Development of the PC-7, a Quantifiable Assessment of Spiritual Concerns of Patients Receiving Palliative Care Near the End of Life

Exploring Psychedelics for Alleviating Existential and Spiritual Suffering in People With Serious Illnesses: Links to the Theory of Self-Transcendence

The fields of palliative and holistic Nursing are dedicated to providing comprehensive care for the person, emphasizing special attention to the existential and spiritual aspects of care. Psychedelic-assisted therapy has emerged as a promising approach for symptom management in individuals with serious illnesses, particularly those of existential and spiritual origin. People who undergo challenging experiences, as is the case with serious illnesses, often undergo an identity crisis and question the purpose of their lives. Psychedelic therapy, when conducted properly by trained professionals, can facilitate self-exploration and self-transcendence, opening doors to states of expanded consciousness and fostering a profound connection with oneself. This experience can help patients develop a greater sense of self-awareness and a deeper understanding of their existential and spiritual issues, enabling them to find meaning and inner peace. The Theory of Self-Transcendence theory provides a Nursing framework for understanding how psychedelic-assisted therapy can facilitate, through self-transcendence, the journey of spiritual and existential healing, offering the possibility of achieving wellbecoming from a state of vulnerability.

Providing spiritual care to cancer patients in the outpatient context: a pilot study

The aim of this pilot study was to test an effort to provide spiritual care (SC) to oncology outpatients in the Ascension healthcare system. Medical providers referred patients who would benefit from spiritual and emotional support. Twenty-seven cancer outpatients from 5 states were enrolled in the project. Based on the chaplain assessment, 45% of the patients had moderate or severe spiritual concerns. On average patients had 4 sessions with a chaplain (range 2-9). Of the 136 chaplain sessions, 56% were in-person in the clinic and 35% were by phone. The most common chaplain activities were active listening (87% of the sessions) and demonstrate caring and concern (55%). For the 20 patients who provided follow-up data, there were decreases in all measures of religious/spiritual distress, though statistically insignificant, and a marginally significant increase (p < .054) in well-being. The study adds to the emerging literature that describes the importance of SC in the outpatient context.

Unmet spiritual needs in palliative care: psychometrics of a screening checklist

BACKGROUND

While studies in palliative care use measures of spirituality and religious belief, there have been few validation studies of a screening tool that identifies unmet spiritual needs.

METHODS

A multidisciplinary research team developed and examined the usefulness, reliability and validity of a 17-item Spiritual Concerns Checklist (SCC) as a screening tool for unmet spiritual needs. A cohort of patients recruited from three palliative care services in Sydney and Melbourne, Australia completed anonymous questionnaires. Factor structure and item response theory were used to examine its properties; concurrent validity employed the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp-12).

RESULTS

Among 261 patients, while only 15% directly sought spiritual care, nearly 62% identified at least one spiritual concern. Existential needs (fear of the dying process 32%; loss of control 31%), regret (20%), need for forgiveness (17%), guilt (13%), loss of hope (13%) and meaning (15%) were prominent concerns. Eleven concerns were present for more than 10% of the participants and 25% of religiously orientated participants expressed >4 concerns. The 17-item SCC was unidimensional, with satisfactory reliability. Concurrent validity was evident in the reduced sense of meaning and peace on the FACIT-Sp-12.

CONCLUSION

This preliminary Rasch analysis of the newly developed SCC has demonstrated its usefulness, reliability and validity. Our findings encourage refinement and ongoing development of the SCC with further investigation of its psychometric properties in varying populations.

Finding the Hidden Professional Culture of Mental Health Nursing-Spiritual Care for Individuals with a Co-morbid Life-Limiting Illness

People with severe mental illness are dying up to thirty years earlier than the general population. The limited literature on their experience of dying indicates that they often suffer from inequities in their access to healthcare services, and further, what care they do receive is frequently poor. Living with both a mental illness and facing death can engender spiritual concerns and dying at a younger age is a risk factor for spiritual despair. Hence, addressing spiritual concerns can be an important dimension of mental health nursing care. The aim of this ethnographic study of 11 senior and experienced mental health nurses was to determine if the culture of the mental health service impacted their spiritual care for those patients who were facing death. The data highlighted that the nurses felt comfortable in providing spiritual care when the person was suffering from psychosis. Yet, the results also revealed that nurses felt disempowered by the dominance of the biomedical culture, in which they felt unable to articulate their care. However, it was identified that their spiritual care was inherent within the professional values, knowledge, and skills of mental health nursing and framed through their therapeutic relationships. Therefore, strategies need to be used by the organization to assist nurses to reclaim their power and assist the mental health service to further develop and engage in spiritual care practices.

