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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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  • Hospice Care
  • Clergy and Faith Communities
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    Back to Module 3: Whole-Patient Assessment
    Nine Dimensions

    Step 7. Spiritual Step 8. Practical

    Step 7. Spiritual Assessment

    Importance of the Spiritual Life to Social Assessment

    • Each person has a spiritual or transcendent dimension to his or her life
    • Physicians often hesitate to inquire into this universal dimension of human experience, yet studies suggest patients welcome the inquiry
    • Spiritual life is understood by some in terms of religious feeling, and by others in terms of personal meaning in a larger context
      • We mean here to cover either interpretation of the term

      • Find the interpretation most fitting to the patient

      • In either case there is no need to emphasize a mysterious aspect to this part of a person’s experience. It is a universal and important part of each individual’s life
    • Individuals who report a strong spiritual life often also report:
      • A greater sense of purpose
      • A greater sense of having come to terms with dying
      • Better communication
      • Better relationships
    • The physician should bear in mind the possibility that patients can experience significant spiritual growth and gain meaningful fulfillment during their last stage of life
    • The physician should know:
      • How spiritual this patient has tended to be in the past
      • How inclined toward spiritual life he or she now is
      • Whether or not he or she would like (or has) a pastor to visit
      • Whether there are religious rituals that are important to the patient

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    Meaning of Illness and Fears

    Fears and Concerns about Illness

    • Patients facing a life-threatening illness are often thinking about questions that they do not articulate easily or freely
    • It often requires someone, such as the physician, to give permission
    • Nearly universal questions include:
      • What will happen to me?
      • How will the illness proceed?
      • What will happen to my child?

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    Fears and Concerns about Death and Dying

    • Patients frequently will be thinking about death and dying, with questions such as:
      • How will I die?
      • Where will I die (home, nursing home, ICU, hospice etc.)?
      • What do I need to do (estate planning, life review, advance care planning etc.)?
      • How will my child die? Where will my child die?
    • The physician may give permission for people to talk about these things by introducing the subject in a general way by saying,
      • "Many people in your situation think about dying. Is that something you are thinking about?"

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    Changes and Losses

    • As patients face these questions, they also have to adjust to major changes and losses
    • In their personal world, they will likely be thinking:
      • Who will care for the people I love that depend on me?
      • Who will care for me?
      • Will I be a burden?
      • Will they still love/respect me?
      • What about my job?
    • Parents of a dying child will be thinking:
      • How can I go on without my child?
      • How can I let my child die?

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    Loss of Control

    • People face, or fear, loss of control in multiple spheres
    • Plans are trumped by the illness
    • Independent people who have never considered being otherwise now face dependence
    • Loss of body control, including the ability to feed, bath, and toilet oneself, is certainly a frequent concern
    • These losses of control are associated in many people’s mind with indignity and shame

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    Spiritual Activities

    Importance of Religion

    • While it is helpful know the religion and religious denomination a person affiliates with, the degree to which religion is important must be evaluated separately
    • Ask questions about:
      • How often the patient has gone to services in the past and whether he or she would like to do so now

      • If there are particular prayers or scriptural resources that mean a lot to the patient that he or she may need help with
    • Some patients engage in spiritual activities that are outside of organized religion. The level of activity in these pursuits is also relevant

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    Religion and the Patient-Provider Relationship

    • Occasionally, physicians feel comfortable praying with a patient
    • Many patients would like their physician to do so
    • This is not a necessary part of the patient-physician relationship
    • However, it can be helpful if the physician is comfortable allowing the patient to express religious feeling
    • The physician should be sure that the best available resources have been made available to the patient for his or her spiritual care

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    Clergy

    • Training in end-of-life care for clergy is not more developed than for physicians
      • Many pastors working in the community have not received any specific training in end-of-life care
    • However, end-of-life care is a part of most religious groups’ framework
    • Some patients will do better with their own pastor from their existing community as part of the treatment team
    • Chaplains working in health care institutions:
      • May have much more training related to the spiritual care of people who are very ill

      • May be able to assist the patient and their local clergy

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    Rituals

    • Ask if the patient wants special prayers, declarations, rituals or last actions
    • Someone should be sure that special prayers or actions and last prayers or declarations are carried out as the patient and family would like them to be

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    Spiritual Suffering and Spiritual Crises

    • Many aspects of advanced illness are not commonly appreciated to be fundamentally spiritual. Yet...
      • The search for meaning and purpose in life is a spiritual quest

      • Perceived loss of connection to a community or to a way of life may challenge the sense of meaning and purpose

      • Feelings of guilt or unworthiness may be manifestations of spiritual suffering
    • If these aspects of spiritual suffering remain unrecognized, an appropriate plan for relief cannot be instituted
    • Other aspects of advanced illness may be more conventionally noted to be spiritual. For example, patients may:
      • Question their faith
      • Express a desire for forgiveness and reconciliation
      • Feel abandoned by God

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    Approaches to Spiritual Assessment

    • Suspect spiritual pain in a patient who is facing a life-threatening illness
    • Establish a conducive atmosphere that invites discussion of spiritual issues
    • Express interest and ask specific questions, such as:
      • "Are you a spiritual person?"

      • "What role does religion play in your life?"

      • "Have you thought about what will happen after you die?"

      • "What are the things that matter most to you?"

      • "How have you tried to make sense of what’s happening to you?"

      • "If you were to die suddenly, are there important things you feel would be left undone?"

      • "As you look back on your life, what has given your life the most meaning?"

      • "What are some of the things that give you a sense of hope?"
    • Listen for broader meanings in patients’ descriptions of their situation and how they are feeling
    • Be aware of your own beliefs and biases towards religion and the spiritual dimension
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