Spirituality in Healthcare: a case-based Inquiry
Multi-faith Spiritual Health Practitioners (SHPs) can treat symptoms of “Spiritual Distress” and are trained to counsel patients and families in all stages of living and dying. In providing Culturally Safe, Person and Family Centred Care (PFCC), members of the multidisciplinary team participate in “caring for the soul”. There are many benefits for patients and families in being accompanied on their care journey by attentive and competent Multi-faith SHPs.
To better understand the scope of “spirituality” and “wholeness” we offer reflections interspersed with cases, inclusive of many cultures, beliefs, and traditions to illustrate the expertise and competencies of Multi-faith SHPs: certified by the Canadian Association of Spiritual Care (CASC) after qualifying with a master’s and hospital internship.
CONFIDENTIALITY DISCLAIMER; The identities and circumstances of patients, families, staff, and settings in these educational cases have been changed to protect their privacy. Some cases are a composite of several stories, while others are fictional. Any resemblance to known cases is entirely coincidental.
“Helping, fixing, and serving represent three different ways of seeing life. When you help, you see life as weak. When you fix, you see life as broken. When you serve, you see life as whole. Fixing and helping may be the work of the ego, and service the work of the soul” — Rachel Remen, MD
Case 1 Ayesha, a 31 yr. old woman of Islamic faith is recovering in the ICU from cardiac complications of Sarcoidosis. Being in ICU was disrupting her normal prayer routines. The SHP offers supported prayer by sitting quietly beside her while the patient prayed. This was helpful, and an accepted “prescription” of 15 minutes of daily prayer from the SHP led to a great improvement in the patient’s emotional well-being.
“Spirituality encompasses the realm of how individuals find hope and healing during serious illness, stress, or loss, but also how individuals find resiliency in the face of stress. Spirituality, therefore, encompasses all of care and not only palliative care.” -Puchalski MD Restorative Medicine p.197
Case 2 Feng is a 79 yr. old Asian patriarch with advanced prostate cancer whose son insists on non-disclosure of diagnosis and prognosis to protect his father from despair. The SHP with the ethics service offers support to family and staff by building trust, addressing moral distress, and assisting with end-of-life preparation.
“Compassion can be thought of as spirituality in action. Spirituality forms the glue that binds what is referred to as the mind-body-spirit aspects or biopsychosocial- spiritual aspects of caring for the patient.”- Puchalski MD Restorative Medicine p.197
Case 3 Ohghwa is a 21 yr. old Indigenous man recovering from endocarditis and valve replacement. He is unable to attend his best friend’s funeral several days’ journey away. The SHP offers cultural humility, fosters trust, and employs visualization (an imaginary exchange of fishing rods at the graveside), to facilitate honouring and grieving his friend. The patient said he felt relieved of some of the burdens of loss and is less reluctant to return home and visit his friend’s grave.
“Spirituality is the aspect of humanity of experiencing connectedness to the moment, to self, to others, to nature, and to the significant or sacred.” -Puchalski MD Restorative Medicine p.199
Case 4 Maryann, a 52 yr. old woman is unconscious for over a month after sustaining a head injury in an accident in which her husband was driving. She is suffering from seizures which are difficult to control. Her evangelical Christian husband is holding hope for divine healing. Their faith community has judged that lack of healing is evidence of inadequate faith. The SHP assists with spiritual distress, exploration of world views, and supporting end-of-life decision-making.
“Spiritual distress can manifest as helplessness, guilt, mistrust, isolation, grief, and a conflicted belief system.” -Puchalski MD pgs. 198, 202 Restorative Medicine
Case 5 Kiki, an 84 yr. old Indigenous matriarch suffers a stroke affecting speech and swallowing. The family requests smudging with sage and to feed her traditional medicines at risk of aspiration. The SHP liaises with cultural wisdom keepers to foster trust and offer sacred spaces for ceremonies and healing while negotiating to mitigate risks. The SHP and ethicist support the staff who are experiencing moral distress and compromise about feeding at risk.
