wellness, wholeness and spiritual care

Wellness, wholeness and spiritual careOn the occasion of 100 years of King’s College Hospital in Camberwell: 25th September 2013

Revd Dr Peter SpeckHon Senior Lecturer Dept of Palliative Care, Policy and RehabilitationKing’s College London

www.kcl.ac.uk/palliative

Overview• Introduction• What is wellness?• What is health and wholeness?• Spiritual care as a component of care• Is there evidence to support its inclusion?• Who should be responsible for meeting

spiritual needs?


From the time of admission patients can quickly begin to experience loss – of identity, of control, or being seen as a whole person – in addition to the effects of the illness or treatment.

On discharge

will patients

have achieved wellness

or wholeness

?


Wellness• Usually described as the absence of disease or

illness• A product of measures to eradicate disease

(treatment) or of the pursuit of a healthy lifestyle• Modern medicine has been described as a

“disease attacking” service (Illich 1975) and not necessarily focussed on enhancing health or addressing multiple needs of the whole person. But this is now changing [eg elderly care, palliative care etc.]


Health and Wholeness“Health is a state of complete physical, mental and social wellbeing and not merely absence of disease or infirmity” WHO 1948

defn. [unchanged since 1948] includes well-being, well-working, and being unimpeded in realising one’s true nature.

The NHS Constitution implies relevant for staff as well as patients in the commitment to provide support and opportunities for staff to maintain their health, well-being and safety. (The NHS belongs to us all. DH 2011)


• Heal means “to make sound or whole” from root haelan, the condition of being hal / whole (Eisenberg 1983).

• Hal is also the root of ‘holy’/ spiritually pure (Cassell 1991)

• “Healing” can mean different things to different people – as shown by the cartoonist Callahan !


• The Greeks initially understood health as a harmony between the parts of the human organism, with healing as a restorative process.

• However, the goddess Hygeia and the god Asclepius came to represent two approaches:

• Hygeia was the goddess of holistic health and the root of her name gave us Hygeine meaning ‘living well’ or ‘well way of living’.

• Asclepius, as the god of medicine, replaced her In 4th cent and the emphasis shifted to a less integrated view of health with greater focus on treating ailments and symptoms.

• On occasion Hygeia and Asclepius worked together - implying times when a combined approach was more appropriate.


Hygeia and Asclepius offer healing in the temple

In Trivandrum, S. Kerala Ayervedic priest commented …


Medical model

The traditional medical model applies skills and resources to cure or mitigate the effects of a disease process.

Those skills are exercised by people who have undertaken formal training along scientific, empirically based lines.


Medical model

Acknowledging that the medical model has to work

in partnership with the social model allows service

planners and providers to take a more holistic

approach in service delivery – and recognise the

significance spirituality plays within a diverse and

multi-belief society.

Now reflected in policy/guidance docs. + greater

emphasis on inter-professional teamwork.


Need for a collaborative approach

• This was brought into focus by Dame Cicely Saunders when (in the mid 1960’s) she proposed her ‘total pain’ model. Although a qualified social worker, nurse and doctor she recognised the need to draw on the skills of others to meet the many and complex needs of the patients she cared for.

= a widening of a purely bio-medical approach


Total pain model: based on Saunders 1967

Bureaucratic

Cultural

Sexual

PsychologicalSpiritual

SocialPAIN

Other physical symptoms


Health & wholeness: a process over time

• Health is a journey towards wholeness – a process, not a state, an adventure (Lambourne 1985)

• The many aspects of the ‘total pain model’ reflect the complexity of needs, over time, of many who seek wellness (initially) and then (perhaps) wholeness of being. In this process spiritual care has a significant role as reflected in recent guidance docs.


Spirituality guidance docs:

DH 2009 Holloway, Adamason, McSherry, Swinton Jan 2011

NICE guidance supportive care for adults with cancer2004

Quality Standard for End of Life Care for Adults(2011) NICEStatement 6: People approaching the end of life areoffered spiritual and religious support appropriate to their needs and preferencesSpiritual Support and Bereavement Care Quality Markers for End of Life Care (May 2011) NHS : NELCP


Spirituality as a component of holistic care• In recent years increased interest in the

possible benefits of addressing the spiritual needs of patients. Spiritual care has become a focus for research with developing evidence base for relationship between spirituality, well-being and various health outcomes.


