Introducing Spirituality in Medical Care: Title and subTitle BreakTransition From Hopelessness to Wholeness

When cure eludes patients with devastating conditions, healing measures become of utmost importance to the patients and their families.^{1 - 2} In an integrative approach to care, healing and curing are introduced in parallel as soon as any diagnosis, especially a critical one, is made.³ In this model, healing addresses the human experience of illness and curing the organic aspects of disease. Because loss can be experienced even in the absence of death, bereavement is represented as a continual process from the outset and usually increases after death.³

Since many diagnoses cause devastation to patients and their families, this approach to medical care has an element of universality. For example, when parents learn that their newborn child has significant, life-threatening problems⁴ or that their 3-year-old has cancer,⁵ they must deal with a profound sense of loss from the outset, even if death is not imminent.³ Similarly, when one member of a couple is afflicted with a profound, neurologically incapacitating injury⁶ or severe, progressive dementia,⁷ the unaffected spouse also may be affected cognitively, emotionally, and spiritually. In the face of such experiences, this spouse may enter a state of hopelessness, lose all sense of control and meaning, and become unable to cope. The consequences of not addressing the family's loss and bereavement are well known. In some cases, the absence of an intervention can lead to permanent problems.⁸ Addressing the human experience may help restore a sense of control and meaning.^{1 - 2}

During critical illness, particularly with end-of-life or life-altering situations, certain existential questions of ultimate meaning may arise: Why me? Why my child? What purpose does this serve? What does it all mean? Since the questions may have intangible, unanswerable qualities, formulating responses may require a shift to the spiritual domain that can be defined as a concern for what exists beyond oneself and the physical world. Exploring this domain requires transcending an individual's physical, cognitive, and emotional sense of reality and the individual's material or tangible world.

Experience with certain infants and their families and the notion that the spiritual enables a sense of self-transcendence and a sense of meaning construction^{1 - 2 ,9 - 10} have led to the hypothesis that forging a spiritual connection among mother, father, and infant—or, for that matter, any patient and his or her significant others—can restore a sense of control, meaning, and the ability to cope, allowing patients and families undergoing catastrophic events to shift from a state of hopelessness to wholeness.

Facilitating spiritual connections—including the ritualistic (prayer) and the experiential (guidance)—can help families cope with grief or despair. There is no consensus as to which discipline should introduce the spiritual; eg, medicine or chaplaincy. There are advocates for each^{11 - 12} ; however, the better choice may be dictated by the situation.

Healing and curing can coexist within the clinical setting.^{3 - 4} By using a “healing space,” a spiritual intervention can serve as an experiential basis to restore a sense of order and meaning for patients and their families, improving their ability to cope and to attain a sense of wholeness. This healing space can be facilitated by 1 or more members of a team of facilitators, including a physician, a nurse, and a social worker or chaplain. To emphasize the “healing” aspect of this space, a site of “being with,”³ where the families are permitted and encouraged to connect with their loved ones and each other, it is physically separated from the curing space, a site of “doing to,”³ with a curtain or other movable barrier.

A healing space introduces multiple opportunities for meaning construction—a process of sense-making in the face of illness interruption¹⁰ —not apparent in a curing space. For example, in the process of forming a relationship with the family of a critically ill patient, facilitators may initially address the family's cognitive and emotional needs. The team may then address the family's spiritual needs. The team can elicit a history regarding any spiritual path the family may follow, honoring any faith-based path and encouraging prayer if it is consistent with the family's traditions and rituals. A facilitator can also guide the family experientially, so that the family members can use their own voices, touch, thoughts, and feelings, with intention, to connect with the ill family member. Similarly, the same facilitator can guide the family experientially to connect to the universe, a higher power, or whatever source of support to which they may turn. The reference to a higher power is not to alienate the nonbeliever. If a background of nonbelief were to be discovered in the initial spiritual history, the facilitator would not refer to a higher power in the experiential component but would instead use the experiential connection primarily to enhance a one-with-one connection between the family and the patient. During the experiential periods, the facilitators may help the family find meaning in their caregiving experience.⁹ The facilitators would encourage these individuals to share or explore their narratives² if they are comfortable doing so. This may be a valuable exercise in meaning construction. Since the goal is to restore a sense of meaning and a sense of wholeness, storytelling should be encouraged. For patients, the process of telling their stories is a way of reclaiming the self and a way of making sense of their lives. It also serves to reaffirm important relationships in their lives.¹⁰

A criticism of much research designed to assess the role that spirituality plays in physical health is that such research has been conducted without a strong theoretical framework.¹³ In addition, little is known about how spirituality is translated into health outcomes.¹³ The contextual model of family stress has been proposed as a theoretical framework for conducting research involving families during critical life transitions.¹⁴ An explanatory model of health that represents an empirical application of the contextual model may allow a researcher to demonstrate how spirituality translates into health outcomes. Using the explanatory model, internal resources (eg, sense of control, meaning, and ability to cope), external resources (eg, marital and social support), perception of the situation, the relationship between the elements of the model, and health outcomes including grief reactions, marital satisfaction, and family function can be tested.¹⁴ Thus, this model would lend itself to a thorough assessment of the effects of a spiritual intervention.

Interventions using the idea of a healing space can be studied using a simple experimental design for testing the influence of alternative interventions. The explanatory model of health can be used to assess the effects of a spiritual intervention. Instruments such as the Lang and Goulet Hardiness Scale, designed to assess internal resources,¹⁵ and other instruments¹⁴ can be administered to each family member separately. These instruments can be administered at successive time points. A researcher would be able to compare each family member serving as his or her own control and also compare the families receiving this intervention with a control group of families with whom facilitators primarily address the cognitive and emotional needs but not the spiritual needs.

Comparable experimental designs using appropriate instruments could be developed in the face of catastrophic medical situations. These might examine the effects of a spiritual intervention on patients and their families to enhance internal and external resources, perception of the situation, the relationships between the elements in the model, and health outcomes. Lang et al¹⁴ hypothesize that increasing internal resources may be associated with greater satisfaction in marital and social support, a more positive appraisal of the situation, and a higher health index or outcome in parents undergoing perinatal bereavement. Whether similar effects would be present in other patients and their families dealing with catastrophic medical situations could be tested. Before undertaking such a study, methodological specifics regarding the Lang and Goulet Hardiness Scale or any other instruments specifically designed to assess the effects of a spiritual intervention would be warranted.

Studies designed to assess spiritual interventions are rarely pursued because spiritual aspects are not fully embraced as part of conventional medical “culture.” Even though spiritual aspects may be addressed in current medical school curricula under course titles such as “doctoring,” spiritual measures are rarely included in practice. The contextual model of family stress, and specifically the explanatory model of health, may provide the theoretical and empirical frameworks, respectively, from which to evaluate spiritual interventions. Establishing the value of a spiritual intervention to shift from a state of hopelessness to wholeness through study may further the likelihood of its inclusion earlier in care by more practitioners. Its inclusion in care may extend beyond a last rites experience or simply a referral to chaplaincy services.