Transcript Improving the Quality of Spiritual Care as a Dimension of

Improving the Quality of Spiritual Care as
a Dimension of Palliative Care:
A Consensus Conference Convened February 2009
Principal Investigators
Christina Puchalski, MD, MS, FACP
Betty Ferrell, PhD, MA, FAAN, FPCN
Supported by the Archstone Foundation, Long Beach, CA. as a part of their End-of-Life Initiative.
Executive Summary published in the Journal of Palliative Medicine, October 2009
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Background
• Goal of palliative care is to
prevent and relieve suffering
(National Consensus Project,
2009)
• Palliative care supports the best
possible quality of life for
patients and their families
(NCP, 2009)
• Palliative care applies to
patients from time of diagnosis
of serious illness to death
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Consensus Conference Goal
• Identify points of agreement about
spirituality as it applies to health
care
• Make recommendations to advance
the delivery of quality spiritual care
in palliative care
• 5 key elements of spiritual care
provided the framework
1. Spiritual assessment
2. Models of care and care plans
3. Interprofessional team training
4. Quality improvement
5. Personal and professional
development
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The NCP Guidelines Address Eight Domains of Care
• Structure and processes
• Physical aspects
• Psychological and psychiatric
aspects
• Social aspects
• Spiritual, religious, and existential
aspects
• Cultural aspects
• Imminent death
• Ethical and legal aspects
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A Consensus Definition of Spirituality was Developed
“Spirituality is the aspect of humanity that refers to the
way individuals seek and express meaning and
purpose and the way they experience their
connectedness to the moment, to self, to others, to
nature, and to the significant or sacred.”
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Conference Recommendations
Recommendations for improving spiritual care are
divided into seven keys areas:
1. Spiritual care models
2. Spiritual assessment
3. Spiritual treatment/care plans
4. Interprofessional team
5. Training/certification
6. Personal and professional development
7. Quality improvement
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1. Spiritual Care Models
Recommendations
• Integral to any patient-centered health care system
• Based on honoring dignity
• Spiritual distress treated the same as any other
medical problem
• Spirituality should be considered a “vital sign”
• Interdisciplinary
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Biopsychosocial-Spiritual Model of Care
Sulmasy, D.P. (2002). A biopsychosocial-spiritual model for the care of patients at the end of life.
Gerontologist, 42(Spec 3), 24-33. Used with permission.
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Inpatient Spiritual Care Implementation Model
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2. Spiritual Assessment of Patients and Families
Recommendations
• Spiritual screening
• Assessment tools
• All staff members should be trained to recognize
spiritual distress
• HCP’s should incorporate spiritual screening as a
part of routine history/evaluation
• Formal assessment by Board Certified Chaplain
• Documentation
• Follow-up
• Response within 24 hours
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Spiritual Screening
• Do you have any spiritual beliefs that might
affect your stay here at the hospital?
• Are there any spiritual beliefs that you want to
have discussed in your care with us here?
• Would you like to see a chaplain or someone
from pastoral care?
• How important is spirituality in your coping? and
“How well are those spiritual resources working
for you at this time?”
© C.Puchalski
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Spiritual History
• Comprehensive
• Done in context of intake exam or during a
particular visit such as breaking bad news, end
of life issues, crisis
• Done by the clinician who is primarily
responsible for providing direct care or referrals
to specialists such as professional chaplains.
