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Palliative Care Perspectives : Chapter 7: Psychosocial and Spiritual Aspects of Care : Spirituality

Palliative Care Note
"Why" questions that do not depend upon technical answers are often spiritual in nature.
Charles von Gunten, Personal statement.

Dr. Charles von Gunten has served as the chair of the American Board of Hospice and Palliative Medicine and as coprincipal investigator for the EPEC (Education for Physicians on End-of-Life Care) Project. He is also a dear friend.

"Do you believe in God?" "What do you think will happen to us when we die?" "Why did God do this to me?" "Doctor, will you pray for me?" Some would say that the clinician has no business dealing with spirituality or religion. How, then, should we answer questions such as these? Whatever our beliefs about the nature of the universe and our roles as clinicians, we cannot escape the fact that for many of our patients and their families, spirituality (or religion) is central to their lives and becomes particularly important as they approach death.50,51 If we are to be of some assistance, we must deal with people as they are, and this means we have no choice but to deal with the spiritual aspects of their experience. Studies have suggested that many patients want, but rarely receive, physician involvement in their spiritual care. King, for example, studied 203 adult inpatients and found that 77% of those surveyed thought that physicians should consider patients' spiritual needs; 37% wanted physicians to discuss religious beliefs more frequently. However, 68% reported that physicians had never discussed religious beliefs.52

Spirituality is that aspect of a person's beliefs and experience that transcends the everyday world. Religion is an organized belief system. These may be my definitions, but what matters more is what they mean to our patients and their families. Some may reject both terms outright: "I have no beliefs," or "I'm an atheist." Fine; these, too, are beliefs that arise from a certain understanding of what makes the universe tick. What is meaningful to such a person? How does such a perspective affect that individual's understanding of his or her living and dying? Where is suffering to be found, and where solace? The danger in working with people who express "no beliefs" is in taking such statements at face value. Questions of meaning, suffering, and solace are still highly relevant and, in the broadest sense, are also spiritual.53

Some will take offense at the term spirituality, thinking this refers to some cultlike belief system. "I'm a born-again Christian." "I'm Jewish" (or "Buddhist," or whatever). Fine; what does that mean to you? We are burdened in such exchanges by preconceptions. We may know something about Christianity, Judaism, or Buddhism, and therefore we may think we know something about what it means to this person. Very often we are wrong. The same questions arise: what is meaningful to you, where is your suffering, where is your solace? And how can we help you in all this?

Is this not a job for a chaplain or spiritual care adviser? Certainly. As elsewhere in medicine, clinicians need to know when to refer to others for help. However, not everything can be referred. If a patient asks you, "Doctor, why did this happen to me," or "Doctor, what is your faith," how will you answer? Charles von Gunten, chair of the American Board of Hospice and Palliative Medicine, is fond of saying that "why" questions that do not rely on technical explanations are spiritual in nature. You may choose to answer, "You got cancer because you smoked four packs a day," but is this what the patient is really asking? When asked about your faith, you may begin a lecture on your beliefs or lack thereof, but is this really what the patient needs?

It may seem strange, but an important starting point in addressing spirituality relates to skill training. Spirituality is complex and profound. All of us in some way, I think, are struggling to make sense of this universe. Rather than take on the heaviest of issues, it is better to start with babysteps. Later, we may contemplate the deep inner meaning of it all.

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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.