Spirituality – Another vital sign on the doctor’s check list?

Professor Christina Puchalski (c)Hamid Benalia, the Cicely Saunders Institute

The machine, beeping steadily away in the background, reassuringly spells life. Suddenly it goes haywire. Something’s wrong. The patient needs urgent attention. Visiting family members panic as the monitor warns of their loved one’s impending doom. In rush the concerned clinicians – first the nurses, then the doctors. It’s action stations. Finally, depending on whether the writers have scripted happy or sad endings, the music is jubilant or sorrowful. And then the credits roll.

We are all familiar with Hollywood’s traditionally traumatic version of the fragility that seems to separate life from death. And we might hope and pray never to star in such a drama in real life. But tracking and reacting to dramatic changes in a patient’s vital signs is an essential part of modern-day healthcare. So are we recognising and responding to all the vital signs?

Dr Christina Puchalski, of the George Washington Institute for Spirituality and Health at George Washington University, thinks not. An unwearying champion of the need to assess, acknowledge and accommodate the spiritual needs of patients in hospital settings, Dr Puchalski has “pioneered novel clinical and educational techniques for integrating spirituality into numerous disciplines in healthcare”.

She recently visited the UK to deliver the Sir Halley Stewart Trust International Lecture hosted by the Cicely Saunders Institute of Palliative Care at King’s College London. Among the paradigm-shifting aspirations she shared was the hope that clinicians will one day routinely recognise spirituality as a vital sign demanding their attention.

However, many efforts to promote the importance of spirituality as part of a more “whole-health” approach to healthcare can often flounder on the reefs of definition. This was one of the points taken up at a 2009 Consensus Conference on improving the spiritual element of palliative care, described by Dr Puchalski. The clinicians and non-clinicians attending, some of whom were religious and others who weren’t, came to this workable definition: ”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”.

She noted that the significant and sacred can mean very different things – from God to nature and beauty or whatever holds ultimate meaning for a person. She has consistently found this “aspect of humanity” to be key to the wellbeing of individuals undergoing medical treatment. And following two decades of researching and advocating the integration of spirituality into healthcare she has recently published a comprehensive textbook on the subject.

But how do you recognise the state of someone’s spiritual well-being? Such a vital sign would not be tracked on a digital display or measured by any equipment. Spirituality is highly individual and so too, are the occasions when it is out of kilter. The speaker’s illustrations included a personal tale of experiencing two doctors at opposite ends of the scale of desirable practice.

At the beginning of her mother’s treatment for dementia, the first doctor they saw breezed in with a template of questions designed to test a patient’s mental competence. There was virtually no eye contact as he went through the list and no effort on his part to notice the individuality of the person in his care. Appalled, Dr Puchalski checked off to the offending physician some of the things he had missed – such as appreciating her mother’s character and the rich life she had lived. He hadn’t asked her about her family and what she loves – or what is important to her, including her lifelong Roman Catholic faith.

The second doctor, however – attending just a couple of weeks before her mother’s passing – saw beyond the medical condition to the uniqueness of the individual in his care. He achieved such a rapport with his patient that they actually shared a banana. More astoundingly, when the doctor left them, her mother – who had barely communicated to anyone for months – turned to her daughter and said: “Now Christina, that is a good doctor!”

In her talk, which she stressed was based on her experience with the United States healthcare system, she emphasised the UK would continue to fine tune its own model for increasingly including spirituality in healthcare. Many points in her lecture, though, were universal – including the fact that as we are sensitive to the spiritual needs of others the blessings are mutual.

She said: “We are changed and healed by our patients as much as the other way round”.

I can’t help but feel the second doctor’s obvious love of his patient and his recognition of her as an individual reached through the symptoms that had befogged Dr Puchalski’s mother to reveal a consciousness that was still intact. Could this point to the deeper potential for spiritual care in a health setting – that such love can throw light on a spiritual identity which can sometimes seem eclipsed but is never truly absent?

So, let’s imagine we’re back on the film set.

“Lights. Camera. Action!”

Scene 1: A hospital room

The patient is lying in his hospital bed. His life-signs monitor is beeping away in the background.

The nurse dressing his wounds is chatting with him. He proudly talks about his thirty-year old son and how well he has turned out. The nurse asks: “And do you have any other children?”

Silence. Then tears. She asks: “What’s the problem?” But he won’t answer. Although the life-signs monitor hardly registers a change she can feel the depth of the patient’s unspoken inner turmoil. She holds his arm and takes time to share the silence till his weeping ends. He says “Sorry!” and forces a smile. She smiles back.

Scene 2: A boardroom

The Interdisciplinary Team are gathered together. The nurse tells the doctor, mental health counsellor and chaplain how her conversation shed light on the patient’s inner struggle. They agree they all need to respond to the patient’s deeper distress as well as the physical pain. The doctor says that when he’d sat with the patient and inquired about his spiritual beliefs or practices the patient had hesitated before saying he was a Christian. The chaplain says she will pay a call.

