A convincing body of evidence has emerged demonstrating that spirituality is an integral element of geriatrics care that is associated with patient’s quality of life, satisfaction of care, more hospice use, less aggressive care at end of life, and decreased medical costs. Spiritual care involves serving the whole person, addresses questions of identity, meaning, and purpose, affirms the inherent dignity and value of all persons, and respects different spiritual perspectives and practices—that may or may not be expressed in religious terms.
While referrals to chaplains are the most prevalent form of spiritual care in the literature, it is particularly important to involve all health care providers (eg, physicians, nurses, social workers) in generalist spiritual care—that is, the practice of compassionate care and the integration of spirituality in their routine medical care practice. In clinical care chaplains are the spiritual care specialists and other clinicians are the spiritual care generalists. Generalist spiritual care involves empathy, compassion, respect, sensitivity, and comfort. Spiritual care also fosters trusting, intimate, and meaningful relationships. Out of these relationships with their clinicians, patients may be able to find meaning, hope, and resilience in the middle of suffering.
Young suggested three general guidelines for generalist spiritual care in hospitalized older patients. These include (1) listening actively to what a hospitalized patient is saying (both verbally and nonverbally), (2) identifying his or her religious or spiritual concerns, and (3) responding to those concerns either directly or by referral. The first step in communicating about spiritual issues is to listen to spiritual themes such as meaning, hope, relationships, religious beliefs, and values. As health care provider actively listens to an older patient, it will be possible to know the patient’s full story and to recognize the spiritual concerns of the patient. Inherent to this aspect of spiritual care is the practice of compassionate presence, which can be characterized as being fully present with another as a witness to the patient’s suffering. The experience of compassionate presence by the clinician to the patient may result in a sense of healing by the patient within the context of the relationship with the clinician. Once the health care provider hears the spiritual themes of the patients, they can start asking open-ended questions to invite the patient to share their inner story. The clinician can listen for how important the patient’s spirituality is in their lives and whether the patient’s spirituality impacts his/her health.
Important components in the implementation of spiritual care in geriatrics care include a spiritual screening and history for the nonchaplain clinicians and a full spiritual assessment by a board certified chaplain.
Spiritual screening usually is performed at the time of an initial intake by any clinician, whether it is at an inpatient, nursing facility, or even during admission into home hospice. The primary objectives of the spiritual screen are as follows:
Spiritual screening need not be an overly complicated task and may necessitate only a few simple questions incorporated into initial screening. For example, “How important is religion and spirituality in your coping?”
If patient responds that they are important, then a follow-up question could be, “How well are those resources working for you at this time?”
If the patient describes difficulty with coping and/or that spiritual or religious resources are not working well for him or her, a referral to a trained chaplain is advised.
As with other components of the medical history, a spiritual history is important for clinicians to take, especially during the initial consultation. The goal is to better understand how a patient’s spiritual needs and resources may complement or complicate the patient’s overall care. A spiritual history typically is asked in the context of a comprehensive social history. Targeted questions are employed to invite the patient to share his or her spiritual and/or religious beliefs, and help guide the patient to explore questions of meaning. The questions are not meant as checklists, but as guides to help the clinician invite the patient to share his or her beliefs, hopes, fears, and concerns. Ultimately, for clinicians, the spiritual history can serve the following goals:
To better understand the patient’s beliefs and values
To identify spiritual themes and assess for spiritual distress (meaninglessness, hopelessness) and spiritual resources of strength (hope, meaning and purpose, resiliency, spiritual community)
To connect with the patient in a deeper and more profound way
To empower the patient to find inner resources of healing and acceptance
To identify spiritual and religious beliefs that might affect health care decision making
Finally, the spiritual history serves as a primary opportunity to identify patients who may benefit from referral to chaplains or other resources. An example of a spiritual history is the FICA spiritual history tool, which was initially developed by a focus group of primary care physicians. It is validated, widely used, and integrated into some medical health records. The format of the tool is presented in Table 60-3.
TABLE 60-3THE FICA SPIRITUAL HISTORY TOOL |Favorite Table|Download (.pdf) TABLE 60-3 THE FICA SPIRITUAL HISTORY TOOL
|F—Faith and belief || |
Do you consider yourself spiritual or religious?
Do you have spiritual beliefs that help you cope with stress?
If the patient responds “No,” the clinician might ask, “What gives your life meaning?”
Sometimes patients respond with answers such as family, career, or nature.
|I—Importance || |
What importance does your faith or belief have in your life?
Have your beliefs influenced how you take care of yourself in this illness?
What role do your beliefs play in regaining your health?
|C—Community || |
Are you part of a spiritual or religious community?