I see you: a Chaplain case study on existential distress and transdisciplinary support

In the setting of major disease progression coupled with active pain, hospitalized patients may become disconnected from their metanarratives and personal grounding. Transdisciplinary palliative care teams are poised to foster patients' connection with their metanarratives by collaborating across areas of expertise to establish goals of care and manage total pain. This case study demonstrates: (1) the unique value of the palliative Chaplain in journeying with the patient through existential distress towards self-discovery, and (2) the role of the palliative chaplain in encouraging a transdisciplinary approach to total pain within a palliative care team.

"I need my granddaughter to know who I am!" A case study of a 67-year-old African American man and his spiritual legacy

This case study describes the spiritual care relationship between an African American man receiving palliative care for metastatic cancer and a Chinese American woman chaplain over the period of multiple hospitalizations. It illustrates legacy making as a key spiritual need, one that is complicated by discrimination, structural racism, estranged family relationships, and the patient's own mortality. Included are verbatim conversations that address the impact of racism in the US context and express the complex identities of both patient and chaplain in a dynamic and collaborative intercultural relationship. This case posits the importance of voices of chaplains of color and encourages all chaplains to develop caregiving capacities that address patients' needs for racial justice, meaning, and spiritual legacy.

Layers of Loss: A Scoping Review and Taxonomy of HD Caregivers' Spiritual Suffering, Grief/Loss and Coping Strategies

CONTEXT

Huntington's disease (HD), an incurable, multi-generational, autosomal dominant disorder, creating unique challenges and a myriad of spiritually-related stressors in those affected and their familial caregivers. Spiritual suffering, experiences of grief/loss, and coping strategies have not been systematically studied in HD caregivers.

OBJECTIVES

To comprehensively define spiritual suffering, grief/loss, and coping strategies used by HD caregivers.

METHODS

A PRISMA-ScR scoping literature review was conducted. Data from included research articles were organized thematically using induction and open coding. A grounded, deductive approach was used to delineate a demarcated taxonomy of themes, which encompasses all three over-arching domains. Four reviewers, employing a modified Delphi approach, ascertained which themes were demonstrated by research participants in each study.

RESULTS

36 of 583 articles met the review criteria; none were published in the palliative care literature. Investigations primarily focused on intrapersonal (self-image) distress and existential angst; only rarely looking deeper into divine/transpersonal suffering, disrupted religious relationships, or meaning distress. HD caregivers experience profound grief/loss, expressed as disenfranchised grief that is associated with the ambiguous loss of their loved one, loss of family structure, social connectedness, and personal losses. Half of the studies reported maladaptive HD caregiver coping strategies-characterized by dysfunctional escape schemes; in contrast, transcendent/creative strategies were often unexplored.

CONCLUSION

HD caregivers experience prolonged grief and other forms of spiritual suffering as they progressively lose their loved ones and disruption to their own lives. With an improved assessment tool, teams with spiritual and palliative care experts will better be able to support HD family caregivers.

