Spiritual care key part of holistic approach
Assessment gleans ways to give last days meaning
The patient always seemed to be in good spirits. He was lighthearted, and joked easily with hospice team members. Yet as the man neared death, the nurse discovered that he was terrified of dying and only putting up a brave front. She suggested the patient speak with the chaplain about his fear. He agreed. "Before [he was near death] he thought spiritual care wasn’t important to him," says Tim Townsend, Dmin, chaplain at Hospice of Northern Virginia’s Fairfax office.
Many patients don’t see the value of spiritual care. Only about one-third admitted to hospice request it. Yet it is a vital piece of the hospice philosophy of care that encompasses physical, emotional, and spiritual needs. "Hospice can’t be a holistic approach to care without having some sort of spiritual assessment and spiritual care as part of the package. It is like having a stool with one leg cut off," says Jay Stark-Dykema, MA, hospice pastoral counselor at CareMed Chicago Hospice.
Misconceptions obstruct spiritual care
Some hospices tell patients and their families that as part of the holistic approach a chaplain will come by to visit, but most hospices ask if they would like spiritual care. Misconceptions about the role of the hospice chaplain and past unpleasant religious experiences frequently prevent people from agreeing to a spiritual assessment and care. As a result, many who would benefit from seeing a chaplain don’t receive the service.
"We don’t make the assumption that everyone is religious, but we do make the assumption that everyone has a spiritual dimension. Therefore, the chaplain is as important as the doctor, the nurse, the social worker, or anyone else on the team," says Vincent Guss, Mdiv, director of pastoral care for the Alexandria (VA) Hospital and chairman of the bioethics committee of the Chicago-based College of Chaplains.
What makes the spiritual assessment and care so important? When people are admitted to hospice they are at a point in their lives when spiritual issues are at the forefront. People want to know the meaning of their life and how to make sense out of the situation they are in, says Stark-Dykema.
"A good spiritual assessment addresses the meaning of a person’s life and the meaning within that life of the present suffering they are going through," agrees Catherine Bates, MTS, chaplain and coordinator of pastoral care at Montgomery Hospice Society in Rockville, MD.
With the aid of a good spiritual assessment, the chaplain can help a patient facing death enjoy and celebrate his or her remaining life and find meaning in it, says Guss. The chaplain accomplishes this through conversation with the patient, all the while being attentive to gestures, facial expressions, and tone of voice, as well as words that will help identify issues the patient needs to resolve or spiritual rituals or practices that will bring peace and comfort.
While most chaplains have an assessment form, they leave it at the office and document the information gleaned from the conversation after the visit. Few sit down with a list of questions. Instead, an outline of what needs to be covered is in their mind. "Chaplains don’t want to go in as a nurse or social worker with a sheet to fill in. Developing rapport and getting patients to open up and share spiritual issues is a little different from asking if they have pain or what kind of medications they are on," says Townsend.
The written form Townsend keeps in mind when conducting a spiritual assessment has three sections. They include:
• the faith tradition of the patient and family members, and its importance in their lives;
• spiritual practices that are important to the patient such as prayer, attending worship, or reading scripture;
• issues such as a patient’s attitude toward God, guilt over things he or she has done, unresolved relationships, and fears regarding death.
There is room at the bottom of the form for a chaplain to outline a plan of care. Sometimes the plan of care is as simple as companionship, but more often it is helping a patient resolve an issue such as fear of death. "We are facilitators. We don’t fix problems; we help the patient work through them," says Townsend.
While some information sought during a spiritual assessment is straightforward, such as spiritual affiliation, other information is more difficult to obtain, like the meaning and purpose a person attaches to his or her life. "Everyone’s expression of spirituality is unique. Even though you may have a form with general areas to assess, you can’t [automatically use] any language that will fit everyone across the board. The specifics are on a case-by-case situation," says Stark-Dykema.
However, there are a few questions that work well with most people when soliciting information about a general theme. For example, to open a discussion about what has had meaning in the patient’s life and has been fulfilling, Stark-Dykema might ask: "As you look back over your life, what are the things you feel most proud of, or have been the most important kind of experience?"
The question helps the patient define what has been important and what he or she might regret or wish had been different, and helps the chaplain uncover issues where forgiveness or reconciliation can be applied. "Our conversations aren’t something people normally talk about," says Stark-Dykema.
It’s important to get people to tell their story, says Bates. The story should focus on the spiritual highlights of their life and when they felt the presence or absence of God. Often they can draw upon past experiences to help them through their present situation.
During an assessment Bates covers three areas. They include:
• The person’s concept of God, such as God the Father or a "zapper" God. "You can find out a lot about the person when you have an understanding of what their idea of God is. That also can give you a clue as to what issues they want to address," she says.
• The meaning of the person’s life and what the suffering means to him or her.
• The person’s spiritual support system. This includes a person’s coping mechanisms and strengths in his or her relationship with God and with others, and the exterior support system, such as the people they worship with.
The initial assessment helps the chaplain determine how he or she might begin working with the patient, but the assessment process is ongoing. At each visit, new issues are often discovered. "It is a slow process. It takes time to search for answers and to search for ways to ask the questions," says Bates.
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