Is this of support to you and how?
Is there a group of people you really love or who are important to you?
Communities such as churches, temples, and mosques, or a group of like-minded friends, can serve as strong support systems for some patients.
|A—Address in care/assessment || |
How would you like me, your health care provider, to address these issues in your health care?
Use this category to assess for spiritual distress
For patients who the clinician feels would benefit from a more in-depth conversation with a chaplain, referral for a more formal spiritual assessment is advised. The spiritual assessment is an in-depth, extensive, ongoing conversation and can be performed with patients from any religious or spiritual tradition and belief system. The primary objectives are the following:
Develop a relationship with the patient in a clinical setting
Identify spiritual issues and confirm, elaborate, or make a spiritual diagnosis
Develop a spiritual care plan that can be shared with the treatment team
The aim is to understand the patient’s needs and resources by first listening to the patient’s story. There is no specified set of questions. That is, the assessment strategy is a process without a defined script, which is necessary because the content area itself is not amenable to a formulaic structure. As a result, it requires extensive training, which is part of the certification process for professional chaplains.
As with other aspects of geriatrics care, multidisciplinary collaboration is important when it comes to addressing spirituality. All members of the multidisciplinary team interact with patients, including responding to and addressing all dimensions of patient care: spiritual, religious, and existential as well as the physical, psychological, and social. Each of these components of care provides insight into the patient’s suffering and his or her ability to manage that suffering. Teams occur in inpatient as well as outpatient clinical setting and in communities such as neighborhood community support settings, nursing home, continuum of care facilities, and senior communities.
Chaplains can advise other members of the clinical team on how to work with patients’ spiritual issues, provide spiritual counseling, and contribute to a comprehensive treatment or care plan. Chaplains also can coordinate the involvement of community spiritual care professionals (eg, other clergy, pastoral counselors, or spiritual directors). The role of chaplains is supported by many organizations including Joint Commission for Accreditation of Hospitals, Center to Improve Palliative Care, and others.
Once spiritual distress or issues are identified, they need to be addressed as part of the assessment and treatment plan. Clinicians can also document the patient’s spiritual and psychosocial resources of strength and note those in the assessment and plan. This plan should be based on the biopsychosocial and spiritual model of care, or what many have called “whole person care.” An example of such a plan is presented next. Ms. Brenda Lee is 86 years old, has four children, eight grandchildren, and she is a widow. Ms. Lee has been admitted to a skilled rehabilitation facility following a below-the-knee amputation (BKA) secondary to long-standing diabetes. She also has a history of breast cancer, which is in remission. She has done well with surgery but has been resistant at times to physical therapy in the hospital. Prior to admission she was not regularly adherent to her medication. She denies depression but says she now fears that she will be a burden to her family. She wonders if God is punishing her for something she did and that is why all of this is happening to her (Table 60-4).
TABLE 60-4WHOLE PERSON ASSESSMENT AND TREATMENT PLAN |Favorite Table|Download (.pdf) TABLE 60-4 WHOLE PERSON ASSESSMENT AND TREATMENT PLAN
| ||Ms. Brenda Lee is an 86 y old s/p BKA, recovering well from surgery, insulin-dependent diabetes well controlled in hospital, last HbA1c 7.0, h/o breast cancer, in remission for 8 y. Has been resistant to physical therapy at times, has h/o of noncompliance with medication, also describes fear of being a burden to her family and expresses some distress about being punished by God. |
|Physical || |
Rehabilitation, encourage adherence to physical therapy.
Continue with Lantus, regular glucose monitoring in the rehab, adherence to diet.
|Emotional ||Referral to counselor for support therapy regarding feeling like she is a burden. |
|Social || |
Referral to social work for discharge planning, family meeting.
Patient has strong family support.
|Spiritual ||Explore perception of illness as punishment; chaplain referral, explore punishment concept and adherence. Patient has strong spiritual practice that has helped her in the past during difficult times. |
Her spiritual history using the FICA tool is summarized as below:
F: Nondenominational Christian; her children and God give her meaning
I: Very important in her life, prays daily, attends bible study and Sunday services; believes illness is punishment from God
C: Active in church
A: Referral to pastoral chaplain in rehab and connect her with her pastor and outpatient pastoral counseling
Referral to chaplain and spiritual director for a life review and further explorations of reconciliation, regret, and loss of previous state of functioning, which may be resulting in some meaning issues for her. She has spiritual strengths that help her be at peace. This plan shows how important it is to address all dimensions of the patient’s care. Spiritual suffering can significantly impact patient’s and family’s quality of life and is therefore a critical aspect of good medical care delivery.
