Wellness, wholeness and
spiritual care
On the occasion of 100 years of King’s College
Hospital in Camberwell: 25th September 2013
Revd Dr Peter Speck
Hon Senior Lecturer
Dept of Palliative Care, Policy and Rehabilitation
King’s College London
Overview
• Introduction
• What is wellness?
• What is health and wholeness?
• Spiritual care as a component of care
• Is there evidence to support its inclusion?
• Who should be responsible for meeting
spiritual needs?
www.kcl.ac.uk/palliative
From the time of admission patients can quickly begin to
experience loss – of identity, of control, or being seen as
a whole person – in addition to the effects of the illness
or treatment.
On
discharge
will patients
have
achieved
wellness or
wholeness?
www.kcl.ac.uk/palliative
Wellness
• Usually described as the absence of disease or
illness
• A product of measures to eradicate disease
(treatment) or of the pursuit of a healthy lifestyle
• Modern medicine has been described as a
“disease attacking” service (Illich 1975) and not
necessarily focussed on enhancing health or
addressing multiple needs of the whole person.
But this is now changing [eg elderly care,
palliative care etc.]
www.kcl.ac.uk/palliative
Health and Wholeness
“Health is a state of complete physical, mental and
social wellbeing and not merely absence of disease or
infirmity” WHO 1948
defn. [unchanged since 1948] includes well-being, wellworking, and being unimpeded in realising one’s
true nature.
The NHS Constitution implies relevant for staff as well
as patients in the commitment to provide support and
opportunities for staff to maintain their health, wellbeing and safety. (The NHS belongs to us all. DH 2011)
www.kcl.ac.uk/palliative
• Heal means “to make sound or whole” from
root haelan, the condition of being hal / whole
(Eisenberg 1983).
• Hal is also the root of ‘holy’/ spiritually pure
(Cassell 1991)
• “Healing” can mean different things to
different people – as shown by the cartoonist
Callahan !
www.kcl.ac.uk/palliative
• The Greeks initially understood health as a harmony
between the parts of the human organism, with
healing as a restorative process.
• However, the goddess Hygeia and the god Asclepius
came to represent two approaches:
• Hygeia was the goddess of holistic health and the root of
her name gave us Hygeine meaning ‘living well’ or ‘well
way of living’.
• Asclepius, as the god of medicine, replaced her In 4th cent
and the emphasis shifted to a less integrated view of health
with greater focus on treating ailments and symptoms.
• On occasion Hygeia and Asclepius worked together implying times when a combined approach was more
appropriate.
www.kcl.ac.uk/palliative
Hygeia and Asclepius offer healing
in the temple
In Trivandrum, S. Kerala Ayervedic priest commented …
www.kcl.ac.uk/palliative
Medical model
The traditional medical model applies skills and
resources to cure or mitigate the effects of a
disease process.
Those skills are exercised by people who have
undertaken formal training along scientific,
empirically based lines.
www.kcl.ac.uk/palliative
Medical model
Acknowledging that the medical model has to work
in partnership with the social model allows service
planners and providers to take a more holistic
approach in service delivery – and recognise the
significance spirituality plays within a diverse and
multi-belief society.
Now reflected in policy/guidance docs. + greater
emphasis on inter-professional teamwork.
www.kcl.ac.uk/palliative
Need for a collaborative approach
• This was brought into focus by Dame Cicely
Saunders when (in the mid 1960’s) she
proposed her ‘total pain’ model. Although a
qualified social worker, nurse and doctor she
recognised the need to draw on the skills of
others to meet the many and complex needs of
the patients she cared for.
=
a widening of a purely
bio-medical approach
www.kcl.ac.uk/palliative
Total pain model: based on Saunders 1967
Psychological
Spiritual
Cultural
PAIN
Social
Sexual
Bureaucratic
Other physical
symptoms
www.kcl.ac.uk/palliative
Health & wholeness: a process over time
• Health is a journey towards wholeness – a
process, not a state, an adventure
(Lambourne 1985)
• The many aspects of the ‘total pain model’
reflect the complexity of needs, over time, of
many who seek wellness (initially) and then
(perhaps) wholeness of being. In this process
spiritual care has a significant role as
reflected in recent guidance docs.
www.kcl.ac.uk/palliative
Spirituality guidance docs:
Quality Standard for
End of Life Care for
Adults(2011) NICE
Statement 6: People
NICE guidance supportive
care for adults with cancer
2004
approaching the end of life are
offered spiritual and religious
support appropriate to their
needs and preferences
DH 2009
Spiritual Support and
Bereavement Care
Quality Markers for
End of Life Care (May
2011) NHS : NELCP Holloway, Adamason,
McSherry, Swinton Jan 2011
www.kcl.ac.uk/palliative
Spirituality as a component of
holistic care
• In recent years increased interest in the
possible benefits of addressing the
spiritual needs of patients. Spiritual care
has become a focus for research with
developing evidence base for
relationship between spirituality, wellbeing and various health outcomes.
www.kcl.ac.uk/palliative
Spiritual : EAPC Working Definition 2010
• Spirituality is the dynamic dimension of
human life that relates to the way persons
(individual and community) experience,
express and/or seek meaning, purpose
and transcendence, and the way they
connect to the moment, to self, to others, to
nature, to the significant and/or the sacred.
