Jul 17, 2018, 08:45 AM by Adrianne Dyer, MAPS, BCC; Debra B. Gordon, RN, DNP, FAAN; and Ivan Lesnik, MD

Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose. Spirituality frames the way “people experience their connectedness to the moment, to self, to others, to nature and to the significant or sacred.”^[1] Spirituality has been described as a dimension of life and what it means to be human.^[2] We are more than psychological, social, and physical beings; we are also spiritual beings. Therefore, when faced with a medical illness or injury, a patient not only needs medical care to address a diagnosis and treatment but will also benefit from spiritual care to aid in overall spiritual well-being.

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“Spiritual care aims to empower patients to discover, claim, and rely on their inner religious or spiritual resources as integral and valid treatment interventions as part of a multimodal plan of care.”

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Spiritual well-being is a multidimensional construct that includes a sense of meaning and purpose, inner peace, strength, and comfort.^[3] Spiritual well-being is recognized as an important indicator of quality of life, and the importance of spirituality in holistic patient-centered care is being increasingly recognized.^[4]

Integrating Spiritual Care in an Acute Pain Service (APS)

The Harborview Medical Center (HMC) is a 413-bed, level 1 trauma center located in the center of Seattle. It is part of the University of Washington. As a county-owned and safety-net hospital, HMC's mission is to provide a significant level of care to low-income, uninsured, and vulnerable populations. The HMC APS provides care to a high number of patients with complex pain conditions across multiple key clinical services, including perioperative, emergency, trauma, medical, and palliative care services.

Although many hospitals have dedicated spiritual care services with assignments to intensive care units or palliative care services, our program is unique in having a dedicated spiritual care provider as an integrated member of an anesthesiology-based APS. Our rationale is that the experience of pain is biopsychosocial, rooted not only in physical sensations but also emotional, cognitive, spiritual, and social elements.

Traditionally, an APS focuses on pharmacologic management and regional analgesia offered by physicians with limited interdisciplinary and integrated services. Acute pain, experienced while hospitalized, often short-circuits the reflective process and can lead to a desire to pursue an unrealistic immediate quick fix or resolution with pain medications. When patients experience pain, they may feel a sense of loss of control, become concerned about the source of the pain, experience isolation, or become overwhelmed when the pain becomes dire or chronic.^[5] The treatment of pain from a purely pharmacologic standpoint is rarely, if ever, transformative. In the words of Richard Rohr, “If we do not transform our pain, we will most assuredly transmit it.”^[6] This phenomena points to the vital need to practice more holistic care. Pain and suffering are multifaceted; leaning into pain and suffering is the key to moving through it. Understanding the broader context of pain and suffering that patients experience is necessary to help in the transformation of pain.^[7]

When people encounter a medical condition, sometimes the impact of their experience can lead to a spiritual struggle. Like approaching a fork in the road, patients may engage with their medical reality that leads them to a place of renewal, growth, or change. On the other hand, a medical situation can lead patients to despair, hopelessness, and meaninglessness.^[2]

In response to spiritual struggles, patients may need to confront what they have held as significant or sacred and perhaps need to let go, reframe, or reengage their spiritual resources in a new way.^[2] In that movement of change or transformation, patients may feel afraid and unsure. Spiritual care providers have distinct skills and training to explore spiritual history, identify and respond to spiritual concerns, identify and navigate spiritual struggle, empower patients to draw on their own spiritual resources, and assess how those aspects hinder or help patients journey toward health and well-being.

When patients who are suffering with acute or chronic pain are supported in their human essence to be reflective about their life and assess their personal story, they can better evaluate aspects or decisions they are making in their life.8 That support comes not in the form of a diagnosis but rather through the practice of compassionate care. Christina M. Puchalski, MD, MS, writes that compassionate care occurs when care providers walk with patients in the midst of their pain. The means of effective medical care is to pay attention to the patient as a whole, not just the specific illness or symptoms.^[9]

Spirituality plays an important factor in how patients face illness, suffering, loss, and recovery. Spiritual care providers help patients draw on, search for, and/or assist in reframing meaning and acceptance in the midst of their suffering and illness.^[9] The Association of American Medical Colleges endorses the concept of spirituality as an expression of an individual's search for ultimate meaning through participation in religion or belief in God, family, naturalism, rationalism, humanism, or the arts. Understanding and attending to all these factors can influence how patients and health care professionals perceive health and illness and how they interact.^[10] The integration of a spiritual care provider on the APS team has enhanced efforts to better understand and answer the question of what are we treating (eg, physical pain, emotional distress, spiritual distress, all in one)?