Pain and Spiritual Distress at End of Life: A Correlational Study

Objective: The purpose of this study is to examine the relationship between unmanaged pain and spiritual distress in adults newly admitted to hospice. Background: Current evidence supports the presence of a positive relationship between increased physical pain and spiritual distress for those with advanced cancer and/or receiving palliative care services. Nonetheless, spiritual distress remains a relatively understudied area; anecdotally, assessment and management of physical symptoms often take precedence over interventions for spiritual distress in patients at end of life (EOL) on hospice. Further research is needed to examine the relationships between physical pain, spiritual distress, and factors such as age, gender, and religious affiliation/spiritual practice specific to EOL patients receiving home hospice care. The Total Pain Model underpins this study. Methods: In this cross-sectional correlational study, pre-existing data were extracted from a hospice agency's electronic health record (EHR) to examine age, gender, marital status, race/ethnicity, religious affiliation and/or spiritual practice, hospice diagnosis, pain severity, and spiritual distress in adult patients (age 18 and over) admitted to home hospice services (N = 3484). Descriptive, bivariate, and multivariate analyzes were conducted. Results: The age range for this sample was 25 to 107 years old (M = 82, SD = 12.08). Over half of the sample were female and white. One third of the patients were married or had a designated life partner. Over 85% identified as either Catholic or Protestant. Sixteen percent reported moderate to severe pain and 9.6% experienced spiritual distress. Marital status (χ² (3, N = 2483) = 20.21, P < .001, Cramer's V = .09), hospice diagnosis (χ² (5, N = 3481) = 22.66, P < .001, Cramer's V = .08), pain severity (χ² (1, N = 3464) = 19.75, P < .001, Cramer's V = .08), and age (t (393.17) = 2.84, P = .005, d = .17) were significantly related to spiritual distress. The binary logistic model was statistically significant, χ² (11) = 45.25, P < .001, and cases indicating the highest odds of experiencing spiritual distress had pulmonary disease (OR = 1.8, P = .02), were single (OR = 1.6, P = .02), and had moderate to severe pain (OR = 1.4, P = .04). Conclusions: Moderate to severe pain, marital status, and diagnosis should be considered for inclusion in a refined spiritual distress hospice admission screening process. Future research should examine the unique contributions of diagnosis in predicting spiritual distress, particularly pulmonary disease.

Research Protocol of the Polish Adaptation and Validation of HOPE Scale: Qualitative Measurement of Patients' Spiritual Needs

Background: The HOPE Scale by Gowri Anandarajah is a qualitative tool for examining and assessing the spiritual needs of sick people, which can be used by health care professionals, but also other personnel whose purpose is to support the patient during illness. Aim: The aim of this study was the cultural adaptation and validation of a qualitative tool for examining the spiritual needs of patients. Methods: A six-step procedure was adopted with the inclusion of four independent forward and two backward translations and cognitive debriefing of the Polish version with experts (n = 11) and chronically ill patients (n = 15). These methods were used to verify a semantic validation and comprehensibility of the HOPE scale according to the standards of cultural measure validation and adaptation. Bioethics Committee approval No KE-0254/222/2020. Results: No major problems were encountered during the process of straightforward and backward translation, and the suggested minor linguistic corrections were made. The HOPE scale was found to be comprehensible and readable by experts and patients, and the instructions were clear and did not pose any difficulties for the respondents. Following the six steps of the validation, the final Polish version of the HOPE scale was obtained, adapted stylistically and culturally to Polish conditions. Conclusions: The Polish version of the HOPE scale is culturally and linguistically adapted and is ready to be used for assessing patients' spiritual needs. The scale can be used both for research and in practice when working with chronically ill people.

Patient-Family Experience at the Onset of COVID-19: Interviews with Ten Palliative Chaplains

Background: As thousands of patients, often with complex care needs, were hospitalized due to the coronavirus disease 2019 (COVID-19) pandemic, demand for palliative care was magnified. Part of hospitals' palliative care teams, palliative chaplains delivered emotional support while specializing in the religious, spiritual, and the existential aspects of care. With COVID-19 containment measures increasing isolation and disrupting supportive family connections, the emotional and spiritual well-being of the patients and families were unclear. Objectives: Through the unique perspectives and insights of inpatient palliative care chaplains, we sought to qualitatively capture their perceptions and the patient-family experience as the pandemic emerged. Setting/Subjects: This investigation was based in the United States. Design: Individual semistructured telephone interviews (n = 10) were conducted between April 22 and May 6, 2020. Through thematic analysis, analyses progressed through initial coding sessions, refining a codebook, identifying representative quotes, and recognizing themes. Results: Five themes were identified and described through the coding process and recognizing representative quotes: (1) visitor restrictions-patients, (2) visitor restrictions-families, (3) religious struggle, (4) spiritual distress, and (5) decision making. Conclusions: Inpatient palliative care chaplains were active interprofessional partners caring for patients and families as the uncertainty of the pandemic unfolded. The crises of this pandemic magnified chaplain specialization as they attended to emotional, spiritual, and religious suffering and as well as complex decision making with patients and their family members.