“Spirituality is that place where the utterly intimate and the vastly infinite meet.”- Rick Fields
“In order to be able to have shared decision-making, physicians must know the values and beliefs of the patient.” -Puchalski MD Restorative Medicine p.198
Case 6 Colin is a 48 yr. old man with advanced bowel cancer in the palliative care ward experiencing spiritual distress with grief, pain, and anxiety. He tells the SHP that he is spiritual, but not religious and feels a strong connection to nature. The SHP offers guided meditations and mindfulness where he experiences the support of the earth beneath him. He has a renewed sense of control and the ability to find calmness on his own during anxiety-provoking situations such as waiting for medical procedures and test results during his long hospital stay.
“Human spirituality may have a deep relationship to the natural environment, to justice issues as well as to our families of origin, our physical and mental health, and our personal relationships. Spirituality profoundly guides our worldview; how we make sense of our own personal life and how we understand our role within the world in which we live.” -Jennifer Roosma MD
Case 7 Pema, a 35 yr. old ICU nurse with roots in Buddhism finds it spiritually distressing when a hospital bed and cubicle are quickly cleaned after a patient dies and a new patient is then admitted. She shared this with the SHP and appreciates when an SHP prays a blessing in an empty room where someone has recently died, (even without having been there for a spiritual care visit). When there is a pressing need to move a deceased patient to a private room, she is grateful that the SHP offers prayers at the bedside during the transition when a Buddhist priest cannot attend. Some Buddhist families have asked that their loved ones not be moved, touched, or disturbed for 4 hours after passing to facilitate the soul leaving the body.
“Spirituality can lead to restoration of health for the patient and restoration of professional call for the clinician: to a worldview that allows us to live authentic, meaningful and whole lives, in the midst of our own personal joys and sorrows: everyday spirituality in the workplace.” -Puchalski MD Restorative Medicine p.197 and R Paul Stevens IV Press
Case 8 Luci is a 41yr. old single mother with Amyotrophic Lateral Sclerosis (ALS- Lou Gehrig’s disease). She is living with her 16 yr. child who is transitioning from female to male and lives with obsessive-compulsive disorder, anxiety, and depression. Luci suffers from upper and lower limb weakness, muscle cramps, fatigue, and weight loss requiring a wheelchair and homecare. Due to the progression of her motor neuron disease, she is having difficulty speaking and is facing the need for a feeding tube and assisted ventilation overnight. Psychiatry follows her for depression, anxiety, and panic attacks. Her partner Anthony lives elsewhere but visits daily. Family dynamics are complicated with her ex and family of origin. She feels a burden to her family and that God is absent in her illness. Because of her upbringing and beliefs, she is afraid of going to hell if she chooses Medical Assistance with Dying (MAiD). Her love for those who are living has prevented her from accessing MAiD thus far. She avoids discussing this with her partner and especially her child and asks the SHP to be present when she gives them the news. They apparently suspect she is contemplating an assisted death. She considers the ethical tension surrounding “Playing God” and leaving her young child. The SHP encourages the involvement of SW and hospice society for bereavement counseling. The SHP offers unconditional personal regard. Upon learning about the MAiD assessment, the child and partner are devastated, and she was encouraged to extend the timeline. Luci is worried about the likelihood of dementia and becoming ineligible for an assisted death. Luci wrote a beautiful “Ethical Will” letter to her child describing the virtues, (kindness, patience, and affection) by which she has received their support. Then Luci outlined blessings and hopes for her child’s future; finding meaning, lasting love, and having a family, a vocation, hope, health, happiness, and harmony. Luci asked them to read the letter while she was still alive. Closer to the set date her sister arrived from overseas to reconcile, then her estranged father called. Luci asked for the blessing of her family. The family was also ambivalent, wanting to be supportive of either outcome. Luci’s inner conflict created moral distress for staff and family considering that legal consent must be wholehearted. MAiD was provided with distraught family, staff, and the SHP present. The SHP was available to all involved for debriefing.