Examples of Spiritual Care Interventions for Older Adults
The first part of the treatment plan for any patient is what all clinicians can do. This includes compassionate presence and deep listening to the patient’s concern and witnessing to the suffering of the patient. There are several tested interventions that are based on meaning making and life review. Some activities to support these types of spiritual interventions are explored below.
Spiritual reminiscence developed by MacKinlay and Trevitt is a “particular way of communication that acknowledges the importance of spirituality and seeks to engage the person in a more meaningful and personal way.” Talking about previous life events with emphasis on meaning, gives older people a chance to reframe some of these events and come to a new understanding of the meaning and purpose of their lives. In a recent randomized controlled trial, Wu et al. assessed the efficacy of a 6-week spiritual reminiscence on older patients with mild or moderate dementia. Results showed that the intervention group showed significant improvement in hope, life satisfaction, and spiritual well-being. In another study of 113 older adults with dementia, small groups met weekly over 6 weeks or 6 months for spiritual reminiscence. Qualitative and quantitative analysis showed that life story with an emphasis on meaning and spirituality helped participants to find meaning in life in the present, develop stronger relationships between staff and residents, and develop strategies to accept changes of later life, including losses of significant relationships and increasing disability.
As people age, their sense of dignity can be threatened by illness and care need. Loss of dignity in older people is associated with high levels of psychological and spiritual distress and loss of the will to live. Chochinov proposed dignity therapy (DT), as a brief individualized psychotherapy, designed to address psychosocial and existential distress among patients. The intervention uses 10 core questions that guide an interview, including “What are your most important accomplishments, and what do you feel most proud of? What are your hopes and dreams for your loved ones? What have you learned about life that you would want to pass along to others?” Dignity therapy was designed primarily for the terminally ill patients. Recent studies by Chochinov and other investigators confirmed the feasibility and effectiveness of this intervention for older people in care homes as well. A recent systematic review study found robust evidence for DT’s acceptability, especially in psychosocial-spiritual care.
Prayer is the most universally recognized spiritual/religious practice. According to Gallup surveys in 2010, more than half (55%) of Americans pray every day. Wachholtz and Sambamthoori found that the use of prayer to address health concerns significantly increased from 43% in 2002 to 49% in 2007 in the United States. Prayer has been classified as a spiritual treatment modality by the National Center for Complementary and Integrative Health (NCCIH). In a 6-year follow-up study with almost 4000 older individuals, Helm et al. looked at how the frequency of private religious activities affected overall survival. After dividing the groups into those with impaired versus unimpaired ADLs, they found a protective effect of religious activities on the survival of those with good ADLs. Other prayer-based intervention such as prayer wheel may promote psychological well-being in older adults as well.
Examples of spiritual health intervention are summarized in Table 60-5.
TABLE 60-5SPIRITUAL HEALTH INTERVENTION |Favorite Table|Download (.pdf) TABLE 60-5 SPIRITUAL HEALTH INTERVENTION
|INTERVENTION ||EXAMPLES OF EVIDENCE |
|Meditation, prayer || |
Benson H. The Relaxation Response. New York, NY: William Morrow & Co; 1975;
Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health. New York, NY: Oxford University Press; 2001.
|Mindfulness-based interventions (MBIs) ||Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol. 2003;10(2):144–156. |
|Gratitude ||Wood AM, Froh JJ, Geraghty AW. Gratitude and well-being: a review and theoretical integration. Clin Psychol Rev. 2010;30:890–905. |
|Forgiveness/reconciliation || |
Worthington EL Jr. Dimensions of Forgiveness: Psychological Research and Theological Perspectives. Philadelphia, PA: Templeton Foundation Press; 1998.
McCullough ME, Pargament KI, Thoresen CE (eds). Forgiveness: Theory, Research, and Practice. New York, NY: Guilford; 2000.
|Meaning-oriented therapy ||Breitbart W, Heller KS. Reframing hope: meaning-centered care for patients near the end of life. J Palliative Med. 2003;6:979–988. |
|Dignity therapy ||Chochinov HM, Hack T, Hassard T, Kristjanson LJ, McClement S, Harlos M. Dignity therapy: a novel psychotherapeutic intervention for patients near the end of life. J Clin Oncol. 2005;23:5520–5525. |
|Organized religious activities || |
Hewson P, Rowold J, Sichler C, Walter W. Are healing ceremonies useful for enhancing quality of life? J Altern Complement Med. 2014;20(9):713–717.
Hewson PD, Rowold J. Do spiritual ceremonies affect participants’ quality of life? Complement Ther Clin Pract. 2012;18(3):177–181.