Healing Presence: Healing Presence: Creating a Culture that Creating a Culture that

Promotes Spiritual CarePromotes Spiritual Care

Carol Taylor, CSFN, RN, PhDCarol Taylor, CSFN, RN, PhDGeorgetown University Medical Georgetown University Medical

CenterCenter

Presented at

Recovering Our Traditions II—

Journey to Journey to ExcellenceExcellence A Catholic Health Care PerspectiveOn End-of-Life Care

January 26-28, 2006San Antonio, Texas

Sponsored by

SSupportive upportive CCare are CCoalitionoalitionPursuing Excellence in Palliative CarePursuing Excellence in Palliative Care

Catholic Health AssociationCatholic Health Associationof the United Statesof the United States

The George Washington The George Washington Institute for Spirituality and HealthInstitute for Spirituality and Health

OBJECTIVESOBJECTIVES

At the conclusion of this session participants will be At the conclusion of this session participants will be able to: able to:

• Identify three universal spiritual needsIdentify three universal spiritual needs..• Define spirituality, healing, healing presence, and Define spirituality, healing, healing presence, and

spiritual carespiritual care• Describe spiritual care and related professional Describe spiritual care and related professional

responsibilities.responsibilities.• Value self as a healing presence and recommit to Value self as a healing presence and recommit to

the ministry of presence.the ministry of presence.• Critique institutional cultures in light of their Critique institutional cultures in light of their

capacity to promote spiritual carecapacity to promote spiritual care

Holistic Health, Healing and Holistic Health, Healing and Healing PresenceHealing Presence

Holistic Health: The Theory Practice Holistic Health: The Theory Practice Gap and the Limits of the Bio-Gap and the Limits of the Bio-Psycho-Social Model of HealthPsycho-Social Model of Health

Spiritual Care is not Spiritual Care is not OPTIONAL!OPTIONAL!

Promoting Excellence: Promoting Excellence: Seven End-of-Life Care Seven End-of-Life Care DomainsDomains • Domain 1 - Patient and Family Centered Decision Domain 1 - Patient and Family Centered Decision

MakingMaking• Domain 2 - Communication within the Team & PatDomain 2 - Communication within the Team & Pat

ients/Familiesients/Families• Domain 3 - Continuity of CareDomain 3 - Continuity of Care• Domain 4 – Emotional & Practical Support for PatiDomain 4 – Emotional & Practical Support for Pati

ents/Familiesents/Families• Domain 5 – Symptom Management & Comfort CarDomain 5 – Symptom Management & Comfort Car

ee• Domain 6 – Spiritual Support for Patients/FamiliesDomain 6 – Spiritual Support for Patients/Families• Domain 7 – Emotional & Organizational Support foDomain 7 – Emotional & Organizational Support fo

r ICU Cliniciansr ICU Clinicians

• These domains, quality indicators and These domains, quality indicators and interventions or behaviors were generated interventions or behaviors were generated in a modified Delphi approach as described in a modified Delphi approach as described in the following article: Clarke EB, Curtis JR, in the following article: Clarke EB, Curtis JR, Luce JM, Levy M, Nelson J, Solomon MZ, for Luce JM, Levy M, Nelson J, Solomon MZ, for The Robert Wood Johnson Foundation The Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup Critical Care End-of-Life Peer Workgroup Members. (2003). Quality indicators for Members. (2003). Quality indicators for end-of-life care in the intensive care unit. end-of-life care in the intensive care unit. Critical Care MedicineCritical Care Medicine, 31(9), 2255-2262., 31(9), 2255-2262.

National Consensus Project for Quality National Consensus Project for Quality Palliative CarePalliative Care (2004). (2004). Clinical practice \Clinical practice \guide-lines for quality palliative careguide-lines for quality palliative care

• Domain 5: Spiritual, Religious and Domain 5: Spiritual, Religious and Existential Aspects of CareExistential Aspects of Care (102, 103)(102, 103)

• Guideline 5.1 Spiritual and existential Guideline 5.1 Spiritual and existential dimensions are assessed and dimensions are assessed and responded to based upon the best responded to based upon the best available evidence, which is skillfully available evidence, which is skillfully and systematically applied. and systematically applied. (32, 104) (32, 104)

• http: ://www.http: ://www.nationalconsensusprojectnationalconsensusproject.org.org

The difference between “The difference between “healinghealing” and “” and “curingcuring””

CuringCuring:: the alleviation of symptoms or the the alleviation of symptoms or the termination or suppression of a disease process termination or suppression of a disease process through surgical, chemical or mechanical through surgical, chemical or mechanical interventionintervention

HealingHealing:: may be spontaneous but more often it’s a may be spontaneous but more often it’s a gradual awakening to a deeper sense of self gradual awakening to a deeper sense of self (and of the self in relation to others) in a way (and of the self in relation to others) in a way that effects profound change. Healing comes that effects profound change. Healing comes from within and is consistent with a person's from within and is consistent with a person's own readiness to grown and to change. own readiness to grown and to change.

