16. Outline. Core issues in practice European perspectives. Spiritual Care in Palliative Care. EAPC survey of spiritual research priorities

2/05/16   Outline •  What we bring: mapping assets •  Key issues: seeking collective wisdom •  Finding our place: in collegial practice, in organisat...
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Outline •  What we bring: mapping assets •  Key issues: seeking collective wisdom •  Finding our place: in collegial practice, in organisational structure, in policy

Spiritual Care in Palliative Care SCA Conference, Melbourne, May 2, 2016

Bruce Rumbold, Palliative Care Unit, Department of Public Health


Core issues in practice European perspectives

EAPC survey of spiritual research priorities Responses from 971 practitioners, including 293 palliative physicians, 112 nurses, and 111 chaplains, received from 87 countries (Selman L., Young T. et al 2014). Priorities for research were identified as:

EAPC competencies and research priorities

1. Development and evaluation of conversation

models and overcoming barriers to spiritual care in staff attitudes 2. Screening and assessment 3. Development and evaluation of spiritual care interventions and determining the effectiveness of spiritual care 3



Spiritual conversation models and staff attitudes

Spiritual assessment and screening

•  What occurs in current practice?

•  What is the exact concept being assessed?

•  What are staff members' experiences of and attitudes towards spiritual conversations?

•  What assessment is appropriate in diverse groups?

•  What are the barriers to conversations? •  How effective and cost effective are spiritual conversations? •  What are patients' preferences regarding spiritual conversations?

•  What tools exist, what are their limitations, and when should they be used? •  How effective are screening and assessment? •  What are patients' preferences regarding screening and assessment? •  What training and support do staff need?

•  What training and support do staff need? •  What impact does staff training and education have?

Effectiveness of spiritual care and spiritual care interventions

EAPC core competencies in palliative care: No

•  What are the aims, objectives, components and outcomes of spiritual care?

Palliative care professionals should be able to:

•  What are the best methodologies to study effectiveness? •  Which interventions and models exist and what are their characteristics?

5, meet patients’ spiritual needs 5a

demonstrate the reflective capacity to consider the importance of spiritual and existential dimensions in their own lives


integrate the patients’ and families’ spiritual, existential and religious needs in the care plan, respecting their choice not to focus on this aspect of care if they so wish


provide opportunities for patients and families to express the spiritual and/or existential dimensions of their lives in a supportive and respectful manner


be conscious of the boundaries that may need to be respected in terms of cultural taboos, values and choices

•  How effective and cost effective are spiritual care models/ interventions? •  What are patients' understandings, preferences and expectations regarding spiritual care .... •  What impact do staff education and support models have? •  What is the role of the team in providing spiritual care?



Finding our place in collegial practice

Spirituality involves relationships With places and things (spatial) With self (intra-personal)

Enlisting the listening skills of colleagues: the relational web

With others (inter-personal) Among people (corporate) With transcendence (‘God’,‘Something There’) Lartey, E.(1997) In living colour: an intercultural approach to pastoral care and counselling, London, Cassell, 113.


Spiritual care involves: •  Screening - mapping (and documenting) a person’s web of relationships •  Assessing – if feasible, exploring possibilities and needs with the person •  Developing strategy – interventions that involve settings, stories, and systems of belief

Relational Web Spatial, corporate, inter-personal, intra-personal, transcendent relationships

Triggers What’s important to me? Who is important to me? What helps to keep me centred / at peace? What things in my community do I feel connected to? What places and things are special to me? How do I see /identify myself (eg mother, teacher, confidant, spiritual being, courageous …..)



Strategies for spiritual care •  Settings •  Stories •  Systems of belief

Strands of the Web

Positive Relationship

Lost Relationship

Negative Relationship

Transcendent: The Other

“My faith’s all I’ve got left now”

“Hard to feel God’s presence”

“Bloody angry with God when Bert died” “cheated”


“Getting used to being still”

“I was very active”

“I’m a useless old thing now”


“Dulcie {neighbour} Bowling club is my best friend” Bingo group


A member of the Labour movement all my life

The neighbourhood “After we moved . . Never in which I grew up felt we quite belonged”

Places & things: spatial

Bedroom window “sky”

Garden “miss my veggies”

Estranged sister “speaks in tongues” “not my scene”

Hospital “I’m just another body”

Settings •  Where does the person feel safe? •  Staying connected with this safe place? –  Pictures –  Mementos –  Religious symbols –  Recollection –  Visits –  Reports from others –  Electronic links (images, video feed, Skype ...)




Systems of belief

•  •  •  • 

•  Enquire about rituals and beliefs •  Ask person and/or family to coach caregivers •  Arrange visits from an appropriate religious practitioner •  Prepare for any end-of-life rituals that are requested

Listen to the stories Explore their significance Enquire about missing storylines Encourage them to represent these stories (write, record, draw . . . )

Population  Health  

Finding our place in organisational structures

Tiered  models  of  care  

All patients Many patients Some patients INFORMAL CARE

Few patients





Level One

Level Two

Care needed by all: person-centred care.