“Storytellers take risks. They hope for an audience willing to acknowledge the truthfulness of the story and to accept an ethical responsibility to both story and teller.” -K. Schaffer, S Smith, Human rights and narrated lives p. 6
Case 9 Patrick is a 45 yr. old man living with ventilator-dependent quadriplegia and treated depression who was injured 8 months ago. His mother is a Christian who strongly opposes his legal request to have his ventilator withdrawn, believing his life was spared for a divine purpose. Fearing for his eternal destiny, his mother requests the SHP to encourage him to be baptized. The SHP offers dignity therapy and trauma-informed care for the patient and rituals, prayers, and songs with the mother. The SHP accompanied the distressed mother to return to the bedside to attend her son’s passing. Staff appreciate the support and debriefs regarding conscientious objection, confidentiality, and grief.
“To draw an analogy: a person’s suffering is similar to the behavior of a gas. Thus, suffering completely fills the chamber of the human soul, no matter if the suffering is great or little. Therefore the “size” of human suffering is absolutely relative.” -Viktor Emil Frankl, Man’s Search for Meaning
Case 10 Fred is a 55 yr. old, retired fireman in and out of the Bone Marrow Transplant Ward for treatment of leukemia. He was reluctant to chat with the SHP however he asked to have an occasional wave from the door when he was in isolation. Once, he asked the SHP to debrief an altercation with a roommate. The SHP listened to the patient’s preparation to meet with higher management. When he was in ICU suffering Graft Versus Host rejection, he reached out again to the same SHP, sobbing about his shortcomings and regrets while significantly short of breath (Respiratory Therapy was present). For over 6 months until he passed, the SHP provided unconditional regard and connection in an unobtrusive way. At end of life, the patient asked the SHP to witness confession and facilitate forgiveness.
“But there was no need to be ashamed of tears, for tears bore witness that a person had the greatest of courage, the courage to suffer.” — Viktor E. Frankl, Man’s Search for Meaning
Case 11 Martha is a 49 yr. old woman with declining capacity due to a progressing brain tumor. She is fearful, confused, and ambivalent about the proposed surgery. She attributes a very recent estrangement from her family to their religiously based disapproval of her gay partner. The SHP addresses the patient’s spiritual distress, (anxiety and isolation) and assists with prayerful reconciliation within the family. The SHP supports the team by exploring collateral sources to help them determine who is an appropriate surrogate to consent to surgery on the declining patient’s behalf.
“In a patient-centred holistic approach to health, when the patient’s treatment plan is individualized to include their values and beliefs, healthcare outcomes improve. The spirituality of the patient is an important dimension of their being, and hence of their overall health.” -Puchalski MD Restorative Medicine p197
Case 12 Terrance, a 65 yr. old man of colour living with schizophrenia is hospitalized for delusions. He is now in a surgical ward for treatment of diabetic complications affecting his leg. The SHP addresses his spiritual needs given his isolation and experiences of racial stigmatization. Staff often find him angry and his prophecies intrusive, despite the patient’s well wishes being generally positive about winning lotteries and retiring early. The SHP assists staff with reframing the patient’s “blessings” to be expressions of his care and interest. His Caribbean grandmother was respected for her prophecies. The SHP liaises with the SW to find him a supportive housing community and an outpatient group to continue the anger management work begun with the SHP.
“Spirituality refers to that dimension of the human person that fosters a sense of meaning. Going beyond religion and culture, though often connected to both, spirituality is linked to the way people find coherence and authenticity in life. It encompasses our relationships, our values, and our life purpose. It may or may not involve belief in, or an active relationship with a higher power.” -Puchalski MD Restorative Medicine
Case 13 Neville is a 74 yr. old man, a former ICU/ER nurse living in residential care after suffering 2 strokes 3 years ago which left him with right hemiplegia (paralysis), spasticity, and difficulties speaking. He is a devoted Catholic who struggles with treatment-resistant depression. He is grieving the loss of his role as father to a 17 yr. old son who lives with cognitive challenges though his son finished high school and is working in a grocery store hoping to attend community college. His wife has expressed frustration being for the most part a single parent. He has occasionally denied her and their son visits. Neville’s spiritual distress manifests as disillusionment and disappointment that God has not healed him despite having lived a pious life. He describes cognitive dissonance between his spiritual beliefs and his suffering which he perceives as a punishment from God and abandonment. He denies an alleged suicide attempt. SHP visits include validation of ambivalence and meditations on the meaning of suffering and ways to mentor his son through the creation of an “Ethical Will” and spiritual legacy. Neville writes a biography highlighting examples of his son’s goodness over his 17 years, and the many reasons he is a beloved son. Neville offers blessings for the life his son will live without a father. Neville asked for his son to read the letter after he was gone. Neville suffered another stroke and passed in Palliative Care supported by the SHP.
