[Sent – 17 September 2019 to the 170+ surgeons et al of our Surgical Ethics (Education) Consortium]
Greetings from St. Louis and WashU. For ‘Surgical Ethics Education Resources’ communication #22, I am sharing with you the first of two selections from the most recently revised/updated draft of a Grand Rounds presentation I initially prepared/delivered two decades ago titled “Addressing patients’ spiritual wellbeing”. The impetus then was the opportunity to participate in the creation at Vanderbilt of a training video for in-servicing hospital staff in response to the new Joint Commission accrediting standard re addressing patients’ spiritual needs. Note – the definition/differentiation of the spiritual dimension of patient care I am offering for your consideration in this and the following communication focuses on the integrity of every patient and family whether or not they are religious. I remain convinced that this definition of and approach to spirituality is relevant to ethics. I welcome your feedback and would be pleased to learn about ways you have found to incorporate attention to patients’ spiritual (in)stability when challenged by illness or injury. Doug
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[These reflections represent the most recently revised draft of a Grand Rounds presentation on the subject of assessing patients’ spiritual wellbeing I was invited to deliver in August 2000 for the Obstetrics and Gynecology residents in the Phoenix area. I prefaced the presentation by (1) describing my role with an intervention project at the University of Miami for 125 cocaine-abusing women who had prematurely delivered cocaine-exposed babies, (2) explaining my responsibilities as a member of the executive leadership team for a non-profit community health center serving medically un(der)served patients and families in three truly rural counties of eastern Tennessee and Kentucky, (3) summarizing my contributions as an adjunct faculty member with Michigan State University’s Center for Ethics and Humanities in the Life Sciences in the development of a curriculum for addressing spirituality in medical education, and (4) recalling my first wife’s fourteen-year struggle against her deterioration and eventual death due multiple sclerosis. The impetus for clarifying my thought re ‘spirituality and medicine’ came from preparing to participate in the creation of an training video that was being developed at Vanderbilt in 2000 as a tool for in-servicing hospital staff re assessing patients’ spiritual needs (which Joint Commission had recently added as an accrediting standard).]
Greetings from St. Louis and WashU. For ‘Surgical Ethics Education Resources’ communication #22, I am sharing with you the first of two selections from the most recently revised/updated draft of a Grand Rounds presentation I initially prepared/delivered two decades ago titled “Addressing patients’ spiritual wellbeing”. The impetus then was the opportunity to participate in the creation at Vanderbilt of a training video for in-servicing hospital staff in response to the new Joint Commission accrediting standard re addressing patients’ spiritual needs. Note – the definition/differentiation of the spiritual dimension of patient care I am offering for your consideration in this and the following communication focuses on the integrity of every patient and family whether or not they are religious. I remain convinced that this definition of and approach to spirituality is relevant to ethics. I welcome your feedback and would be pleased to learn about ways you have found to incorporate attention to patients’ spiritual (in)stability when challenged by illness or injury. Doug
___________________
[These reflections represent the most recently revised draft of a Grand Rounds presentation on the subject of assessing patients’ spiritual wellbeing I was invited to deliver in August 2000 for the Obstetrics and Gynecology residents in the Phoenix area. I prefaced the presentation by (1) describing my role with an intervention project at the University of Miami for 125 cocaine-abusing women who had prematurely delivered cocaine-exposed babies, (2) explaining my responsibilities as a member of the executive leadership team for a non-profit community health center serving medically un(der)served patients and families in three truly rural counties of eastern Tennessee and Kentucky, (3) summarizing my contributions as an adjunct faculty member with Michigan State University’s Center for Ethics and Humanities in the Life Sciences in the development of a curriculum for addressing spirituality in medical education, and (4) recalling my first wife’s fourteen-year struggle against her deterioration and eventual death due multiple sclerosis. The impetus for clarifying my thought re ‘spirituality and medicine’ came from preparing to participate in the creation of an training video that was being developed at Vanderbilt in 2000 as a tool for in-servicing hospital staff re assessing patients’ spiritual needs (which Joint Commission had recently added as an accrediting standard).]
Assessing a Patient’s Spiritual Wellbeing: A Few Suggestions (1)
Douglas Brown, PhD
1. When to consider a patient’s spiritual wellbeing:
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 way to frame a patient’s meaning.)