Care needed by many: person-centred care sensitive to the spiritual domain.

Competency to provide this care: all practitioners (staff and volunteers) who have casual contact with patients and families should have basic skills of awareness, relationships and communication; understand that all people have spiritual needs and be able to distinguish spiritual and religious needs; and be able to refer concerns to members of the multidisciplinary team. Screening is likely to be unobtrusive – alert to spiritual issues rather than enquiring about them.

Competency to provide this care: practitioners whose duties require contact with patients and families/carers have level one skills with, in addition, increased awareness of spiritual and religious needs, and how these may be identified and responded to. Screening more likely to include direct enquiry about spiritual concerns.

Level Three

Level Four

Care needed by some: care that addresses spiritual and religious issues.

Care needed by a few: care for complex spiritual and religious needs.

Competency to provide this care: practitioners who are members of the multidisciplinary team, have training to assess spiritual and religious need, and to develop care plans to respond to spiritual, religious and ethical issues. Competency in recording sensitive and personal patient information is required as this level.

Competency: practitioners whose primary responsibility is for the spiritual and religious care of patients, families/ carers. These people are able to work with complex spiritual and religious need, particularly need arising from people’s encounters with finitude and death; able to journey with others, focusing on the needs and agendas of those others; are equipped to liaise with external resources as required; and can act as a resource for support, training and education of practitioners working at levels one to three. Rumbold B. (2013)



Finding our place in policy

Victoria - where are we now Government

End of Life Care Frameworks Ottawa Charter: health promoting pastoral care


Palliative care funding $120M in 2015-16


21 health services supporting 289 beds


31 community palliative care services in rural, regional & metro Melbourne


Medical training program, nurse practitioners & volunteers

Policy framework • 

Strategic focus on building palliative care service capability across Victoria


Establishing and fostering interdisciplinary specialist palliative care


Best practice guidelines and research




Access & equity for CALD and Aboriginal people


Where do we want to go

Community voice • 

People want care to be provided as close to home as possible


People want access to acute like services at home »  pain relief

A future where services are wrapped around people, not providers, or institutions; where preference is taken into account, based on honest information about survival and complications; where dignity and comfort are respected; and where quality of life matters most.

»  fluid replacement »  supportive care; and »  24/7 on-call supports. • 

People want to be involved in decisions regarding their end of life care


Carer support



How do we get there

Government commitments

New policy framework

Victorian Government has committed to undertaking two key reforms to support end of life care choices:

•  End of Life Care framework •  Community and sector consultation to inform: Ø  Identify what practical improvements can be made to support people’s choices about end of life care looking at the; Ø  How to better equip services to deliver quality end of life care to individuals and their families; and

•  Enabling the statutory recognition of advance care directives so competent Victorians can document treatment preferences for existing and/or future conditions and articulate their end of life care wishes; and •  Undertake a program of appropriate improvements to palliative care services to provide responsive, appropriate and innovative home-based care models.

Ø  What system changes are required to deliver a better integrated service that supports people to be cared for in their place of choice and die in their place of choice.

Victoria’s End of Life Care policy framework

OTTAWA CHARTER 1986 The New Public Health

Key focus areas of the End of Life Care framework will include: •  Improving access to specialist palliative care

In promoting health we must:  

•  Eliminating the mismatch between what patients want and what is provided

Enable,  mediate,  advocate  

•  Improve specialist palliative care capacity

Create  suppor?ve  environments  

•  Increase knowledge about of end of life care amongst all clinicians and services

Strengthen  community  ac?on  

•  Reduce fragmentation across service delivery

Develop  personal  skills  

•  Build community capacity outside health services

Reorient  health  services  



Health  Promo?ng  Pastoral  Care   1.  Promote, advocate and educate for assets-based approaches to health 2.  Encourage individuals to identify, develop and use their knowledge, skills in supportive relationships 3.  Develop sustainable communities characterised by compassion 4.  Develop partnerships, especially with public health and community development 5.  Pursue equity: confront injustice and inappropriate uses of power

Strategy: pastoral care as partnerships •  Forming partnerships that add value, encourage resilience and promote coherence •  Assets-based, not just problem-based, approaches to care •  Collaborations across and beyond disciplines, and across and beyond medical and religious institutions •  Attention to natural networks of support as well as professional networks that may be required

References Puchalski, C., Ferrell, B. et al. 2009. Improving the quality of spiritual care as a dimension of palliative care: The report of the consensus conference. Journal of Palliative Medicine 12(10): 885-904. Rumbold, B. (2013). Spiritual assessment and healthcare chaplaincy. Christian Bioethics. doi: 10.1093/cb/cbt027 Selman S., Young T. et al (2014). Research priorities in spiritual care: An international survey of palliative care researchers and clinicians. Journal of Pain and Symptom Management, accepted for publication


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