Spirituality
We regard spirituality as an important aspect of palliative care. However, we do not have regular chaplain services in our program and so it often gets neglected. How can we broach spiritual issues with patients?

Assessing and responding to the spiritual needs of patients and families are important aspects of person-centred, comprehensive palliative care. However, hospice palliative care programs and settings vary widely in their spiritual care resources. Ideally, every palliative care team should include a certified spiritual care provider (i.e., chaplain) to attend to spiritual needs and concerns. While spiritual care providers are specialists, primary spiritual care falls within the purview of palliative care professionals in accordance with their training and comfort level.[1] The report on the 2009 Consensus Conference on Spiritual Care in Palliative Care refers to this as an “interprofessional spiritual care model.”[2]

The key capacity that palliative care team members need for attending to patient spirituality is the ability to identify:

  • spiritual concerns or distress; and
  • spiritual resources for coping with illness.

This capacity can be easily developed by any team member who recognizes the importance of spirituality. By asking a few simple questions about the patient’s spirituality, a team member can determine whether the patient needs the team’s assistance in meeting his or her spiritual needs. The spiritual assessment tool, FICA (© 1999 Christina Puchalski), provides clinicians with an efficient and useful way of taking a spiritual history[3]:

F—Faith, belief, meaning

  • “Do you consider yourself to be spiritual or religious?”
  • “Do you have spiritual beliefs that help you cope with stress?”
  • “What gives your life meaning?”

I—Importance and influence

  • “What importance does your faith or belief have in your life?”
  • “On a scale of 0 (not important) to 5 (very important), how would you rate the importance of faith/belief in your life?”
  • “Have your beliefs influenced how you take care of yourself in this illness?”
  • “What role do your beliefs play in regaining your health care decision making?”

C—Community

  • “Are you part of a spiritual or religious community?”
  • “Is this of support to you and how?”
  • “Is there a group of people you really love or are important to you?”

A—Address/action in care

  • “How would you like your health care provider to use this information about your spirituality as he or she cares for you?”

Depending on the patient’s response, you might ask additional questions, such as the following:

  • “How well is your faith (or spirituality) working for you at this time?”
  • “What spiritual (or religious) practices give you inner strength during your illness?” “Do you need any help with these?”
  • “What spiritual (or faith) community supports you?” “Are you in contact with them?” “Do you need help to connect with them?”

Ask questions like these in a respectful and sensitive way because they probe areas that may be at the core of the patient’s identity. When patients share what is important to them spiritually during their illness, they provide the information you need to include spiritual care in your plan. If a patient expresses spiritual distress or has specific spiritual needs, teams without a designated spiritual care provider may need to refer the patient to a community spiritual leader, spiritual care volunteer, spiritual director, pastoral counsellor or parish nurse. Such referrals should be made only with the patient’s consent.

Spiritual distress is not limited to patients who consider themselves religious. Even if a patient has indicated that religion or spirituality are unimportant, team members should be alert for signs of spiritual distress. Expressions of any of the following are common signs of spiritual distress:

  • meaninglessness;
  • despair/hopelessness;
  • alienation/estrangement;
  • abandonment/isolation;
  • guilt/shame; and
  • anger.

When a patient strongly expresses any of these feelings, team members should ask about their root and inquire whether the patient needs assistance in working through them.

Including community spiritual leaders as part of the larger palliative care team is especially important for teams without regular chaplain services. This requires becoming acquainted with your community’s spiritual leaders and what they have to offer. According to the consensus report, “when building relationships with community religious leaders or spiritual care providers, it is important for the interprofessional teams to determine what training the person has, since this can vary widely.”[2]

The health care team needs to be confident that patients and families referred to community spiritual leaders will receive respectful, compassionate and competent spiritual care. The team can work with community spiritual leaders who are able to provide appropriate spiritual care to develop methods for making referrals. Discussions with these leaders about the use of pain medicines and life-sustaining treatments within the palliative care program could help to develop common understandings and supportive relationships. The palliative care team could also work with community spiritual leaders to develop a training program for spiritual care volunteers in the palliative care program.

Knowledge of spiritual issues related to illness and bereavement is regarded as fundamental to end-of-life care according to Canadian Hospice Palliative Care Association (CHPCA)’s A Model to Guide Hospice Palliative Care.[4] Trained and certified spiritual care providers (chaplains) can play an important role in helping palliative care teams develop their spiritual care capacity. While there is much that a palliative care team can do to meet the spiritual needs of patients without the leadership of a chaplain, adding a chaplain to the team should be an important goal. How to reach this goal will depend on the setting. It may require strategic planning at the team, organizational, regional or provincial level, or at a combination of these. Perhaps you have a role in helping this happen by continuing to highlight the spiritual needs of your patients and working to find ways of responding to them effectively.

References

1. Sinclair S, Chochinov, HM. Communicating with patients about existential and spiritual issues: SACR-D work. Prog Palliat Care. 2012; 20(2):72-78.

2. Puchalski C, Ferrel B, Virani R, et al. D. Improving the quality of spiritual care as a dimension of palliative care: the report of the consensus conference. J Palliat Med. 2009;12(10):885-904.

3. Puchalski CM, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med 2000;3:129-137.

4. Ferris FD., Balfour HM, Bowen K et al. A Model to Guide Hospice Palliative Care. Ottawa, ON: Canadian Hospice Palliative Care Association; 2002.