et al. Physicians' Experience and Satisfaction with Chaplains: A national survey. Arch Int Med 2009; 169:1808-1810.
7. Ehman JW, et al. Do patients want their physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Int Med 1999;159:1803-1806.
8. Jacobs LM, et al. Trauma death: Views of the public and trauma professionals on death and dying from injuries. Arch Surg 2008;143:730-735.
9. Balboni TA, et al. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol 2007;25:555-560.
10. Balboni TA, et al. Provision of spiritual care to patients with advanced cancer: Associations with medical care and quality of life near death. J Clin Oncol 2010;28:445-452.In addressing spiritual care for their patients at the end of life, physicians often face the challenge of how to mesh the spiritual concerns with objective science, which is a challenge that sometimes results in a "significant disconnect" with patients, said Rabbi Barry M. Kinzbrunner, MD.
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