Healing is the integration of self. People move from Healing is the integration of self. People move from a a

sense of brokenness to a sense of wholeness. sense of brokenness to a sense of wholeness. C. C. PuchalskiPuchalski

Healing TestimoniesHealing Testimonies

• Seven years ago I was faced with three Seven years ago I was faced with three life-threatening events in a period of life-threatening events in a period of three years. Those life-threatening three years. Those life-threatening experiences taught me that it is experiences taught me that it is possible to “heal” and to live fully even possible to “heal” and to live fully even when we are in the abyss of suffering. when we are in the abyss of suffering. I believe everyone would benefit if we I believe everyone would benefit if we redefined “healing.” Here are redefined “healing.” Here are elements I now include in my definition.elements I now include in my definition.

Healing is:Healing is:• Becoming whole, a life-long journey of Becoming whole, a life-long journey of

becoming fully human, involving the totality becoming fully human, involving the totality of our being: body, mind, emotion, spirit, of our being: body, mind, emotion, spirit, social and political context, as well as our social and political context, as well as our relationships with others and with the Divine. relationships with others and with the Divine. Healing does not necessarily mean being Healing does not necessarily mean being happy or getting what we think we want out happy or getting what we think we want out of life; it means growth, often with pain.of life; it means growth, often with pain.

• Becoming our authentic self, releasing old Becoming our authentic self, releasing old unreal self-images, discovering who we unreal self-images, discovering who we really are, not what we think we should be, really are, not what we think we should be, knowing why we are here and what we really knowing why we are here and what we really value, restoring our ability to heed our value, restoring our ability to heed our aspirations.aspirations.

• Reconnecting lost aspects of ourselves, Reconnecting lost aspects of ourselves, paying attention to buried feelings and paying attention to buried feelings and places inside us that are distressed or sick, places inside us that are distressed or sick, enabling us to express our self in fullness, enabling us to express our self in fullness, both the light and shadow sides.both the light and shadow sides.

• Being open to change and new possibilities; Being open to change and new possibilities; responding to problems by changing the responding to problems by changing the picture; being willing to let in more life, to picture; being willing to let in more life, to open up to what may have been previously open up to what may have been previously closed or destroyed for us and that which closed or destroyed for us and that which holds promise of giving us new life and holds promise of giving us new life and fulfillment.fulfillment.

• Facing our fears and refusing to be injured or Facing our fears and refusing to be injured or wounded; changing our belief systems; wounded; changing our belief systems; breaking unnecessary taboos; letting go of breaking unnecessary taboos; letting go of what is familiar, and stepping into the what is familiar, and stepping into the unknown.unknown.

• Accepting that problems, pain, and suffering Accepting that problems, pain, and suffering are part of life and inseparable from us – not are part of life and inseparable from us – not a peripheral relationship, not something a peripheral relationship, not something isolated and avoidable – enabling us to enter isolated and avoidable – enabling us to enter into problems and use suffering, pain, and into problems and use suffering, pain, and life-threatening events to enrich our lives.life-threatening events to enrich our lives.

• Being empowered by the Divine; discovering Being empowered by the Divine; discovering meaning in our defects, disorders, problems, and meaning in our defects, disorders, problems, and disease; experiencing new degrees of creativity and disease; experiencing new degrees of creativity and life forces that we might never have imagined before life forces that we might never have imagined before our difficulty; finding that our pains and fears are our difficulty; finding that our pains and fears are transformed into relief and confidence.transformed into relief and confidence.

• Recognizing the value and preciousness of life, Recognizing the value and preciousness of life, knowing that every moment is unique and knowing that every moment is unique and significant, which usually leads to greater significant, which usually leads to greater appreciation of the wonder of our minds, bodies, and appreciation of the wonder of our minds, bodies, and spirits and of the Divine.spirits and of the Divine.