 

We developed an APS model that includes availability of a spiritual care provider throughout the pain service continuum of care (Figure 1). Spiritual care provides a variety of interventions (Figure 2) to support patients, their families, and staff that is culturally sensitive and compassionate, respecting diversity, demographics, faiths, and beliefs. Spiritual care providers listen intently to patients stories in order to capture aspects of their internal soul and how that soul is integrated or detached from their health concerns.^[11] By using spiritual care assessment (Figure 3), the APS team is able to understand the patient’s needs, hopes, distress, and religious or spiritual resources. Finding meaning and purpose many not be about doing things differently but rather seeing familiar things in new ways.^[12]

Spiritual care services provides the APS team, including resident anesthesiologists, and pain clinic staff with information and didactics to help broaden their understanding of spiritual care. Spiritual care providers round together with the entire APS team (and independently), providing oral and written communication to increase the team's awareness of patients' spiritual distress, connection to pain, and inner resources.

Spiritual care aims to empower patients to discover, claim, and rely on their inner religious or spiritual resources as integral and valid treatment interventions as part of a multimodal plan of care. For example, a patient was admitted for a complex infection; the patient was alone, in distress, and had high pain management needs. As spiritual care engaged in the patient's story, it became apparent that the patient was suffering from unresolved grief (the loss of a loved one a year prior). The patient's unresolved grief was interwoven with his discomfort and limited his ability to cope with acute pain. As the patient's grief was addressed and supported, the patient's physical discomfort decreased, and the patient was better able to cope through the duration of his hospital stay.

 

In another example, a patient came to the pain clinic for a presurgical consultation for back surgery. The patient was feeling apprehensive about having another surgery because of her history of chronic back pain and previous back surgeries. Spiritual care was able to meet with the patient in the pain clinic and listen to the patient's anxiety, concerns, and hopes for her upcoming surgery and long-term health. Spiritual care was able to assess the patient's spiritual resources and draw on them during her subsequent hospital stay to help her cope through discomfort and anxiety while being hospitalized. Upon hospital discharge and pain clinic follow-up, the patient was appreciative of the holistic support she received from the APS team throughout her medical care and procedure.

Summary

It has been our experience that integration of spiritual care in an APS has demonstrated an increase in building of essential trust, rapport, and patient engagement in plans of care. The focus of pain service treatment has deepened and broadened to include reinforcement of spiritual resources and greater empathy for how grief and spiritual distress affect patients. When patients feel heard and understood and believe that their spiritual needs have been addressed, providers report decreased need for opioid pain medications. Affirming and assisting patients in reframing their connection to meaning, purpose, and spiritual resources establishes hope for transformation. It has also created opportunity to draw on nonpharmacologic resources as tools to assist with effective pain management.

References

1. Puchalski C, Ferrell B, Virani R, et al. 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.
2. Pargament K. Spiritually Integrated Psychotherapy. New York, New York: The Guilford Press; 2007.
3. Bai M, Dixon JK. Exploratory factor analysis of the 12-item functional assessment of chronic illness therapy-spiritual well-being scale in people newly diagnosed with advanced cancer. J Nurs Meas 2014;22(3):404–420.
4. Mundle R. A narrative analysis of spiritual distress in geriatric physical rehabilitation. J Health Psychol 2015;20(3):273–285.
5. Cassel EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982;306(11):639–645.
6. Rohr R. Things Hidden: Scripture as Spirituality. Cincinnati, Ohio: Franciscan Media; 2008.
7. Groves RF, Klauser HA. The American Book of Living and Dying: Lessons in Healing Spiritual Pain. Berkeley, California: Celestial Arts; 2009.
8. Nouwen H. Can You Drink This Cup? Notre Dame, Indiana: Ave Maria Press; 1985.
9. Puchalski C. The role of spirituality in health care. Proc (Bayl Univ Med Cent) 2001;14(4):352–357.
10. Association of American Medical Colleges. Report III: Contemporary issues in Medicine: Communication in Medicine. Medical School Objectives Project. 1999:25–26. https://members.aamc.org/eweb/upload/Contemporary%20 Issues%20In%20Med%20Commun%20in%20Medicine%20Report%20III%20. pdf. Accessed December 12, 2017.
11. Hilsman GJ. Spiritual Care in Common Terms: How Chaplains Can Effectively Describe the Spiritual Needs of Patients in Medical Records. London, United Kingdom: Jessica Kingsley Publishers; 2017.
12. Remen RN. My Grandfather's Blessing: Stories of Strength, Refuge, and Belonging. New York, New York: Riverhead Books; 2000.