• Nolan, Saltmarsh & Leget (2011) Eur.J.Pall Care 18, 86-89
www.kcl.ac.uk/palliative
Spiritual/religious and
secular beliefs should
be differentiated - though
inter-related
religious
spiritual
Secular/
philosophical
Now better accepted that
spiritual relates more to how
people understand and live their lives in view of
core beliefs and values, and their perception of
‘ultimate meaning and purpose’.
Can become very important in times of crisis, or
elderly and e-o-l care.
Early (US) research confused rel/sp
www.kcl.ac.uk/palliative
Spiritual care in current healthcare
• Commonly defined inclusively: applicable to all – rel/ sp/
philiosophical
• Supports those grappling with questions and the despair that
can arise in crises.
• Aims to alleviate sp. distress and increase sp. well-being
Spiritual
distress:
helplessness,
meaninglessness,
suffering, lack of
peace…ritual
Spectrum
spiritual
well-being:
Hope, meaning,
peace,
forgiveness,
acceptance ..
www.kcl.ac.uk/palliative
Support for spiritual care
• Increase of policy guidance globally eg Domain 5 of
Holistic Common Assessment – sp.well-being and life goals:(DH 2011)
• Spiritual distress highly prevalent in incurable
progressive illness (Moadel et al Psychoonc 1999, Astrrow et al
JCO 2007)
• Spiritual care is wanted: (Ehrman et al Arch Intern Med 1999,
MacLean et al J Gen Intern Med 2003, Hebert et al J Gen Intern Med
2001, Puchalski et al Pall Med 2009)
• Spiritual well-being a unique contributor to QoL
(Whitford et al PsychoOnc 2008)
• More sig. than physical well-being. (King & Speck Soc Sc
& Med 2001, Heyland et al CMAJ 2010)
• Yet…. Often neglected (LCP audits + Balboni et al JCO 2013)
www.kcl.ac.uk/palliative
Relevance of spiritual care
 Murray SA, Kendall et al (2004) Exploring the spiritual needs of
people dying of lung cancer or heart failure: a prospective
qualitative interview study of patients and their carers.
Palliative Medicine 18: 39-45
For heart failure: hopelessness, loss of confidence, and isolation
dominated throughout.
For lung pts: sp concerns important esp at diagnosis and again at end
of life. Meaninglessness evident in both]
 Selman L, Beynon T, Higginson IJ, Harding R. (2007)
Psychological, social and spiritual distress at the end of life in
heart failure patients. Current Opinion in Supportive and
Palliative Care. 1: 260-266.
[shows social support/ spiritual belief important coping resources and
importance of assessment and management of wider needs]
www.kcl.ac.uk/palliative
Study of what’s important to cancer patient
• King, Jones, Barnes et al (2005)Psychol Med. 36, 1-9
found people with advanced cancer did not always refer to
illness, more concerned with wider meanings of life. Clear that
illness had made them reflect and they attributed their coping
to their spiritual/religious beliefs.
People with no clear sp/rel belief found it difficult to express
their experiences, coping strategies and belief.
c/f earlier King, Speck and Thomas studies of cardiology pts (1995, 1999,
2001) – where the philosophical gp were the least clear and struggled with
beliefs and coping strategies.
www.kcl.ac.uk/palliative
Relevance of spiritual/ religious care
• Koffman J, Morgan M, Edmonds P, Speck P, Higginson I.
(2008) ‘‘I know he controls cancer’’: The meanings of religion
among Black Caribbean and White British patients with
advanced cancer. Soc Science & Medicine. 67. 780-789.
• [Importance of church community, how rel & belief in God helped them
comprehend cancer for both groups. For black carib. helped strengthen
religious identity]
• Koffman J, Morgan M, Edmonds P, Speck P, Higginson I
(2008) Cultural meanings of pain: a qualitative study of Black
Caribbean and White British patients with advanced cancer.
Palliative Medicine. 22: 350-359.
• [WB pts reported cancer related pain: BC saw pain as challenge, test of
faith or punishment for wrong doing]
www.kcl.ac.uk/palliative
Relevance of spiritual care
• Thuné-Boyle et al (2010) Religious coping strategies in
patients with breast cancer in the UK. Psycho-Oncology DOI
10.1002/pon.1784
Used RCOPE (Pargament) and Brief-COPE (Carver) to capture religious
and non-relig coping
[Rel/Sp coping strategies common in early stages of breast cancer.