• Having faith and hope – important preconditions for Having faith and hope – important preconditions for mental and physical health; having a belief in the mental and physical health; having a belief in the Divine, the meaning of human life, and the universe; Divine, the meaning of human life, and the universe; helping us to claim our capacity to create and make helping us to claim our capacity to create and make something new.something new.

• Finding inner peace, contentment, Finding inner peace, contentment, and tranquility amid the realities of and tranquility amid the realities of daily life, including its problems, daily life, including its problems, changes, and chaos; experiencing a changes, and chaos; experiencing a sense of fullness that makes the sense of fullness that makes the burdens of pain or illness lighter.burdens of pain or illness lighter.

• Being forgiving of ourselves and Being forgiving of ourselves and others and being forgiven; giving others and being forgiven; giving ourselves and others the freedom to ourselves and others the freedom to let go of rivalry, strife, anger, hated, let go of rivalry, strife, anger, hated, fear and limitations.fear and limitations.

• Feeling connected to one another, a sense Feeling connected to one another, a sense of interdependence; knowing we are not of interdependence; knowing we are not isolated or autonomous, giving up the isolated or autonomous, giving up the illusions of boundaries in life; taking illusions of boundaries in life; taking responsibility, acting justly, and accepting responsibility, acting justly, and accepting that we share our humanity.that we share our humanity.

• Being loving and loved; loving one’s self Being loving and loved; loving one’s self and wanting to love and serve others, as and wanting to love and serve others, as well as being capable of receiving love; well as being capable of receiving love; having an ability to trust, a feeling of having an ability to trust, a feeling of aliveness, and a sense of greater aliveness, and a sense of greater participation in life.participation in life.

Healing PresenceHealing Presence

Healing presence is the condition of Healing presence is the condition of being consciously and being consciously and compassionately in the present compassionately in the present moment with another or with moment with another or with others, believing in and affirming others, believing in and affirming their potential for wholeness, their potential for wholeness, wherever they are in life.wherever they are in life.

Healing PresenceHealing Presence

• You cannot You cannot dodo healing presence—you become healing presence—you become healing presence, expressing it gently yet firmly healing presence, expressing it gently yet firmly in various ways:in various ways:

– Listening, holding, talking, being silent, being still, Listening, holding, talking, being silent, being still, being in your body, coming home to yourself, being being in your body, coming home to yourself, being receptive…receptive…

• You can deepen your healing presence by:You can deepen your healing presence by:– slowing down, doing only one thing at a time, reminding slowing down, doing only one thing at a time, reminding

yourself regularly to come back to the present momentyourself regularly to come back to the present moment

• You can encourage healing presence by being:You can encourage healing presence by being:– appreciative, forgiving, humble, kind.appreciative, forgiving, humble, kind.

Miller, EJ and Cutshall, SC. 2001.Miller, EJ and Cutshall, SC. 2001. The art of being a healing presence. A The art of being a healing presence. A guide for those in caring relationships. guide for those in caring relationships. Willogreen Publishing.Willogreen Publishing.

Why Healing Presence Why Healing Presence MattersMatters• When one is truly present to another there is: When one is truly present to another there is:

– An alleviation of lonelinessAn alleviation of loneliness– An affirmation of one’s authentic self and An affirmation of one’s authentic self and

invitation to wholenessinvitation to wholeness– Potential for spiritual bondingPotential for spiritual bonding– A deeper sense of our common humanityA deeper sense of our common humanity– A recognition and acknowledgement of the other A recognition and acknowledgement of the other

as personas person– An invitation to self-transcendenceAn invitation to self-transcendence– Possibility for greater self reflection & self Possibility for greater self reflection & self

revelationrevelation– Sharing on a deeper level, spiritual level [Butler]Sharing on a deeper level, spiritual level [Butler]

Developing Healing PresenceDeveloping Healing Presence• Steps for Being a Healing Presence: Steps for Being a Healing Presence:

Miller, EJ and Cutshall, SC. 2001.Miller, EJ and Cutshall, SC. 2001. The art of being a healing presence. A The art of being a healing presence. A guide for those in caring relationships. guide for those in caring relationships. Willogreen Publishing.Willogreen Publishing.