Scene 3: The hospital room

The chaplain’s compassion is clearly touching the patient as they, too, talk about how dear his son is to him and as he fondly reminisces about his wife, who he lost to illness a decade ago. He doesn’t mention another child.

They also exchange stories of their mutual love of nature.

Gently probing, the chaplain asks “Is there anything on your mind to attend to before you die?” But he just answers with a smile: “My rose-beds!” She laughs along with him.

Building on the rapport they have achieved, she quietly asks: “Is there anything you wish had turned out differently?”

The chaplain sits by the patient’s bedside quietly, waiting, as the question hangs in the air.

Silence. Tears again. But when the sobbing stops the patient turns to the chaplain and the story pours out. His daughter decided to live with her boyfriend without marrying and he rejected the pair as “living in sin”. They haven’t spoken for twenty years. The patient says he is angry with God for giving him a daughter who wouldn’t live up to the moral standards he believes in.

The chaplain pauses, praying thoughtfully to herself. Then she clasps the patient’s hand, and says: “Do you think it might be possible that God loves you, your daughter and her boyfriend – and that He wants you to fully embrace them in your heart?”

Scene 4: The hospital room

The patient is again pictured with tears streaming down his face. But this time he is holding a telephone. The scene cuts to a woman on her phone who is also crying as she squeezes her partner’s hand.

Scene 5: The hospital lobby

The patient hugs the nurse and then the chaplain as he leaves the hospital and walks into a crisp autumn morning. Looking totally at peace he walks down the road, sees a local church, hesitates and then enters. He sits alone on a pew staring blankly into space for a few moments. Then he breaks into a broad, joyful smile.

The picture fades out and the credits roll.

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• milkybar251

  I couldn’t read this through without gagging. Good bed-side manner is one thing; it can make a patient feel better but it doesn’t physically make them better. If you want spirituality go to church.

• icarus_69

  The definition of spirituality they appear to have decided on has been made so general and bland, presumably to avoid any specifics that people might object to, that it has become devoid of meaning. I happen to think it is devoid of meaning anyway, so this just goes some way to confirming my view.

• g0annahead

  What is spirituality then? In it’s most condensed form it can be understood as unconditional love and compassion, the “Jesus likeness”.
  Seen any of that around in the world lately? No?
  Wonder why humanity suffers so much.

• Jay Cross

  Spirituality is what the first doctor did not talk about. It’s part of us that’s not muscle and blood. People without it are not as happy in life as those who do. Nor do they live as long.

• Muttlee2

  This may be ‘emperors clothes’ kind of stuff but does the word ’spiritual’ actually mean anything? I know what people think it means,but in the end,isn’t it just a vague concept based around belief? It’s not really something that can be scientifically measured is it?

  And I’d be a bit angry if I had to put up with religionists clustered by my sickbed around me in hospital. As if hospital food and being ill is not bad enough.

• Muttlee2

  I doubt this is really true or if there is any scientific statistical evidence for it. You might believe it to be true but then again you presumably believe a lot of things to be true without any evidence.

  I do tend to agree with the late great Spike Milligan,who noted that in his experience,rather than benefit from religion,people tended to suffer from it,as if it was some kind of illness.

• http://3Info2U.com helloitsmefolks

  The mind and body are tightly bound when dealing with illness and death and a major part of the mind is the spiritual element. Many in our ‘rational’ world will of course deny this, but when the inevitable day arrives to leave this life the need to make sense of it and go in peace becomes paramount.

  Dr Puchalski you are to be commended.

• Colin Nicholas

  Can atheists be spiritual? I mean I chat to myself frequently, without moving my lips of course – (move your lips and they lock you up). It sounds as if being spiritual is talking to a spirit, a God, or some dead person. Or is being spiritual just thinking things? Whatever it is religious people seem to believe it’s something cool that belongs mainly to them. They can have it if it makes them feel better. But I prefer to call it thinking.

• Colin Nicholas

  LIstening to Debussy while stoned is the ultimate in spirituality for me. That’s being spiritual. In fact just being stoned is being spiritual. One lives inside ones mind. You don’t need to be religious to be spiritual. Just stoned.

• Individuality

  Spirituality is as individual as there are individuals on this planet. It is as invisible as are the inner paths each single one of us travels. It becomes as tangible in our lives as we chose to make it or it stays hidden within us without it being any less relevant for us personally. Some are healed (physically and/or mentally) in the care of a doctor who incorporates spiritually in his practice, others totally reject spirituality (and they, too, are healed). Ought we then not appreciate rather than question/oppose/condemn/etc. each single contribution any one of us is making to the uplifting, individually and collectively, of our consciousness? After all, opinions and experiences (not just in the area of spirituality) are always subjective. Caring for each other – and in this context here, listening to each other – is the highest expression of the one concept that makes life a worthwhile (and oftentimes joyous) adventure: “…love your neighbour as thyself…” – whether we agree to this or not, have experienced it or not, and in spite of the many cruelties that threaten to surmount our thinking. And a disposition like this (it’s not about the words which I’ve used, it’s about the idea behind for which someone else may find other words) heals. The evidence to that end cannot any longer be neglected.