[Sent 7 July 2021 to my wife and our three daughters]
Good evening. I deeply appreciate our conversations today, recognizing my reaching the proverbial ‘three score and ten’ life marker. As this day approached, I have paused frequently to reflect in fresh ways on one answer to the question “What have these 70 years been about?” – i.e., a search for ‘a very healthy center’ (eine sehr gesunde Substance – a phrase from Dietrich Bonhoeffer’s 24 July 1943 secret letter smuggled out of a Nazi prison).
To illustrate, I have inserted below the first section from the most recently revised draft of a Grand Rounds presentation on assessing patients’ spiritual wellbeing I was invited to deliver in August 2000 for the Obstetrics and Gynecology residents in the Phoenix area. The selection inserted below introduces how a search for ‘a very healthy center’ has merged/integrated my personal experience with my professional experience. The impetus for the 2000 Grand Rounds presentation came from my preparation for participating in the creation of an educational video being developed at Vanderbilt as a tool for in-servicing hospital staff re assessing patients’ spiritual needs (which Joint Commission had recently added as an accrediting standard).
To strengthen my attention, I have returned to a set of comments chosen from the writings of one of the abiding seminal/pivotal thinkers in my ‘search for a very healthy center’ – Simone Weil.
The
afflicted have no need of anything else in this world except someone
capable of paying attention to them. The capacity to pay attention to an
afflicted person is something very rare, very
difficult. Nearly all those who believe they have this capacity do not.
Warmth, movements of the heart, and pity are not sufficient. The
fullness of love for neighbor is simply the capacity to ask the
question, ‘What is your agony?’ It is to know (recognize)
that the afflicted exist, not as a unit in a collection, nor as an
example of a social category labeled ‘the afflicted,’ but in all their
humanity, exactly like us, who have been stamped and marked by an
inimitable mark, by their affliction. For this reason,
it is sufficient but also indispensable to know how to look upon them
in a certain way. This look is first of all an attentive look, when the
soul empties itself of all its own contents in order to receive into
itself the being that it is looking at, just
as it is, in all its truth. It is only capable of this if it is capable
of attention. Attention is the rarest and purest form of generosity.
With unending love, Doug/Dad
_________________
[Selection from my essay -- Assessing a Patient’s Spiritual Well-being]
For several years, the senior physician – David McRay, MD -- at the Appalachia community health center where I worked (1997-2006 as a member of the executive leadership team) and I met weekly to review his most perplexing and burdening patient encounters. Consider this summary narrative of one such case:
It was a busy Wednesday afternoon. The patient – new to our health center -- was in her late-20s, had four children, and was now 32-weeks pregnant. The fetus’ fundal height was smaller than expected. She had received no prenatal care. A colleague asked David to do an ultrasound. The patient was sitting on the edge of the exam table when David and a nurse entered the room. David helped the patient into a supine position. She was covered with a sheet up to her blouse. The nurse turned down the light. As David began the exam, the patient said barely above a whisper, “I have a lot of scars.” David’s first thought – “surgery . . . perhaps a previous c-section”. Once he saw the scars, he thought – “accident . . . perhaps a burn”. He asked the patient, “Did you have a car accident or . . . ?” She interrupted and, as she starred at the wall, said quietly, “My mother set me on fire when I was three.” David had no response. It turned out the baby was fine. As we later reflected on the case, David explained to me, “Her life is so far removed from my range of experiences. I did not know how to respond. She will never be free of this childhood experience, these scars. If my mother had . . .” His voiced trailed off.
When the patient whispered “I have a lot of scars”, she was making an existential as well as a literal comment about her wellbeing. Simply put, she was saying, “My story is broken. Can you help me fix it.” (Howard Brody, MD/PhD, is my source for this ‘story’ way to frame a patient’s meaning.)
Patients hope that entering a hospital or a clinic will be no more than a quick pit stop or, at most, a repair shop delay in their day-to-day routines and life journeys. The circumstances that lead patients to seek medical attention are often benign and/or soon resolved. In these situations, assessing a patient from a spiritual perspective may remain (by patient choice and/or by caregivers’ choice) on the periphery. By ‘periphery’ I mean that caregivers remain attentive to subtle or incidental indications that, in addition to the patient’s immediate problem, there may be a deeper ‘wound’. Such indications put the caregivers in the tough position of deciding whether they have the time, emotional capacity, expertise, and resources to determine if indeed there is a deeper ‘wound’. The circumstances that lead patients to seek medical attention may in fact have to do with a deeper ‘wound’. In these situations, caregivers need a language and perspective re spiritually in order to attend to this deeper ‘wound’.
Defining ‘Spiritual/ity’ The root meaning for ‘distress’ has to do with pressure or strain. To be distressed, therefore, is to be tense, troubled, oppressed, threatened.
‘Spiritual distress’ has to do with the loss of peace, joy, hope, and resolve individuals experience (to varying degrees) when faced with unsettling life circumstances that threaten to overwhelm their core paradigm by/within which they live day-to-day. I begin with the premise that all individuals are more than the insights made possible through various empirical analyses. In the health care sphere, this premise implies that patients are more than potential or actual illnesses and accidents; professionals, more than highly skilled scientists/technicians. To consider this ‘more’, a vocabulary and a manner of discourse -- in addition to scientific/clinical language -- are required. I have found that most (perhaps all) individuals have, with varying levels of sophistication, such vocabulary and manner of discourse. Such vocabulary and manner of discourse disclose, in the most elemental and inclusive way, each individual’s spirituality. An individual’s spirituality reaches, shapes, and sustains his/her integrity (i.e., wholeness, oneness, character).
The definition of ‘spirituality’ that has worked well over the years for me in opening discussions with health care professionals is:
‘Spirituality’ has to do with the sort of person a patient is, with the basis upon which patients’ lives have integrity and balance. Patients reveal their spiritual identity when they share their core ideas and life values and when they explain how they sustain these ideas and values. Fear, loneliness, and guilt as well as happiness, contentment, and wonder are windows into a patient’s spirituality. The definition of and approach to spirituality used in a hospital, in a clinic, and by a medical team need to be inclusive of all the patients for whom care is being delivered. Not all patients are religious. Not all patients are affiliated with a particular religion. Not all patients are members of any one sub-division of one particular religion. And crucial non-religious aspects of every patient’s spirituality are missed when ‘being spiritual’ is viewed as interchangeable with or a subset of ‘being religious’. Concerning these missed windows into a patient’s spirituality, here are some examples:
- a morning/evening walk
- participation in community/civic organizations a refreshing hobby (e.g., photography or gardening or hiking or . . .)
- participation in volunteer community service activities
- reminders of life-changing experiences
- travel opportunities
- inspiring music
- the company of a pet
- a thought-provoking book
- a favorite art gallery or museum
- social pleasures (e.g., a glass of wine or a pleasant dinner or a theater outing or a sports event)
- a special friend