By David Lichter
This issue of Vision is dedicated to end-of-life care. We are grateful to all of the authors who have contributed. Certainly, the clinical discipline of palliative care has contributed greatly to integrating spiritual care and viewing it differently from just a set of protocols and practices. I appreciated Timothy Daalman and his co-authors, who described spiritual care at the end of life as “a series of highly fluid interpersonal processes in the context of mutually recognized human values and experiences, rather than a set of prescribed and proscribed roles.” While spiritual care at end of life is indeed a “series of highly fluid processes,” the board-certified chaplain is comfortable in this realm and helps guide the patient, family, and interdisciplinary team through identifying, exploring, and addressing the meaning, purpose, and myriad of relationships that facing end-of-life decisions require.
If you have not yet reviewed the Clinical Practice Guidelines for Quality Palliative Care, fourth edition, please do. It improves significantly upon the third edition (2013), especially Domain 5, dedicated to helping patients and family face the spiritual, religious, and existential issues they encounter. I want here to highlight three improvements I appreciated.
First, it uses the more expansive definition of spirituality while building on the excellent definition of spirituality provided us in 2009 by the National Consensus Project. As you recall the 2009 definition was: “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.” The fourth edition’s description of spirituality is “a dynamic and intrinsic aspect of humanity through which individuals seek meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices.” Thus, the Guideline 5.1 makes special note of assessing and respecting the spiritual beliefs and practices of the patient and his/her family, as well as highlighting the importance of the entire interdisciplinary team to be aware of their own unique spiritualities and “opportunities are provided to engage the staff in self-care and self-reflection regarding their own spirituality.” The chaplain both models and assists the IDT in the self-reflection and self-care.
Secondly, in NCP 5.2, the fourth edition revises the list of potential areas to examine in a spiritual assessment. Again, I think this is an improvement. The third edition included “spiritual and existential concerns” such as: “life review, assessment of hopes, value, and fears, meaning, purpose, beliefs about afterlife, spiritual or religious practices, cultural norms, beliefs that influence understanding of illness, coping, guilt, forgiveness, and life completion tasks.” This fourth edition includes a more organized set of “spiritual concerns” such as but not limited to: “a. Sources of spiritual strength and support b. Existential concerns such as lack of meaning, questions about one’s own existence, and questions of meaning and suffering c. Concerns about relationship to God, the Holy, or deity, such as anger or abandonment d. Struggles related to loss of faith, community of faith, or spiritual practices e. Cultural norms and preferences that impact belief systems and spiritual practices f. Hopes, values and fears, meaning, and purpose g. Concerns about quality of life h. Concerns or fear of death and dying and beliefs about afterlife i. Spiritual practices j. Concerns about relationships k. Life completion tasks, grief, and bereavement.” I believe it is helpful to begin with identifying the sources of spiritual strength and support critical to addressing the others. In fact, NCP 5.3 emphasizes “maximizing patient and family spiritual strengths.”
Thirdly, the new edition added a fourth guideline regarding the need for ongoing care, remaining vigilant to changing circumstances and flexible with an evolving care plan. NCP 5.4.1 describes this practice as: “Throughout the trajectory of the patient’s illness, the IDT performs spiritual screening to identify new or emergent issues, identifying services and supports to help navigate these transitions. Changes in prognosis and other significant transitions prompt reassessment of spirituality.” This practice aligns well with Daalman and colleagues’ description of spiritual care as “a series of highly fluid interpersonal processes in the context of mutually recognized human values and experiences, rather than a set of prescribed and proscribed roles.”
These are just three improvements I note. However, the entire document invites a thorough read. I am particularly grateful for the integration and prominence of the board-certified chaplain in Domain 5. I hope you will read this at your convenience.