Spiritual : EAPC Working Definition 2010

• Spirituality is the dynamic dimension of human life that relates to the way persons (individual and community) experience, express and/or seek meaning, purpose and transcendence, and the way they connect to the moment, to self, to others, to nature, to the significant and/or the sacred.

• Nolan, Saltmarsh & Leget (2011) Eur.J.Pall Care 18, 86-89


Spiritual/religious and secular beliefs should be differentiated - though inter-related

Now better accepted that spiritual relates more to how people understand and live their lives in view of core beliefs and values, and their perception of ‘ultimate meaning and purpose’. Can become very important in times of crisis, or elderly and e-o-l care. Early (US) research confused rel/sp

spiritual

religious

Secular/philosophical


• Commonly defined inclusively: applicable to all – rel/ sp/ philiosophical

• Supports those grappling with questions and the despair that can arise in crises.

• Aims to alleviate sp. distress and increase sp. well-being

Spectrum

Spiritual care in current healthcare

Spiritual distress: helplessness, meaninglessness, suffering, lack of peace…ritual

spiritual well-being:Hope, meaning,

peace, forgiveness,

acceptance ..


Support for spiritual care

• Increase of policy guidance globally eg Domain 5 of Holistic Common Assessment – sp.well-being and life goals:(DH 2011)

• Spiritual distress highly prevalent in incurable progressive illness (Moadel et al Psychoonc 1999, Astrrow et al JCO 2007)

• Spiritual care is wanted: (Ehrman et al Arch Intern Med 1999, MacLean et al J Gen Intern Med 2003, Hebert et al J Gen Intern Med 2001, Puchalski et al Pall Med 2009)

• Spiritual well-being a unique contributor to QoL (Whitford et al PsychoOnc 2008)

• More sig. than physical well-being. (King & Speck Soc Sc & Med 2001, Heyland et al CMAJ 2010)

• Yet…. Often neglected (LCP audits + Balboni et al JCO 2013)


Relevance of spiritual careMurray SA, Kendall et al (2004) Exploring the spiritual needs of

people dying of lung cancer or heart failure: a prospective qualitative interview study of patients and their carers. Palliative Medicine 18: 39-45

For heart failure: hopelessness, loss of confidence, and isolation dominated throughout. For lung pts: sp concerns important esp at diagnosis and again at end of life. Meaninglessness evident in both]

Selman L, Beynon T, Higginson IJ, Harding R. (2007) Psychological, social and spiritual distress at the end of life in heart failure patients. Current Opinion in Supportive and Palliative Care. 1: 260-266.

[shows social support/ spiritual belief important coping resources and importance of assessment and management of wider needs]


Study of what’s important to cancer patient • King, Jones, Barnes et al (2005)Psychol Med. 36, 1-9

found people with advanced cancer did not always refer to illness, more concerned with wider meanings of life. Clear that illness had made them reflect and they attributed their coping to their spiritual/religious beliefs.

People with no clear sp/rel belief found it difficult to express their experiences, coping strategies and belief.

c/f earlier King, Speck and Thomas studies of cardiology pts (1995, 1999, 2001) – where the philosophical gp were the least clear and struggled with beliefs and coping strategies.


Relevance of spiritual/ religious care

• Koffman J, Morgan M, Edmonds P, Speck P, Higginson I. (2008) ‘‘I know he controls cancer’’: The meanings of religion among Black Caribbean and White British patients with advanced cancer. Soc Science & Medicine. 67. 780-789.

• [Importance of church community, how rel & belief in God helped them comprehend cancer for both groups. For black carib. helped strengthen religious identity]

• Koffman J, Morgan M, Edmonds P, Speck P, Higginson I (2008) Cultural meanings of pain: a qualitative study of Black Caribbean and White British patients with advanced cancer. Palliative Medicine. 22: 350-359.

• [WB pts reported cancer related pain: BC saw pain as challenge, test of faith or punishment for wrong doing]


Relevance of spiritual care• Thuné-Boyle et al (2010) Religious coping strategies in

patients with breast cancer in the UK. Psycho-Oncology DOI 10.1002/pon.1784

Used RCOPE (Pargament) and Brief-COPE (Carver) to capture religious and non-relig coping

[Rel/Sp coping strategies common in early stages of breast cancer.

