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  • 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
  • More About:

  • Hospice Care
  • Clergy and Faith Communities
  • Additional Links
    Site Index
    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


    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?


    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?"


    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?


    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


    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


    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



    • 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



    • 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


    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


    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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