1.1. Open YourselfOpen Yourself2.2. Intend to Be a Healing PresenceIntend to Be a Healing Presence3.3. Prepare a Space for Healing Presence to Take PlacePrepare a Space for Healing Presence to Take Place4.4. Honor the One in Your CareHonor the One in Your Care5.5. Offer What You Have to GiveOffer What You Have to Give6.6. Receive Gifts that ComeReceive Gifts that Come7.7. Live a Life of Wholeness and BalanceLive a Life of Wholeness and Balance

** ** We cannot give what we don’t have. Unless our own needs We cannot give what we don’t have. Unless our own needs are met we will never be able to be truly present to another. are met we will never be able to be truly present to another. Thus the art of being a healing presence requires a lifestyle Thus the art of being a healing presence requires a lifestyle that supports this.that supports this.

The Healer’s Personal Spiritual The Healer’s Personal Spiritual CareCare

• Hold spiritual beliefs that meet needs Hold spiritual beliefs that meet needs for meaning and purpose, love and for meaning and purpose, love and relatedness, and forgivenessrelatedness, and forgiveness

• Derive from these beliefs strength for Derive from these beliefs strength for everyday living, especially when everyday living, especially when confronting pain, suffering, and death confronting pain, suffering, and death in his or her professional practicein his or her professional practice

• Set aside regular periods to nurture Set aside regular periods to nurture his or her spiritual selfhis or her spiritual self

• Demonstrate in interactions with others peace, Demonstrate in interactions with others peace, inner strength, warmth, joy, caring, and creativityinner strength, warmth, joy, caring, and creativity

• Respect the spiritual beliefs and practices of Respect the spiritual beliefs and practices of others even when they are different from the others even when they are different from the HEALER's ownHEALER's own

• Increase knowledge of how the spiritual beliefs Increase knowledge of how the spiritual beliefs of others influence their lifestyles, responses to of others influence their lifestyles, responses to illness, healthcare choices, and treatment optionsillness, healthcare choices, and treatment options

• Demonstrate sensitivity to the spiritual needs of Demonstrate sensitivity to the spiritual needs of patients and their family caregiverspatients and their family caregivers

• Develop successful strategies to assist patients Develop successful strategies to assist patients and their caregivers experiencing spiritual and their caregivers experiencing spiritual distressdistress

•PISCES ScalePISCES Scale(Physical, Intellectual, Spiritual, Emotional, Social)(Physical, Intellectual, Spiritual, Emotional, Social)

I do nothing for I do nothing for I do all I can for I do all I can for

my physical self my physical selfmy physical self my physical self

__________________________________________________________ Examples:Examples:

One action I will take for my physical self:One action I will take for my physical self:

__________________________________________________________________________________

Questions for reflection:Questions for reflection:1.1. To what degree do recent recipients of my To what degree do recent recipients of my

care experience me as a healing presence? care experience me as a healing presence? 2.2. What kind of person must I be to be a What kind of person must I be to be a

“healing presence”?“healing presence”?3.3. When I am exhausted and “running on When I am exhausted and “running on

empty” how do I renew my spirit and ability empty” how do I renew my spirit and ability to care? What is lifegiving in my life?to care? What is lifegiving in my life?

4.4. In what ways might my lifestyle need to In what ways might my lifestyle need to change for me to become a better healing change for me to become a better healing presence?presence?

5.5. What kind of institutional culture, ethos, What kind of institutional culture, ethos, promotes our being a healing presence for promotes our being a healing presence for one another?one another?

Questions for corporate Questions for corporate reflection:reflection:1.1. Are the patients, families and staff better (more Are the patients, families and staff better (more

“integrated” or “whole”) at the end of the day as “integrated” or “whole”) at the end of the day as a result of experiencing our institutional culture.a result of experiencing our institutional culture.

2.2. What specific elements in our culture promote or What specific elements in our culture promote or constrain healing? What should we celebrate constrain healing? What should we celebrate and what do we need to change?and what do we need to change?

3.3. Who is responsible for healing and spiritual care? Who is responsible for healing and spiritual care? Who establishes performance standards, Who establishes performance standards, develops requisite competencies, monitors our develops requisite competencies, monitors our performance and holds us accountable?performance and holds us accountable?

4.4. Budgets reveal corporate values. What do the Budgets reveal corporate values. What do the institutional resources we commit to healing and institutional resources we commit to healing and spiritual care reveal about the value we attach spiritual care reveal about the value we attach to promoting a healing culture? to promoting a healing culture?

Spiritual CareSpiritual Care

SpiritualitySpirituality

• Spirituality is recognized as a factor that Spirituality is recognized as a factor that contributes to health in many persons.contributes to health in many persons.