Imagine you and the care team are looking down a hallway with patients in most of the exam rooms. Whether or not the patients in these rooms share similar definitions of or approaches to spirituality is immaterial to each patient. The patients are not together in the hospital as a community. What does matter to each patient ultimately is his/her own particular spirituality. However, you and the care team – moving from room to room – need a definition of and an approach to spirituality that prepare you to meaningfully integrate the ‘spiritual’ and the ‘physical’ in caring for each patient. Finding/clarifying such a definition of and approach to spirituality is no simple task.
Most hospitals and outpatient clinics exist to respond to patients’ physical needs and, therefore, are centered by scientific/clinical language. Scientific/clinical language is the ‘first language’ of these health care settings. With symptoms, with injuries, with diseases, . . . – patients enter anticipating that their physical conditions can be corrected or brought under control. The expansion/deepening of the scientific knowledge base and the introduction of increasingly sophisticated technologies continue to concentrate attention on patients’ physical interests in health care settings.
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’. And 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 the patient’s needs.
2. Objectives for considering a patient’s spiritual wellbeing:
Given the immediate attention in most health care settings to patients’ physical needs, the objectives for integrating attention to spiritual wellbeing into patient care need to be precise and appropriately circumscribed. Hospitals and outpatient clinics do not have purposes parallel to spiritual retreat centers, synagogues, churches, mosques, . . . . What would be objectives for attending to a patient’s spiritual wellbeing that are consistent with the purposes of health care settings? Possible answers might be (1) to insure effective communication, (2) to show respect for and understanding of patient preferences regarding their medical care, (3) to maximize the health benefits associated with optimizing a patient’s capacity to implement the treatment plan, (4) to search for factors contributing to a patient’s failing health, (5) . . . .
Attending to patients’ spiritual wellbeing, then, has to do with minimizing the spiritual disturbance they are experiencing due to being in a hospital and/or due to injury/illness in order to maximize the benefits from their spiritual resources (1) for making decisions about their care and (2) for realizing their full measure of healing. To make the objectives for assessing a patient’s spiritual wellbeing concrete, think in terms of assessing patients’ centeredness – their balance and focus. It is crucial that a patient has (or recovers) sufficient balance and focus to communicate well (which requires listening carefully, thinking courageously, and speaking clearly) and to participate appropriately in decisions about his/her care.
Attending to patients’ spiritual wellbeing, then, has to do with minimizing the spiritual disturbance they are experiencing due to being in a hospital and/or due to injury/illness in order to maximize the benefits from their spiritual resources (1) for making decisions about their care and (2) for realizing their full measure of healing. To make the objectives for assessing a patient’s spiritual wellbeing concrete, think in terms of assessing patients’ centeredness – their balance and focus. It is crucial that a patient has (or recovers) sufficient balance and focus to communicate well (which requires listening carefully, thinking courageously, and speaking clearly) and to participate appropriately in decisions about his/her care.
Assisting patients in the recovery of balance and focus is, in my judgment, the primary goal/consequence that makes giving attention to spiritual wellbeing pertinent to caring for patients. (Fear of) serious illness or injury can challenge/threaten patients’ balance and focus, thus raising crucial questions about the credibility of the spiritual foundation upon which they have built their lives. A hospital is a particularly difficult setting in which to face this possibility. Sheer pain may eclipse a patient’s use of his/her spiritual resources. By being in a clinic exam room or in a hospital, s/he is distant from (or even cut off from) the activities and experiences essential to his/her spirituality. Then again, a patient’s spirituality may be contributing to his/her loss of balance and focus.
Loss of balance and focus may be a deeply significant process by which a patient’s spirituality is tested and eventually strengthened. How many individuals, before being confronted with (the possibility of) significant injury or disease, have ever taken seriously the existential premise that facing one’s finitude is prerequisite to authentic living? Whatever the number who have, the fraction is far too low for caregivers to assume that patients will retain their balance and focus when faced with (the real possibility of) life-threatening injury or disease. Caregivers, thus, may face a dilemma -- (1) on the one hand, they need their patients to be balanced and focused in order for treatment decisions/plans to flow, (2) while on the other hand, they may have to give some of their patients time/opportunity to experience the spiritually refining/restructuring that may be necessary for them again to be centered.
[continued in Part 2]