Top Ten Tips Palliative Care Clinicians Should Know About Spirituality in Serious Illness

Assessment of spiritual suffering and provision of spiritual care are a central component of palliative care (PC). Unfortunately, many PC clinicians, like most medical providers, have received limited or superficial training in spirituality and spiritual distress. This article, written by a group of spiritual care providers, and other PC and hospice clinicians, offers a more in-depth look at religion and spirituality to help to enhance readers' current skills while offering a practical roadmap for screening for spiritual distress and an overview of partnering with colleagues to ensure patients receive values-aligned spiritual care provision.

Spiritual AIM: assessment and documentation of spiritual needs in patients with cancer

The chaplain is an essential member of the palliative care (PC) team, yet, standard methods to document chaplain assessments are lacking. The study team performed a retrospective analysis of chaplaincy documentation in an outpatient PC clinic at an academic medical center over 6 months (April 2017 to October 2017). The study team identified unique adult patients with cancer, then manually extracted variables from the electronic medical record. The primary objective was to assess the number of spiritual assessments documented by the chaplain. Secondary objectives included descriptive analysis of identified spiritual needs. Out of the 376 total patient encounters, 292 (77.8%) included documentation of a chaplain's spiritual assessment. The most frequent spiritual need was self-worth/community (n = 163, 55.8%).This study demonstrates that chaplains can effectively document Spiritual AIM-based screening and assessment. Moreover, this may be an effective documentation method across institutions to facilitate chaplain-based data.

Essential Package of Palliative Care for Women With Cervical Cancer: Responding to the Suffering of a Highly Vulnerable Population

Women with cervical cancer, especially those with advanced disease, appear to experience suffering that is more prevalent, complex, and severe than that caused by other cancers and serious illnesses, and approximately 85% live in low- and middle-income countries where palliative care is rarely accessible. To respond to the highly prevalent and extreme suffering in this vulnerable population, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an essential package of palliative care for cervical cancer (EPPCCC). The EPPCCC consists of a set of interventions, medicines, simple equipment, social supports, and human resources, and is designed to be safe and effective for preventing and relieving all types of suffering associated with cervical cancer. It includes only inexpensive and readily available medicines and equipment, and its use requires only basic training. Thus, the EPPCCC can and should be made accessible everywhere, including for the rural poor. We provide guidance for integrating the EPPCCC into gynecologic and oncologic care at all levels of health care systems, and into primary care, in countries of all income levels.

Statistical fit is like beauty: A rasch and factor analysis of the Scottish PROM

Chaplains help people face some of the most complex, intractable and traumatic issues in their lives. Spiritual care works. Unfortunately, spiritual needs are rarely met in health and social care because a) spiritual distress is not recognised as such, and b) chaplain interventions are undervalued and misunderstood. The Scottish Patient Reported Outcome Measure (PROM) © was created to help provide evidence for the impact of chaplain interventions. The aim of this study was to establish whether the PROM could also be used to identify patients in need of chaplain interventions. To test this psychometrically, Rasch and Confirmatory Factor Analysis was conducted on an international dataset of post intervention PROMS from UK, Europe and Australia completed between 2018-2020 (n = 1117). The data fit the Rasch model, and the PROM demonstrated uni-dimensionality, construct validity and reliability, meaning PROM scores represent a coherent concept. Higher scores represented lower levels of spiritual distress, and the mean score was 12 out of 20. PROM score of 9 was one standard deviation below the norm, a metric routinely used to identify 'clinically important difference' in psychometric scales. A Scottish PROM^© score of 9 and under could therefore identify people for whom chaplaincy may be beneficial. The clinical implications of this are considerable.

