Abstract
By Christina M. Puchalski and Betty Ferrel. West Sonshohocken, PA: Templeton, 2010, 266 pages, $34.95.
Caring for the religious and spiritual needs of patients has been established as a core domain of quality palliative care by the National Consensus Project (NCP) for Quality Palliative Care guidelines and the National Quality Forum (NQF) preferred practices. Making Health Care Whole: Integrating Spirituality into Patient Care contains a comprehensive discussion of proceedings from a recent consensus conference convened to formulate practice standards for spiritual care within palliative care. The consensus conference report, published in shorter form in 2009 within this journal, represents the first collaborative effort of palliative care leaders to establish guidelines for implementing spiritual care as suggested by the NCP and NQF. This book expands upon the shorter consensus statement by including an extensive review of research on spirituality and health, providing theoretical backing for the suggested practice guidelines, and interspersing patient vignettes. The book is structured in two parts: first an introduction to the role of spirituality in end-of-life care, then recommendations for implementing the NCP guidelines and NQF preferred practices.
The book begins with Cicely Saunders' idea of “total pain” encompassing physical, psychological, social, and spiritual pain. The authors then expound upon the spiritual dimensions of health, suffering, and transformative growth. The book supports an inclusive vision of spiritual care, building upon the following consensus panel 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.” (p. 25). The authors emphasize respect, patient-centeredness, and “following the patient's lead” as a foundation for engaging patients in spiritual matters (pp. 40–41). These principles are supported by an extensive review of research in spirituality and health, along with touching patient stories to illustrate the concepts presented. Attention is then turned toward implementation strategies to promote spiritual care within palliative care, beginning with theoretical principles and moving toward practical guidelines. After a review of spiritual care models, the authors offer practical suggestions for assessing patient spirituality with a condensed yet useful review of common spiritual issues encountered at the end of life. All members of the palliative care team are encouraged to participate in an initial spiritual screen, but the authors embrace a “generalist-specialist model,” strongly suggesting that all patients see a board-certified chaplain trained to conduct in-depth spiritual assessments and interventions. Beyond assessment, the authors emphasize creating “spiritual treatment plans,” whereby patients and families are empowered to formulate spiritual goals” (p. 109) to be discussed with providers and reevaluated to monitor progress.
The most powerful message of the book and its greatest strength was the authors' imagined ideal state in which spiritual issues are screened for and tended to with the same urgency as physical pain. Prioritizing spiritual growth may be a vital way that palliative care can promote positive transformation for patients who may otherwise be consumed by physical decline and loss. Several suggestions did seem overly influenced by a clinical mindset. For example, the authors suggested a patient struggling with hopelessness “might co-create a treatment plan by making specific goals about finding hope. This goal might be measured using a [visual analogue scale] from 1 to 10.” Adopting the language of “spiritual diagnoses” and “treatment plans” along with several complicated flow diagrams and decision trees added a medical flavor to the spiritual interventions proposed.
Along the spectrum of spiritual care, the book seemed to favor psychosocial/existential support (e.g., meaning-oriented psychotherapy, dignity-conserving therapy) rather than the more traditionally religious/spiritual side of care. For example, the single example of acceptable prayer was a patient and physician with a long-standing clinical relationship who were members of the same Church. Even still, the authors cautioned, “her doctor was not seeking to pray with her but utilized a spiritual resource the patient had used many times” (p. 48). Given the centrality of prayer to many patients' (and providers') relationship with God, such a cautiously therapeutic approach to prayer seems limited and reflects, perhaps, a professional tendency to value the medical/therapeutic over the spiritual. In favor of being topically exhaustive, several chapters lack the depth of discussion I found myself desiring. For example: chapter four explains historical approaches to death within the major world religions with one very short paragraph for each faith. The descriptions were just enough to pique my interest, but fell short of being practically helpful.
Nevertheless, guidelines such as those presented in this book are critical to establishing the place of spiritual care within palliative care. The field will need special humility to refrain from imposing an excessively clinical or psychological frame around our patients' spirituality and religious faith. The authors rightly conclude with Jewish philosopher Abraham Heschel's antidote to this tendency. Medical professionals are encouraged to develop their own spiritual lives with the following challenge: “to heal a person, one must first be a person.”