• It is expressed in an individual’s search It is expressed in an individual’s search for ultimate meaning through for ultimate meaning through participation in religion and/or belief in participation in religion and/or belief in God, family, naturalism, rationalism, God, family, naturalism, rationalism, humanism and the arts. humanism and the arts. MSOP Report III: Association of MSOP Report III: Association of American Medical Colleges, 1999.American Medical Colleges, 1999.

• Puchalski’s meaning with a Puchalski’s meaning with a capital and small “m”capital and small “m”

– ““M”eaning: Values, beliefs, practices, M”eaning: Values, beliefs, practices, relationships, experiences, that lead you relationships, experiences, that lead you to the awareness of to the awareness of God/divine/transcendence and a sense God/divine/transcendence and a sense of ultimate value and purpose in life. of ultimate value and purpose in life.

– ““m”eaning: Activities, relationships, m”eaning: Activities, relationships, values that are meaningful to you but values that are meaningful to you but don’t define the ultimate purpose of don’t define the ultimate purpose of your life.your life.

Spiritual NeedsSpiritual Needs

• According to Fish and Shelly (1978) According to Fish and Shelly (1978) there are three spiritual needs there are three spiritual needs underlying all religious traditions underlying all religious traditions and common to all people: and common to all people:

1.1. Need for meaning and purposeNeed for meaning and purpose

2.2. Need for love and relatednessNeed for love and relatedness

3.3. Need for forgivenessNeed for forgiveness

Spiritual CareSpiritual Care

Care that enables individuals to Care that enables individuals to meet basic spiritual needs: (1) need meet basic spiritual needs: (1) need for meaning and purpose, (2) need for meaning and purpose, (2) need for love and relatedness, and (3) for love and relatedness, and (3) need for forgivenessneed for forgiveness

Spiritual Care and the Spiritual Care and the HealerHealer• Offering Supportive PresenceOffering Supportive Presence

When you made a cross on my forehead When you made a cross on my forehead with your thumb, it felt very foreign to me. with your thumb, it felt very foreign to me. No one has ever done that before. It felt No one has ever done that before. It felt unfamiliar–but perfect. Like a blessing with unfamiliar–but perfect. Like a blessing with no conditions–no strings. How liberating. no conditions–no strings. How liberating. Affirming. Loving. And to think you did it Affirming. Loving. And to think you did it with just your thumb. And your heart. with just your thumb. And your heart. Thank you.Thank you.Human Caring Facilitates Healing. We care Human Caring Facilitates Healing. We care first and primarily by being present to first and primarily by being present to others in a manner that is compassionate, others in a manner that is compassionate, affirming, and healing.affirming, and healing.

• Facilitating the Practice of ReligionFacilitating the Practice of Religion• Nurturing SpiritualityNurturing Spirituality

Spiritual Care and the Spiritual Care and the HealerHealer

• Praying With OthersPraying With Others

• Responding to Human Suffering and Responding to Human Suffering and Engendering HopeEngendering Hope

• Counseling the Patient SpirituallyCounseling the Patient Spiritually

• Contacting a Spiritual CounselorContacting a Spiritual Counselor

• Resolving Conflicts Between Spiritual Resolving Conflicts Between Spiritual Beliefs and TreatmentsBeliefs and Treatments

Creating a Culture that Creating a Culture that Promotes Spiritual CarePromotes Spiritual Care

An institutional culture that values spiritual care:An institutional culture that values spiritual care:

• Clearly articulates in its mission a commitment Clearly articulates in its mission a commitment to identifying and meeting spiritual needsto identifying and meeting spiritual needs

• Includes identifying and meeting spiritual Includes identifying and meeting spiritual needs in the job descriptions and core needs in the job descriptions and core competencies for all clinicianscompetencies for all clinicians

• Uses ritual to “call forth” and empower Uses ritual to “call forth” and empower healing giftshealing gifts

• Uses identifying and meeting spiritual needs Uses identifying and meeting spiritual needs as a core element in performance reviewsas a core element in performance reviews

• Holds employees responsible for holistic Holds employees responsible for holistic self-care:self-care:– Physical, intellectual, spiritual, emotional and socialPhysical, intellectual, spiritual, emotional and social

• Is characterized by respectful and loving Is characterized by respectful and loving relationships among all parties relationships among all parties

• Holds leadership accountable for creating a Holds leadership accountable for creating a culture that promotes spiritual care; culture that promotes spiritual care; responsibilities of governance and responsibilities of governance and management are identifiedmanagement are identified