What Did Chaplains Do During the Covid Pandemic? An International Survey

Chaplains' unique contribution is to healthcare is to respond to the spiritual, religious and pastoral needs of patients and staff. This is their sole purpose, to provide a presence and space to meet individual need and promote healing, even when cure isn't possible. Their value is priceless to families in desperate times. However, despite growing evidence for their impact, chaplains are commonly undervalued and misunderstood by their organisations, and the global pandemic revealed the consequences of this confusion. Whilst some chaplains were applauded as heroes along with their fellow health colleagues, others were seen as little more than an infection risk. A survey was designed to capture and learn from the full range of chaplain experiences of the impact of the pandemic across the globe. In June 2020, 1657 chaplains responded from 36 countries. They all experienced considerable disruption to their usual practice, with enforced social distancing having the biggest impact. Out of necessity they embraced technology to maintain contact with patients and families, and shifted focus of their support to staff. Whilst some chaplains were viewed as essential employees by their organisations, most were not. Despite the majority thinking that their organisations understood what they did, chaplains themselves were neither clear or unclear about their role during and post pandemic. More surprisingly, they felt similarly unclear about their role before the pandemic. This paper concludes that in general chaplains lack leadership skills, and confusion about their role will persist until this changes.

Commentary on Chaplain-Physician Interactions From the Chaplain's Perspective: A Mixed Method Analysis

Gomez and her colleagues have presented a helpful study of the relationship of the chaplains in her health system to physicians which highlights several barriers to a well-integrated relationship and thus to more optimal patient care. We have seen these same barriers as we have consulted with health systems nationally and have also identified many best practices that mediate or even eliminate many of these barriers. This commentary describes some of what we have seen as chaplain-generated causes of those barriers and effective strategies that have been employed to overcome them. We also provide some resources for chaplains who wish to institute some of these best practices themselves.

A quality improvement project to standardize chaplain documentation in the electronic medical record

Medical record documentation by hospital chaplains is an under-researched and under-published field. Because documentation serves both as a register of chaplain interventions and as a collaborative tool for interdisciplinary communication, it should be written in a way that is clear, concise, and consistent. As chaplains continue to integrate with other medical professions in interdisciplinary care, careful attention should be given to the way in which communication of the chaplain role, functioning, and patient information obtained is conveyed. This quality improvement project standardized chaplain documentation in one health system of 15 medical centers, provides insights and resources devised from the project, and offers considerations for other systems contemplating future changes toward standardizing documentation.

Chaplaincy in the outpatient setting-getting from here to there

One of the most evident trends in US health care and health care generally in the developed world is that more and more care is shifting to outpatient settings. This change opens up substantial opportunities, and in many cases, expectations for chaplains to extend the breadth of the care they provide in any health system. However, it also brings many challenges. This paper describes the journey of four very different inpatient chaplaincy services into the outpatient setting. These four examples focus on settings that would historically be thought of as outpatient-those that see patients within the brick and mortar of the health system.

Expanding the Interdisciplinary Palliative Medicine Workforce: A Longitudinal Education and Mentoring Program for Practicing Clinicians

CONTEXT

The disparity between gaps in workforce and availability of palliative care (PC) services is an increasing issue in health care. To meet the demand, team-based PC requires additional educational training for all clinicians caring for persons with serious illness.

OBJECTIVES

To describe the educational methodology and evaluation of an existing regional interdisciplinary PC training program that was expanded to include chaplain and social worker trainees.

METHODS

From 2015 to 2017, 26 social workers, chaplains, physicians, nurses, and advanced practice providers representing 22 health systems completed a two-year training program. The curriculum comprises biannual interdisciplinary conferences, individualized mentoring and clinical shadowing, self-directed e-learning, and profession-focused seminar series for social workers and chaplains. Site-specific practice improvement projects were developed to address gaps in PC at participating sites.

RESULTS

PC and program development skills were self-assessed before and after training. Among 12 skills common to all disciplines, trainees reported significant increases in confidence across all 12 skills and significant increases in frequency of performing 11 of 12 skills. Qualitative evaluation identified a myriad of program strengths and challenges regarding the educational format, mentoring, and networking across disciplines.

CONCLUSION

Teaching PC and program development knowledge and skills to an interdisciplinary regional cohort of practicing clinicians yielded improvements in clinical skills, implementation of practice change projects, and a sense of belonging to a supportive professional network.

