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June 2012 Article of the Month
Puchalski, C. M. "Spirituality in the cancer trajectory." Annals of Oncology 23, suppl. 3 (April 2012): 49-55.
SUMMARY and COMMENT: Our featured article for June is not a report of a single study but rather a very research-minded overview by a physician leader in spirituality & health that should serve as a good entrée to the field for CPE summer interns. Christina Puchalski, MD, is the founder and Director of the George Washington Institute for Spirituality and Health (GWish), an extensive resource useful to all chaplains [--see Related Items of Interest, §I, below]. The article covers basic terms, the current medical perspective on spirituality in general, and particular issues related to cancer --a diagnosis that, according to a National Cancer Institute estimate, will be experienced by 41% of Americans born today [p. 50; and see the NCI source]. The author mentions chaplains at a number of points. The opening paragraphs present a broad description of the relation of spirituality to cancer patients: From initial diagnosis, through treatment, survivorship, recurrence, and dying, cancer patients’ understanding of their illness and their lives with their illness range from the physical, social, emotional, and spiritual. A diagnosis raises spirituality-related questions and concerns, both existential and religious. Diagnosis of cancer changes the lives of patients forever, the diagnosis often triggering deep questions of meaning and purpose, and with the journey through treatment, deep issues of hope and fulfillment. The uncertainties and myriad decisions may raise spirituality-related issues more often in persons diagnosed with cancer than with other long-term illnesses. Spirituality is also an important component of quality of life of patients with cancer. [p. 49]The author then addresses the concept of spirituality, as defined (in the author's work elsewhere) as "the way people find meaning and purpose, and how they experience their connectedness to self, others, the significant, or sacred" [p. 49]. The research basis for statements in this article is immediately apparent by the copious references to studies, and the reader should be drawn to flip back and forth to the 91-item list of endnote citations. Of special note is the discussion of "spiritual distress" as a clinical diagnosis and a table of examples [--see p. 51]. A further section looks at the "biopsychosocialspiritual assessment and treatment plan" [--see pp. 52-53] and offers a case illustration and examples of spiritual care interventions [--see tables on p. 53]. The model for spiritual care here is guided by the "principle that all members of the healthcare team are responsible for attending to a patient’s spiritual issues, recognizing that the board-certified chaplain is the spiritual expert on the team" [p. 52]. The biopsychosocialspiritual model... ...recognize[s] that spirituality underlies all the dimensions of care.... In this model, spirituality is the essence of humanity as described by Viktor Frankl. The inner core of the person is not possible to understand, diagnose or treat. However, where spirituality interacts with the other domains is the area that is relevant for clinical care. So, physical pain may in fact be an expression or complication of spiritual distress. ...The biopsychosocialspiritual model recognizes the distinct dimensions--biological, psychological, social, and spiritual--of a person and the fact that no dimension can be left out when caring for the whole person. [p. 52]A section on barriers providing spiritual care considers the quandary that "[d]espite evidence that spirituality plays an integral role in helping oncology professionals understand how a person defines quality of life in the context of his or her cancer experience, cancer patients report their psychosocialspiritual needs are not understood--and that healthcare professionals do not recognize, treat, or offer appropriate referrals to address their spiritual needs" [p. 52]. The author comments on physician reluctance and issues of education and communication, plus concerns about assessment and documentation systems as well as the complexities of ethics and confidentiality. Note: there is no discussion of barriers other than those related to caregivers, such as the many barriers brought to the clinical encounter by patients themselves. The idea of "trajectory," while part of the title, is not explored in detail here [--but see Related Items of Interest, §II, below], yet the sense of a patient's process is implicit throughout: e.g., "From the moment of diagnosis of cancer through treatment, survivorship, recurrence, and dying, patients with cancer are faced with spiritual issues that may cause spiritual distress or may help them as they face their illness" [p. 53]. Also, "Evidence shows...that addressing spiritual distress and spiritual resources of strength are integral to care across the trajectory of illness," and "Attention to a patient’s spiritual well-being can help the individual find meaning and live life to the fullest from diagnosis through treatment, survivorship, and dying" [p. 51]. Trajectory allows for a varied course, including survivorship, but it is in practice a term rooted in palliative care as defined as "care span[ning] the time from diagnosis to eventual death" [p. 52]. Puchalski is certainly addressing physicians, and making a research-based case for the criticality of attending to spiritual needs in patient care, but for chaplains the article constitutes a brief and effective review of how medicine currently may see grounds for the work of chaplaincy across the full trajectory of illness/treatment. Suggestions for the Use of the Article for Discussion in CPE: This is a well-crafted article that should engage CPE students, including summer interns or others new to the spirituality & health literature. Discussion could start with a general question: "What is the role and importance of research in making the case for spiritual care?" It is simply a nice way to make a case, or is it something more essential? Students might discuss how physicians may see spiritual care, and inviting an oncology physician (and/or a physician who sits on the CPE center's advisory committee) to join in the discussion could benefit students' thinking. How do students react to the statement, "Not addressing spirituality could result in poorer outcomes, increased non-compliance with the treatment plan, and failure to help patients find effective coping mechanisms" [p. 51]? Does it comport with their own sense of why they are interested in chaplaincy? And what about the author's definition of spirituality? The table of examples of spiritual distress [p. 51] could also be a thought-provoking list of "diagnoses" and key features. How does the wide-angle view of a trajectory of illness and patient experience strike students? Might it provide a broad context for specific clinical encounters? Finally, the article puts forward an integrated biopsychosocialspiritual model, but do students understand their work as truly integrated or somehow separate from the bio-psycho-social aspects of health care? Related Items of Interest:
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If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at john.ehman@uphs.upenn.edu
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