An Exploratory Study of Spiritual Care at the End of Life

Timothy P. Daaleman; Barbara M. Usher; Sharon W. Williams; Jim Rawlings; Laura C. Hanson

doi:10.1370/afm.883

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Author Response
Timothy Daaleman, DO, MPH

Published on: 10 October 2008
Spiritual Distress as Part of Spiritual Care
George F. Handzo

Published on: 19 September 2008

Published on: (10 October 2008)
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Author Response
Timothy Daaleman, DO, MPH, Chapel, Hill, NC
As a chaplain, Dr. Handzo provides an important perspective to the major questions that drive our work. Who provides spiritual care and how is it delivered at the end of life? Is spiritual care associated with salient outcomes, such as better overall care and satisfaction with care? To begin, it’s critical to keep in mind that patients are largely receptive to the assessment of their spiritual care needs, but in specifi...
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As a chaplain, Dr. Handzo provides an important perspective to the major questions that drive our work. Who provides spiritual care and how is it delivered at the end of life? Is spiritual care associated with salient outcomes, such as better overall care and satisfaction with care? To begin, it’s critical to keep in mind that patients are largely receptive to the assessment of their spiritual care needs, but in specific clinical contexts. Few patients, for example, desire such an assessment during routine physician office visits, and most are unwilling to trade off time spent discussing medical issues for conversations related to spiritual concerns.(1) However seriously ill and dying patients do want greater attention given to their spiritual needs, and there is an acknowledged recognition of the spiritual care provided to patients and family caregivers approaching the end of life.(2)
In such settings, our data consistently demonstrate that spiritual care is not the exclusive domain of chaplains and clergy. For example, from a stratified sample of 100 long-term care facilities across 4 states, family members reported that residents who died in long-term care (LTC) facilities received spiritual care from multiple sources, including clergy and chaplains (85%), family and friends (62%), facility staff (37%), and others (17%).(3) Another sample of seriously ill patients and their families also identified several types of spiritual care providers; family and friends (41%), health care providers (29%), and clergy (17%).(4)
We could not verify, as Dr. Handzo posited, that spiritual/religious struggle and distress were major components of spiritual care, a finding which Fitchett reported in 15% of seriously ill patients.(5) In our quantitative study – the companion to the current qualitative study under discussion – recipients of spiritual care identified 21 different types of spiritual care activities.(4) The most common types were helping to cope with the illness and helping to be at peace with loved ones; helping with spiritual/religious struggle and distress were not reported.(4)
We were pleased to find that most dying patients and family members reported receiving spiritual care, and that this care was associated with better overall end-of-life care.(3, 4) In long-term care settings, overall care was rated more highly among those who received care from facility staff, but there was no difference if care was received from clergy, or family and friends.(3) We also found considerable variation in the quality of spiritual care that was reported. Only half of patients and family caregivers, for example, were very or somewhat satisfied with the spiritual care that they received at the end of life. Notably, satisfaction was not associated with who provided it.(4)
In summary, our data suggest that role-based models of spiritual care,(6) advocated by Dr. Handzo, may need to be seriously reconsidered. Before mandating spiritual care guidelines, it would be useful to know how to best meet the spiritual care needs of those patients and family members living in the light of death, that most human of experiences.
REFERENCES
1. MacLean CD, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality. Journal of General Internal Medicine. 2003;18:38-43. 2. Field MJ, Cassel CK. Approaching Death. Washington, DC: National Academy Press; 1997. 3. Daaleman TP, Williams CS, Hamilton VL, Zimmerman S. Spiritual care at the end of life in long-term care. Medical Care. 2008;46:85-91. 4. Hanson LC, Dobbs D, Usher B, Williams SW, Rawlings J, Daaleman TP. Providers and types of spiritual care during serious illness. Journal of Palliative Medicine. 2008;11:907-914. 5. Fitchett G, Murphy PE, Kim J, etal. Religious struggle: prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients. Int J Geriatr Psychiatry. 2004;34:179-196. 6. Puchalski CM, Lunsford B, Harris MH, Miller RT. Interdisciplinary spiritual care for seriously ill and dying patients: a collaborative model. Cancer Journal. 2006;12:398-416.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (19 September 2008)
Page navigation anchor for Spiritual Distress as Part of Spiritual Care
Spiritual Distress as Part of Spiritual Care
George F. Handzo, New York, USA
Dr. Daalman and his colleagues have produced an important and well done study which starts to describe the landscape of spiritual care to those at the end of life. If, as we believe, dying is primarily a spiritual event, then it is essential for care teams to know what spiritual care is in this context and how it can best be delivered. It is also important to highlight, as this paper does well, that spiritual care can be and sho...
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Dr. Daalman and his colleagues have produced an important and well done study which starts to describe the landscape of spiritual care to those at the end of life. If, as we believe, dying is primarily a spiritual event, then it is essential for care teams to know what spiritual care is in this context and how it can best be delivered. It is also important to highlight, as this paper does well, that spiritual care can be and should be delivered by any and every member of the team. The three elements of spiritual care enumerated in this article are well described and should be helpful to any care team that is open to the true breadth of what spiritual care means. They all emphasize the importance of interpersonal relationships and openness on the part of all care givers to this degree of intimacy. This is clearly not a mechanical process that can be administered from afar. The major omission of the study is its failure to appreciate and include spiritual/religious struggle and distress as essential components of spiritual care. The literature review seems to have missed some of the work of George Fitchett in this area (Fitchett G, et al (2004) Religious struggle: Prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients. International Journal of Psychiatry in Medicine 34, 179-196) as well as the work of the National Comprehensive Cancer Network’s Distress Management Guidelines Panel. The case examples from Interviews 2 and 9 in the section on Barriers to Spiritual Care are good examples of spiritual distress that did not seem to be recognized by the team. While it is true that, especially at the end of life, every team member has a role in every realm of care including physical, psycho-social and spiritual, each one of these realms has a specialist whose job it is to assess and properly treat the more complicated issues. In spiritual care, that specialist is the board certified chaplain. A certified chaplain has the skills to deal with the spiritual/religious issues depicted in these two interviews and to assist people in resolving spiritual/religious distress. Thanks again to Dr. Daalman and his group for this well-done and helpful study.
Competing interests: None declared
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Competing Interests: None declared.