• Can be utilized by others such as volunteers but
then not in the treatment context, more as
opening up conversation
© C.Puchalski
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Spiritual Diagnosis Decision Pathways
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3. Formulation of Spiritual Treatment Care Plan
Recommendations
• Screen and access
• All HCPs should do spiritual screening
• Diagnostic labels/codes
• Treatment plans
• Support/encourage expression of needs and beliefs
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3. Formulation of a Spiritual Treatment Plan
Recommendations cont’d
• Spiritual care coordinator (chaplain)
• Documentation of spiritual support resources
• Follow up evaluations
• Treatment algorithms
• Discharge plans of care
• Bereavement care
• Establish procedure
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4. Interprofessional Considerations: Roles and Team Functioning
Recommendations
• Policies are needed
• Policies developed by clinical sites
• Create healing environments
• Respect of HCPs reflected in policies
• Document assessment of patient needs
• Need for Board Certified Chaplains
• Workplace activity/programs to enhance spirit
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5. Training and Certification
Recommendations
• All members of the team should be trained in
spiritual care
• Team members should have training in spiritual
self-care
• Administrative support for professional
development
• Spiritual care education/support
• Clinical site education
• Development of certification/training
• Competencies
• Interdisciplinary models
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6. Personal and Professional Development
Recommendations
• Healthcare settings/organizations should support
HCP’s attention to self-care/stress management
training/orientation
staff meetings/educational programs
environmental aesthetics
• Spiritual development
resources
continuing education
clinical context
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6. Personal and Professional Development
Recommendations cont’d
•
Time encouraged for self-examination
•
Opportunities for sense of connectedness and
community
interprofessional teams
ritual and reflections
staff support
•
Discussion of ethical issues
power imbalances
virtual based approach
opportunity to discuss
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7. Quality Improvement
Recommendations
• Domain of spiritual care to be included in QI plans
• Assessment tools
• QI frameworks based on NCP Guidelines
• QI specific to spiritual care
• Research needed
• Funding needed for research and clinical services
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Conclusions
• Spiritual care is an essential to improving quality
palliative care as determined by the National
Consensus Project (NCP) and National Quality
Forum (NQF)
• Studies have indicated the strong desire of patients
with serious illness and end-of-life concerns to have
spirituality included in their care
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Conclusions (cont’d)
• Recommendations provided for implementation of spiritual
care in palliative, hospice, hospital, long-term, and other
clinical settings
• Interprofessional care includes Board Certified Chaplains
• Regular ongoing assessment of patients’ spiritual issues
• Integration of patient spirituality into treatment plan with
appropriate follow-up with ongoing quality improvement
• Professional education and development of programs
• Adoption of these recommendations into clinical site policies
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Go to : www.gwish.org
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Case Studies
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Determinism/Meaning
• Is everything that happens determined
by God?
• If not, how/why do “bad things” happen?
• How does this cause translate into
meaning?
• Differentiating illness as gift or
punishment
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Grief
• Spiritual/existential losses
• Loss of sense of immortality
• Loss of sense that God will protect you
from all harm
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Judge or Comforter?
• Is God a “judging” God?
– Does God punish people while they are still
alive?
• Is God primarily a “comforting” God?
– Is God’s primary role to support people
through hard times?
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Forgiveness
• Sin is what the patient perceives it to be
• Important to not impose caregiver
values and beliefs
• Religions have a distinct way of
expiating sin
• Suffering itself may be seen as a way to
“work off” sins
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Case 1: My Life is Meaningless
Ms. Harper is a 75 yo former advocate for
the homeless, who recently suffered a
stroke that left her with mild cognitive
impairment and hemi paresis. The
meaning in her life came from her work
and since the stroke she is unable to work
and feels life is meaningless.
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Spiritual History
F:
Atheist, meaning in social activism
I:
Work in her life and her whole sense
of who she is
C:
Activist community
A:
Interested in passing on her dreams
to younger people who will carry on
her work when she dies
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Case 1: Biopsychosocial-Spiritual Model
Assessment and Plan
Ms. Harper is a 75 yo s/ cva with hemi paresis and mild cognitive
impairment
Physical
• On-going physical therapy, rehab
Emotional
• Grief reaction over loss of previous state of
functioning
• Supportive counseling, presence
Social
• Engage activist community in her care as much as
possible
• Needs home health aid
• Financial issues about long-term care
Spiritual
• Meaninglessness, consider referral to pastoral
counselor or chaplain
• Connection with younger people at medical school
interested in helping homeless
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Chaplain’s Spiritual Assessment
• Explore Ms Harper’s sense of meaning and
existential concerns more completely. Work
per se may not give meaning—what is it
about the work?
• What is it about social activism that is
meaningful?
• Why is it meaningful?
• Why is she drawn to the homeless?
• What events in her life made her who she
is?
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Interventions by the Team
• Help patient create a dream list and facilitate
passing onto others
• Compassionate presence, provide
connection
• Life story
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Case 2: Hopelessness
Ms. R is a 52 yo female with end-stage
ovarian cancer. Seven-and-a-half years
after the multiple surgeries and
chemotherapy, with good outcomes, she
is now faced with advanced disease for
which there is no longer any treatment.
