2023 Palliative Hospice and Spirituality Forum Series Ⅰ- A Comprehensive Umbrella of Care for the Body, Mind, and Soul

Ying-Wei Wang, director of the Hospice Foundation of Taiwan, reflects on his initial thoughts about planning and promoting the Spirituality Forum Series. When he first delved into hospice and palliative care, he found himself busy understanding the physical and emotional conditions of patients and families. Addressing the abstract issue of spirituality, an area that initially intimidated him, proved challenging amid his hectic schedule. However, he soon realized the impossibility of separating the body, mind, and spirit when discussing palliative care. The optimal approach, he discovered, was to involve clergy from various religions. Yet, formal clergy members were so occupied that they couldn't attend to all the needs of patients and their families.

He also contemplated that spirituality and religion should not necessarily be synonymous; spirituality is a personal exploration that everyone should undertake. Therefore, hospice clinicians ought to possess the fundamental ability to engage with patients on a spiritual level. Consequently, he organized a series of spiritual forums for physicians, registered professional nurses, and long-term care staff. The aim was to assist in guiding patients to share their life stories during everyday interactions and encourage them to reflect on their relationships and connections to the past, life, and nature.

Forum 1

The European Association for Palliative Care's White Paper on Spiritual Care Education in Palliative Care 
Guidelines for Spiritual Care to the Elderly in Australia

Ying-Wei Wang, Director of Hospice Foundation of Taiwan, Director of Palliative Care Center, Hualien Tzu Chi Hospital

In 2010, Taiwan ranked 14th in the Global Quality of End-of-Life Care, and first in Asia. By 2015, Taiwan ascended to the 6th position in the Global Quality of Death (GQOD) rankings, and in 2021, it achieved the 3rd position. What transformations occurred in the realm of end-of-life medical care in Taiwan from 2010 to 2021?

According to Ying-Wei Wang, starting in 2021, there has been a heightened focus on the quality of communication and care in end-of-life situations. This includes indicators related to physical, mental, and spiritual well-being, such as being treated kindly, fostering increased medical-patient communication, facilitating emotional adjustment, enabling dying in a preferred place, and addressing spiritual needs. These aspects are deemed crucial for the advancement of palliative care in the future.

Hospice and Spiritual Care

Ying-Wei Wang emphasized the significance of spiritual care as a crucial and necessary aspect of palliative hospice care. While it has been included in the definition for almost 15 years, it has remained one of the most overlooked components. In the pursuit of promoting hospice care, there is a need to reevaluate the issue of spiritual care.

He discussed the European Association for Palliative Care's (EAPC) Spiritual Care Task Force, which focused on research, education and training, the promotion of implementation, the transformation of the task force into a Reference Group in 2019, and the development of the EAPC White Paper on Spiritual Care Education in Palliative Care in 2020.

The EAPC White Paper on Spiritual Care Education in Palliative Care integrates research evidence on best practice models, considering the diverse developments in end-of-life care in the European region. It addresses spiritual education for all palliative hospice professionals. Recognizing the significant lack of spiritual care training for healthcare professionals in the development of palliative care in Europe, the White Paper specifically emphasizes core competencies in spiritual care education, dividing palliative care into three levels: palliative care approach, general palliative care, and specialized palliative care.

According to Ying-Wei Wang, the EAPC White Paper on Spiritual Care Education in Palliative Care outlines 10 core competencies in hospice care. For the 5th point, "meeting the spiritual needs of the patient," hospice professionals are required to have the following competencies:

  • The ability to reflect on the importance of spirituality and the existential dimension in one's own life.
  • Integrate the spiritual, existential, and religious needs of the patient and family into the plan of care and respect their choices.
  • Provide opportunities for patients and families to express their spiritual and/or existential dimensions in a supportive and respectful manner.
  • Recognize boundaries that may need to be respected in terms of cultural taboos, values, and choices.

The EAPC acknowledges that spiritual care is multidimensional, encompassing life meaning challenges, values and attitudes, and religious considerations. This recognition leads to four key recommendations: reflecting on the individual's spiritual dimension; providing opportunities for patients and families to express their spiritual, existential, and religious needs; incorporating the spiritual needs of the patient, family, and caregiver into the plan of care; and respecting limitations posed by different cultures, rituals, and traditions.

Ying-Wei Wang emphasized that the need for spiritual care is not limited to the end of life; spiritual changes occur throughout the course of an illness. Addressing these changes through intervention and providing spiritual care is essential to meeting the patient's needs during these transformations.

Spiritual Care Is Relevant to Everyone

In addressing spiritual care for the elderly, Ying-Wei Wang shared insights from the Guidelines for Spiritual Care to the Elderly in Australia, which encompasses three major aspects: all caregivers, spiritual care practitioners, and representatives of religions. The interdisciplinary team caring for patients and family members includes doctors, spiritual care practitioners, social workers, grief care practitioners, home caregivers, professional therapists, nursing staff, and volunteers.

The guidelines are structured into three main sections: spiritual care, pastoral care, and religious care, collectively referred to as the spiritual care umbrella. They adhere to four principles: the involvement of the entire organization, relational care, the universality of spiritual care, and its focus on the growth and prosperity of the individual.

According to Ying-Wei Wang, the Guidelines for Spiritual Care to the Elderly in Australia emphasize the balanced development of spiritual work, integrating both art and science. The artistic dimension involves person-centeredness, communication, sensitivity, and self-awareness. In contrast, the scientific aspect covers results, indicators, evidence, and ongoing work. Finding a balance between these two facets is crucial to effectively assisting those in need.

Forum 2

Clinical Spiritual Care: Hospice Spiritual Training and Clinical Application

Huey-Wen Lim, Physician, Yishun Community Hospital, Singapore

What is spiritual care? Dr. Huey-Wen Lim explains that spirituality refers to human cognition in the inner search for existence and meaning. It involves the deep relationship between individuals, their environment, nature or divine forces, and even their own selves at any given moment.