“In Spiritual Care, we are confronted with the awesome truth that in speech God’s presence is known and that speech is also our own; in silence, God’s presence is known and that silence is also our own.” -Dietrich Bonhoeffer
Case 14 Candy, is a 25 yr. old Hispanic woman raised in the Jehovah’s Witness faith. Known to have bipolar disorder she was brought to the ED in a crisis by a friend who was worried about her angry allegations, insomnia, and persecutory delusions. Trauma history included sexual and physical abuse. She felt victimized while being stabilized in a seclusion room. Then she was transferred to a private room in the psychiatry ward. She suffered chronic pelvic pain, debilitating menstrual pain, and heavy flow. There was no evidence of infectious disease, but she was profoundly anemic. A pelvic ultrasound revealed a huge endometrioma 20 cm in diameter. This is a cystic collection of old blood released from ectopic endometrial tissue found in the abdominal cavity. Inflammatory tissue and new vessel growth surrounded the mass. Because of the cyst’s size, her pain, and the risk of rupture, gynecology recommended urgent surgery as soon as her hemoglobin was stabilized. This would include an urgent blood transfusion with consent secured for the probable need for intraoperative blood. Psychiatry deemed her capable of consenting to surgery but found her conflicted about refusing blood because of fear of death and estrangement from her family and faith community. While her paranoia had settled, she was still afraid of damnation. She requested “blood conserving surgical techniques” and to speak with an SHP. JW hospital Liaisons were involved and kept a vigil. Staff found her distressed with guilt after the JWL visits. The SHP advocated for her request to have solitude and attended to her only when called. She enjoyed time with the Rec Therapist painting and sculpting clay. With the SHP she explored the goodness and grace of the Creator through scripture and meditations. She becomes certain God will not abandon her but intends for her to live healthily without pain.
“A story in its innate and proper sense is someone’s life. It is the numen of their life and their firsthand familiarity with the stories they carry that makes the story ‘medicine’-: a medicine that strengthens and rights the individual and the community.” -Clarissa Pinkola Estes
Case 15 Brenda, a 52yr old oncology nurse collaborates with an SHP to create ways of saying goodbye to their patients and families. The need was particularly acute after a young mother was abruptly flown home to pass away with her family in a remote coastal community after a very long hospitalization. The staff was distraught not being able to say goodbye. They were very appreciative that the SHP followed up by phone and shared the news that she passed peacefully surrounded by a loving family. Opportunities have arisen to drop in at shift change or lunch to informally remember patients. Staff connects with each other by writing the patient’s name on a heart and sharing a story or remembrance in a blank book kept at the station. SHPs regularly offer communal services for families who have lost children in the previous months. SHPs collaborate with psychiatry and ethics to host workshops on grief, moral distress and compromise, burnout, and strategies for resilience.
“The people live in the shelter of each other.” -Irish Proverb
“An elder once said; ‘A bundle of sticks is not easily broken. I want you to live like this, bundled together.’”
Case 16- Jas is a 26 yr. Punjabi man who suffered severe brain anoxia because of an unwitnessed fentanyl poisoning. He has quadriplegia and blindness. Nine months after his injury he is refusing insulin for his longstanding Type 1 diabetes based on poor quality of life with little hope for improvement. A multi-faith SHP explores texts from the scriptures the patient learned in childhood and he begins to write poetry. A music therapist collaborates with him to create songs. He can communicate with a computer that reads Morse code that he articulates with his head onto headrests. Years later he wins an award for courage and service having spoken to over 100,000 high school students about the dangers of drug use.
“’We cannot give the wind orders, but we must leave the window open.’ The absolute is the wind; our spirit is the window.”- Andre Comte-Sponville on Krishnamurti in the Little Book of Atheist Spirituality.