Rel/Sp struggle can affect adjustment and hence need to assess ]

• Edwards et al (2010) The understanding of spirituality and potential role of spiritual care in end-of-life and palliative care: a meta-study of qualitative research. Palliative Medicine 24. 753-770. [Importance of relationships, and ‘presence’. Identifies barriers to good spiritual care, incl need for prof education] Reflected in new Cochrane Review


New Cochrane review (2012)• Candy B, Jones L, Varagunam M, Speck P, Tookman A,

King M. Spiritual and religious interventions for well-being of adults in the terminal phases of disease. Cochrane Database of Systematic Reviews 2012 Issue 5 CD007544. DOI: 10.1002/14651858.CD007544

• Searched 14 databases to 2011 for RCTs which evaluated outcomes for interventions with sp/rel component. Primary outcomes = well-being, coping with disease and qual of life.

• Results: 5 RCTs with 1130 participants• 2 evaluated meditation; other interventions involving

chaplain or spiritual counsellor.(‘presence’ and pastoral discussion/ counselling highlighted)

• Inconclusive findings, poor research design & detail in findings. Need for > rigorous studies.


Who should meet spiritual needs ?• NICE and other guidance docs make it clear

that spiritual care is a responsibility of everyone [can easily become responsibility of no-one]. Hence need for designated member of ward, directorate or health division as lead for spiritual care.

• Health care chaplains = valuable resource, together with a chapel/ sacred space for quiet reflection or multi-faith worship


• Multi-professional teamwork is key if we are to meet the complex needs of patients. Such teamwork requires the development of trust and respect for the contribution each can make.

• Chaplains and other spiritual care providers have a positive contribution to make in either directly offering spiritual care to people or supporting staff in meeting such needs.


King’s [Hospital] Chapel: consecrated on 25th September 1913 :

Provides an oasis for peace and quiet reflection within the life of a very busy acute teaching hospital.

Supplemented by the work of chaplains to patients and staff of all faiths or none – within the wards and departments of hospital (24/7)


Chaplains are trained professionals, authorised, accountable and their work has been the subject of research & evaluation

• Cobb & Robshaw (1998)The Spiritual Challenge of Health Care. Churchill Livingstone

• Orchard (2000) Hospital Chaplaincy: modern, dependable? Sheffield Academic Press

• Mowat & Swinton (2005) What do chaplains do? The role of the chaplain in meeting the spiritual needs of patients. Mowat Research Ltd. Aberdeen.

• Nolan (2011) Spiritual care at the end of life: The chaplain as a ‘hopeful presence’ Jessica Kingsley


What do chaplains actually do?• Listen to people’s stories• Work in one:one situations,foster relationships and

re-affirm personhood/ humanity • Support people (pts, staff, relatives) at difficult times• Provide training to help staff develop skills in

spiritual care• A resource for information on different faiths, beliefs,

bereavement• Help people connect/ or re-connect with self, others,

the spiritual.• Conduct or arrange religious rituals as appropriate

• [all for 0.000029% of the 2009/10 NHS budget!]


Conclusion• As we celebrate 100 years of the provision

of a hospital Chapel at King’s may we also affirm the relevance of providing for the wider spiritual needs of patients and staff.

• Care which enables people to find meaning, purpose, hope and peace in their lives in the context of whatever beliefs they hold.

• In this way people may achieve wholeness and healing in spite of loss, continued ill-health or death.


Healing is, therefore,More than wellness it is related to wholeness, and wholeness is experienced in the quality of connection with others.

Chaplaincy (through good spiritual, personalised care) can facilitate that connectedness with self, others (patients, staff, relatives) and the sacred.


Conclusion• Healing and restoration, therefore, happens

in relationship and in community. • Dame Cicely Saunders, in an interview with

Dr Thomas Egnew [Ann Fam Med 2005, 3(3)] said:

In the context of real connection - with self, others or the sacred - we may then move from ‘wellness’ to ‘wholeness’

“You are missing something, as well as the patient missing something, unless you come not merely in a professional role but in a role of one human being meeting another” (C.Saunders)

wellness, wholeness and spiritual care

Documents

spiritual care wellness

absence of disease

disease treatment

disease process

goddess of holistic

elderly care

god asclepius

integrated view of health