The Urgency of Spiritual Care: COVID-19 and the Critical Need for Whole-Person Palliation

The coronavirus disease 2019 (COVID-19) crisis has amplified the importance of palliative care to countless patients suffering with and dying from this disease, as well as to their families, communities, and the worldwide cadre of overburdened health care workers. Particularly urgent is the need for spiritual care specialists and generalists to address spiritual suffering given the degree of isolation, loneliness, and vulnerability caused by this pandemic. Although spiritual care has long been recognized as one of the domains of quality palliative care, it is often not fully integrated into practice. All disciplines are ultimately responsible for ensuring that spiritual care is prioritized to improve quality of life and the experience of patients and families facing spiritual emergencies amid the complex life-and-death scenarios inherent to coronavirus disease 2019. Although the pandemic has revealed serious fault lines in many health care domains, it has also underscored the need to recommit to spiritual care as an essential component of whole-person palliative care.

Toward a clinical model for patient spiritual journeys in supportive and palliative care: Testing a concept of human spirituality and associated recursive states

OBJECTIVE

In 2015, a Chaplaincy Research Consortium generated a model of human spirituality in the palliative care context to further chaplaincy research. This article investigates the clinical fit of (a) the model's fundamental premise of universal human spirituality and (b) its 4 proposed stage descriptors (Discovery, Dialogue, Struggle, and Arrival).

METHOD

First, we collected qualitative data from an interdisciplinary palliative care focus group. Participants (n = 5) shared responses to the statement "the human spirit has essential commonalities across [ … ] groups and [ … ] attributes." Participants also shared vignettes of spiritual care, and 48 vignettes illustrating patients' spiritual journeys were subsequently taken from the transcript of that group. Second, we invited different mixed discipline palliative care professionals (n = 9) to individually card sort these vignettes to the model's 4 stage descriptors; we conducted pattern analysis on the results. We then administered a third step, convening six physicians to complete the card sort again, this time allowing designation of cards to one or two of the 4 stage descriptors.

RESULTS

Focus group participants were supportive of the model's all-encompassing definition of spirituality. The concept of "connectedness" was a shared focus for all participants, connectedness and spirituality appearing almost synonymous. Pattern analysis of assigned 48 vignettes to the 4 stages showed stronger consensus around Discovery and Arrival than Struggle and Dialogue. Results of the additional card sort suggested Struggle and Dialogue involve oscillation and are harder to think of as a steady state as distinct from processes associated with Discovery or Arrival.

SIGNIFICANCE OF RESULTS

"Connectedness" is a productive concept for modeling human spiritual experience near the end of life. As one healthcare professional said: "this connectedness piece is [ … ] what I always look for … " Although further work is needed to understand struggle and dialogue elements in peoples' spiritual journeys, discovery and arrival shared consensus among participants.

An EAPC white paper on multi-disciplinary education for spiritual care in palliative care

BACKGROUND

The EAPC White Paper addresses the issue of spiritual care education for all palliative care professionals. It is to guide health care professionals involved in teaching or training of palliative care and spiritual care; stakeholders, leaders and decision makers responsible for training and education; as well as national and local curricula development groups.

METHODS

Early in 2018, preliminary draft paper was written by members of the European Association for Palliative Care (EAPC) spiritual care reference group inviting comment on the four core elements of spiritual care education as outlined by Gamondi et al. (2013) in their paper on palliative care core competencies. The preliminary draft paper was circulated to experts from the EAPC spiritual care reference group for feedback. At the second stage feedback was incorporated into a second draft paper and experts and representatives of national palliative care organizations were invited to provide feedback and suggest revisions. The final version incorporated the subsequent criticism and as a result, the Gamondi framework was explored and critically revised leading to updated suggestions for spiritual care education in palliative care.

RESULTS

The EAPC white paper points out the importance of spiritual care as an integral part of palliative care and suggests incorporating it accordingly into educational activities and training models in palliative care. The revised spiritual care education competencies for all palliative care providers are accompanied by the best practice models and research evidence, at the same time being sensitive towards different development stages of the palliative care services across the European region.

CONCLUSIONS

Better education can help the healthcare practitioner to avoid being distracted by their own fears, prejudices, and restraints and attend to the patient and his/her family. This EAPC white paper encourages and facilitates high quality, multi-disciplinary, academically and financially accessible spiritual care education to all palliative care staff.