Her hope has always been for a cure. Now
she faces a deep sense of hopelessness.
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Spiritual History
F:
Raised Jewish culturally; meaning
has always been in nature and not
religion.
I:
Spirituality is important, nature calms
her, worried about how she can do
that now.
C:
Friends and family are her support.
A:
Now that she is dying, she would like
to know how Judaism views dying
and what rituals might help her.
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Case 2: Biopsychosocial-Spiritual Model
Assessment and Plan
Ms. R is a 52 yo with end-stage ovarian cancer
Physical
• Pain is well controlled; continue with current medication
regimen
• Nausea; still has episodes of nausea and vomiting, likely
secondary to partial sm bowel obstruction (SBO), add octreotide
to current regimen
Emotional
• Grief reaction that “fight is over”
• Tearful, difficulty sleeping
• Supportive counseling, presence
Social
• Ms. R concerned about how to tell them she is dying
• Work with social work to arrange family meeting
Spiritual
• Hopelessness, main source of meaning in “winning the fight”,
active in Ov Cancer Alliance and seen as inspiration
• Not religious but now wants to learn how “Jewish patients die?”
• Dream list, legacy building, encourage talking with Ov Cancer
Alliance
• Referral to chaplain and to Rabbi
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Chaplain’s Spiritual Assessment
• What was her upbringing from a Jewish
perspective?
• What is her experience of ritual?
• Why did she leave her Jewish practice?
• What does it mean to her to be a “good
Jew”?
• What is her belief in an afterlife?
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Interventions by the Team
• Help patient create dream list
• Talk about all relationships in the person’s
life, including God if that is important. Any
conflicts?
• What are her sources of hope?
• What has she learned of hope from her
religion? From other things?
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Case 3: My Illness as Punishment
Brenda is a 42 yo female, mother of six
children. Her partner is arrested for drug
possession. She finds out he is HIV
positive and comes to a clinic to get
tested. On a follow up visit the doctor tells
her the test is positive. She responds by
saying “God, why are you doing this to me
now?” She goes on to say she was raped
as a 13 yo by an uncle, got an abortion and
now “this is God’s punishment.”
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Spiritual History
F:
Non-denominational Christian; her
children and God give her meaning
I:
Very important in her life, prays daily,
attends Bible study and Sunday
services; believe illness is
punishment from God
C:
Active in church
A:
Referral to pastoral counselor or
chaplain, invite Brenda’s clergy to
next visit, if she wants, to discuss
her illness and spiritual issues
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Case 3: Biopsychosocial-Spiritual Model
Assessment and Plan
Brenda with newly diagnosed HIV, CD4 normal, HIV viral load low
Physical
• Referral to ID clinic for discussion about medications,
though at this point patient is refusing medications
• Labs
• Health maintenance
Emotional
• Referral to counselor to discuss life stress issues
Social
• Referral to social worker in community for assistance at
home with children and getting children tested
Spiritual
• Suspect her perception of illness as punishment may be
reason for refusing medical treatment
• Referral to chaplain
• Invite Brenda’s clergy to next visit to discuss issues if
she would like
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Chaplain’s Spiritual Assessment
• Is the statement “God why are you doing this to
me?” a statement of true belief or a cry of anguish?
• Is there something specific the patient feels she is
being punished for? Would a forgiveness ritual help?
• Does the patient really believe that God punishes
people by making them ill or is that her only strategy
for making meaning in this situation?
• If this is about meaning making, what other
explanations can the patient think of for her illness?
• How does she think her diagnosis is going to be
received by members of her church? Is she afraid
she will be shunned?
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Interventions by the Team
• Listen to patient’s story without judgment
• Invite patient’s clergy to office
• Elicit patient’s explanatory model for
illness; give her the opportunity to further
talk about punishment and what that means
to her
• Distinguish fear of side effects of meds, vs.
denial about illness, vs. spiritual issue as
dynamic in her understanding of illness and
treatment
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Chaplain George Handzo
[email protected]
Chaplain Cassie McCarty
[email protected]
Chaplain Karen Pugliese
[email protected]
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