Rel/Sp struggle can affect adjustment and hence need to assess ]
• Edwards et al (2010) The understanding of spirituality and
potential role of spiritual care in end-of-life and palliative
care: a meta-study of qualitative research. Palliative
Medicine 24. 753-770. [Importance of relationships, and
‘presence’. Identifies barriers to good spiritual care, incl need for prof
education] Reflected in new Cochrane Review
www.kcl.ac.uk/palliative
New Cochrane review (2012)
• Candy B, Jones L, Varagunam M, Speck P, Tookman A,
King M. Spiritual and religious interventions for well-being of
adults in the terminal phases of disease. Cochrane
Database of Systematic Reviews 2012 Issue 5 CD007544.
DOI: 10.1002/14651858.CD007544
• Searched 14 databases to 2011 for RCTs which evaluated
outcomes for interventions with sp/rel component. Primary
outcomes = well-being, coping with disease and qual of life.
• Results: 5 RCTs with 1130 participants
• 2 evaluated meditation; other interventions involving
chaplain or spiritual counsellor.(‘presence’ and pastoral
discussion/ counselling highlighted)
• Inconclusive findings, poor research design & detail in
findings. Need for > rigorous studies.
www.kcl.ac.uk/palliative
Who should meet spiritual needs ?
• NICE and other guidance docs make it clear
that spiritual care is a responsibility of
everyone [can easily become responsibility
of no-one]. Hence need for designated
member of ward, directorate or health
division as lead for spiritual care.
• Health care chaplains = valuable resource,
together with a chapel/ sacred space for
quiet reflection or multi-faith worship
www.kcl.ac.uk/palliative
• Multi-professional teamwork is key if we
are to meet the complex needs of
patients. Such teamwork requires the
development of trust and respect for the
contribution each can make.
• Chaplains and other spiritual care
providers have a positive contribution to
make in either directly offering spiritual
care to people or supporting staff in
meeting such needs.
www.kcl.ac.uk/palliative
King’s [Hospital] Chapel: consecrated on 25th
September 1913 :
Provides an oasis for peace
and quiet reflection within
the life of a very busy acute
teaching hospital.
Supplemented by the work
of chaplains to patients and
staff of all faiths or none –
within the wards and
departments of hospital
(24/7)
www.kcl.ac.uk/palliative
Chaplains are trained professionals, authorised,
accountable and their work has been the subject
of research & evaluation
• Cobb & Robshaw (1998)The Spiritual Challenge of
Health Care. Churchill Livingstone
• Orchard (2000) Hospital Chaplaincy: modern,
dependable? Sheffield Academic Press
• Mowat & Swinton (2005) What do chaplains do?
The role of the chaplain in meeting the spiritual
needs of patients. Mowat Research Ltd. Aberdeen.
• Nolan (2011) Spiritual care at the end of life: The
chaplain as a ‘hopeful presence’ Jessica Kingsley
www.kcl.ac.uk/palliative
What do chaplains actually do?
• Listen to people’s stories
• Work in one:one situations,foster relationships and
re-affirm personhood/ humanity
• Support people (pts, staff, relatives) at difficult times
• Provide training to help staff develop skills in
spiritual care
• A resource for information on different faiths, beliefs,
bereavement
• Help people connect/ or re-connect with self, others,
the spiritual.
• Conduct or arrange religious rituals as appropriate
• [all for 0.000029% of the 2009/10 NHS budget!]
www.kcl.ac.uk/palliative
Conclusion
• As we celebrate 100 years of the provision
of a hospital Chapel at King’s may we also
affirm the relevance of providing for the
wider spiritual needs of patients and staff.
• Care which enables people to find meaning,
purpose, hope and peace in their lives in the
context of whatever beliefs they hold.
• In this way people may achieve wholeness
and healing in spite of loss, continued
ill-health or death.
www.kcl.ac.uk/palliative
Healing is, therefore,
More than wellness it
is related to wholeness,
and wholeness is
experienced in the
quality of connection
with others.
Chaplaincy (through good spiritual, personalised care)
can facilitate that connectedness with self, others
(patients, staff, relatives) and the sacred.
www.kcl.ac.uk/palliative
Conclusion
• Healing and restoration, therefore, happens
in relationship and in community.
• Dame
Saunders,
in an interview
with
“YouCicely
are missing
something,
as well as
Drthe
Thomas
[Annsomething,
Fam Med 2005, 3(3)]
said:
patientEgnew
missing
unless
you come not merely in a professional
role but in a role of one human being
meeting another” (C.Saunders)
In the context of real connection - with self,
others or the sacred - we may then move
from ‘wellness’ to ‘wholeness’
www.kcl.ac.uk/palliative