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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 14: Table of Contents
    Part I: How to Assess Spirituality

    When to Ask
    What to be Prepared for When You Ask
    How to Ask When and How to Refer to Professional Spiritual Caregiver/Chaplain

    How to Ask

    General Guidelines for Spiritual Assessment

    • One approach is to ask one or two brief questions about spiritual/religious beliefs and needs in one or more of the following contexts:
      • Along with the social or lifestyle history

      • Following the discussion of terminal diagnosis

      • As new, major treatment decisions are to be faced

        Case Example

        Mrs. T has just been informed by her oncologist that her breast cancer is no longer responding to chemotherapy and has spread aggressively to other parts of her system. Her doctor recommends hospice care to control the pain and to help her family care for her in the comfort of her own home. Mrs. T expresses concerns about how her adult children will take the news, "I just know this will devastate them." The doctor explains that the hospice team will help her family adjust and communicate about the news. She then asks, "Where do your children usually turn to during difficult times for support? Do your children have any spiritual beliefs or practices that might give them strength or hope?"
    • Another approach is to ask the patient and family what is most important to them during this time of illness and direct your questions to the area they indicate as highest value (e.g., my family, not being in pain, growing closer to God)
    • It is best to begin with a statement that affirms the importance of this area for some, but not all persons and indicate its direct relevance to the medical care you are providing
    • Open-ended questions are preferable
    • Use a format that avoids stereotyping but draws upon generally established beliefs and practices of a spiritual/religious tradition
    • Use language that is interfaith, not grounded in one religious or spiritual tradition
      • For example, use:

        • "Faith community" rather than "church"
        • "Religious leader" rather than "priest"
        • "Higher power" rather than "God"

      • Ask about sources of strength and hope, important customs, practices, and beliefs

      • Listen for “cues” from patient and family and use their language whenever possible
    • Avoid judgment of religious/spiritual practices and beliefs
    • Refrain from extensive intellectual exploration of specific religious doctrines and dogma
    • Be aware of your own framework, biases, and comfort zone in this area
    • Respect patient/family/cultural privacy in this area

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    Assessing the Significance of Religious Beliefs and Practices

    Asking about Religious Affiliation: Benefits and Limitations

    • That a person counts themselves a member of a faith community or religious tradition tells you little about:
      • What they actually believe and practice

      • How their beliefs and practices may influence their health care decisions at the end of life
    • Persons who are alienated from their religious tradition or who have long considered themselves to be “non-practicing” often discover, much to their dismay, the profound impact their earliest religious formation has on their experience of coping with a terminal illness and facing dying and death
    • Other persons may consciously seek reaffiliation with, or embrace certain practices of, their faith tradition at this time of crisis; death bed “conversions” are not unheard of as persons face one of life’s ultimate events
    • The extent to which this newfound religiosity penetrates the corners and crevices of a person’s consciousness directly influences the role it will play in decisions about end of life care not to mention the level of comfort it may bring that person
    • In countries such as the United States that boast religious and cultural diversity, family members may have different and even conflicting beliefs and values that impact decisions about end-of-life care
        For Example
        Considered in the abstract, the Jewish and Christian belief that each human person is created in the divine image both permits and limits the use of life-prolonging medical interventions. On the one hand, if human life is a divine and not a human creation, “doctors should not play god”. On the other hand, that human life is sacred establishes a moral foundation to preserve it, sometimes at all costs.

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    Goals of the Assessment

      To gain a “personalized” understanding of a patient’s and family’s religious/spiritual framework so as to determine how these beliefs and values may influence decisions regarding end-of-life medical care
      A “personalized” understanding requires you learn about:
    • The unique way “traditional” religious teachings have been appropriated, interpreted, and applied within a patient’s or family’s cultural subgroup and life story
        Case Example

        Joe attends weekly Catholic mass, receives sacraments, and wants the priest to do his funeral service even though he disagrees with what the official church has to say about his homosexuality
        Case Example

        Mary considers herself a Christian Scientist yet has always sought Western medical care for her cancer, including surgery and chemotherapy
    • The weight or importance this spiritual/religious framework holds for them at this particular stage in their life and illness
      • Some people return to the religious schooling of their youth as they face their own death, others do not

      • Many persons will consider themselves members of a specific religious tradition, may observe certain religious rituals and holidays, yet have not integrated the beliefs and values into their everyday living or views about illness, death, and dying
    • Conflicting or competing sets of values and beliefs that may limit the impact of the religious framework
        Case Example

        Although Mrs. Smith’s religious tradition teaches that physical life is not all there is and even professes that “man does not live by bread alone,” she is the matriarch of a large Italian family whose primary responsibility has been to show love and sustain life in and through food. She therefore insists that her daughter have a feeding tube placed when the cancer takes away her appetite and makes it hard for her to swallow
      • Remember that the need a patient or family has to prolong physical life may in fact result from psychological causes or family dynamics rather than religious beliefs per se, such as:
        • Fear that the death will cause instability to family roles
        • Unresolved grief
        • Unfinished business
    • Click here for examples of assessment questions related to this goal

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      To respect beliefs and practices related to healing, dying/death, and life after death and to affirm these as resource for patient and family coping
    • Like cultural traditions, religious and spiritual traditions may define how persons understand:
      • Health
      • Life
      • Healing
      • Illness
      • Death
    • In addition, religious and spiritual traditions offer persons ways to:
      • Make sense of suffering
      • Find strength and comfort
      • Sustain hope even when there is no medical or human cure for illness
    • Religious traditions may also offer ritualized means to:
      • Face the unknown and unpredictable
      • Resolve unfinished business
      • Face terminal illness and death
      • Affirm the value of human life
      • Provide hope of continued bonds with loved ones even after death
    • Click here for examples of assessment questions related to this goal

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      To ascertain unmet religious and spiritual needs and to determine patient and family interest in additional spiritual care
    • Just because a patient/family indicates they are “non-religious” or “non-practicing” does not mean they do not have spirituality needs or a spiritual framework that informs their lives and health care decisions
        Case Example

        Health care providers may observe that a patient is very anxious or fearful or may hear statements suggesting the existence of despair or self-blame such as, “I must have done something wrong to deserve this kind of suffering.” The patients may not consider themselves as very “spiritual” and therefore may decline a visit from the “chaplain.” However, these kinds of issues are rightly included as part of the spiritual assessment
    • Recent polls indicate that of those persons with a connection to a faith community, under 50% felt they could turn there for spiritual care at the end-of-life
    • While many clergy are trained to meet the needs of their members at this critical point in life, many are also uncomfortable or unequipped to provide care and counseling in the face of life-threatening illness
    • Click here for examples of assessment questions related to this goal

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      To uncover the existence of spiritual suffering, explore its causes, and develop a plan of care to lessen or alleviate it
    • By definition, most patients and families experience spiritual suffering during this stage of their illness and life
    • However, considerable variation exists among patients and families facing life threatening illnesses in terms of:
      • The degree of suffering
      • How physical pain and spiritual suffering are related
      • The underlying causes spiritual suffering
      • Means to address spiritual suffering
        Case Example

        Mrs. Kane had unrelieved nausea and vomiting from an obstruction in her bowel which caused her to feel as if God had abandoned her in her time of greatest need
        Case Example

        Joseph refused to take his pain medication, even though he complained constantly to the nurses and doctors that his pain was unbearable. Upon further assessment, he confessed the belief that in order to “gain entrance into paradise” he must be purified of all his bad faults and ways through suffering here
    • Click here for examples of assessment questions related to this goal
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