What benefits does spiritual care offer? According to Dr. Lim, studies in the U.S. have shown that spiritual care can reduce the mortality rate of patients in hospitals and increase the rate of transferring patients to hospice.

Clinical spiritual assessment utilizes FICA as a tool, which encompasses four key components: (1) understanding and knowledge of the patient; (2) their life story, including the people and things that are important to them; (3) their interpretation of life; and (4) their interpretation of life's dilemmas. Dr. Lim emphasizes that, akin to obtaining a medical history, caregivers need to inquire about a history of spiritual encounters to comprehend the patient's needs.

Following the spiritual assessment, patients may undergo spiritual distress, exhibiting clinical symptoms such as depression, loss, inability to practice daily religious rituals, wavering trust in beliefs, a sense of purposelessness, spiritual emptiness, feelings of emotional isolation from oneself or others, and negative perceptions about life's meaning. Dr. Lim suggests that diagnosing spiritual disturbance can help patients regain self-confidence and adopt a positive mindset.

Spiritual Care History Spawns the FICA Assessment Tool

F (Faith): What are the patient's spiritual or religious beliefs?
I (Importance): Are these beliefs important?
C (Community): Talk about the people the patient has contact with, including family, friends or religious groups.
A (Assist): What spiritual care does the patient want from the health care provider?

Allow the Patient to Live His or Her Last Days with Dignity and Meaning

In terms of clinical application, spiritual care can be summarized into six major objectives, which are to help patients recover: (1) sense of love and belonging in life, (2) life meaning and purpose, (3) appreciation of the beauty of nature, (4) spiritual/religious guidance, (5) mindfulness, gratitude, and calmness of mind, and (6) management of issues during and after life.

Through the combination of nursing disposition, rehabilitation assessment, and spiritual care, registered professional nurse Bing-Zhen Gao admits, "We can't change the outcome, but we can influence the journey." We are committed to enabling our patients to live their last days with dignity and meaning.

In addition, social worker Xiao-Yi Lim also shared the Bio-Psycho-Social-Spiritual Model, which is commonly used in spiritual care in Singapore:

Bio: diagnosis, prognosis, current and expected health conditions, and behavior.

Psycho: mental ability, mood, personality, and coping ability.

Social: nature of family relationships, family circumstances, resources in the family and community, financial situation.

Spiritual: The meaning of life experiences, personal values, beliefs, and religious rituals.

According to Xiao-Yi Lim, this model can effectively examine symptoms and illnesses, along with their impact on the patient's physical and psychological aspects.

Spiritual care practitioner Shu-Ling Teng pointed out that for clinical cases, in addition to the use of medication, the team--including doctors, social workers, physical therapists, nurses, and others--is also utilized to carry out comprehensive care and spiritual conversations. This allows the patients to share their feelings, life stories, and discuss their beliefs. The patients can even explore and face their strengths, as well as physical regrets and hopes. Shu-Ling Teng said that through the spiritual care journey, medical staffs were able to see positive changes in the patients' lives, even though sadness continued to surround the patients.

Forum 3

Long-term Care Organizations: Hospice Spiritual Care for the Elderly

Fang Liu, Associate Professor and Director, School of Gerontology and Long-Term Care, Taipei Medical University

An individual's spirituality can exist independently of religious beliefs, affiliations, or practices. Spiritual care constitutes a crucial aspect of holistic and compassionate healthcare. Empirical studies have demonstrated that acknowledging and supporting an individual's spirituality can alleviate the suffering experienced by many during illness or at the end of life.

The reason for the consistent emphasis on spirituality lies in its significance as a vital component of long-term care units. It promotes meaningful aging and facilitates the elderly in becoming the best version of themselves in their current circumstances. With an increasing number of long-term care units globally and actively promoting palliative and spiritual care, Fang Liu noted that one of the goals of hospice care is to enable patients to depart peacefully from their homes. Long-term care organizations are often considered by many residents as their home and the final residence in their lives. Therefore, it is imperative for long-term care staff to possess the skills of spiritual care to enhance the quality of life for residents, fostering a sense of belonging and connection.

Spirituality and Quality of Life Are Intertwined

Maintaining and enhancing the quality of life is a primary objective for reputable long-term care facilities. According to the World Health Organization (WHO), spirituality is intricately connected to the quality of life, asserting, "Whether we realize it or not, we all have spiritual needs."

Regarding the relationship between long-term care residents and staff, Fang Liu highlighted that, unlike acute care in hospitals, the bond between residents and staff is notably close. This closeness stems from frontline staff providing 80% of direct care to long-term care residents, maintaining daily or weekly contact with residents' family members and friends. Even without a blood relationship, numerous studies indicate that long-term care residents and caregivers establish a familial connection, forming a close-knit relationship.

What are the benefits of offering spiritual care to the elderly? Fang Liu stated that studies reveal positive impacts of spirituality and religion on elderly individuals with dementia. Beyond sustaining social activities, the comfort derived from prayer and familiar rituals establishes a more regular life rhythm, stimulating neural pathways. Fang Liu emphasizes that meaningful activities in long-term care facilities assist seniors in accepting a dementia diagnosis, slowing the progression of the disease and cognitive decline, and preparing seniors for the end of life.

Five Elements Meeting the Spiritual Needs of the Elderly for Peace of Mind

As long-term care organizations are considered home by many residents, spirituality holds even more significance for this group of elderly individuals and the long-term care units. According to the Guidelines for Spiritual Care to the Elderly in Australia, hospice and spiritual care for the elderly should focus on five key elements:

  1. Organizational leadership and alignment: Embedding and practicing spiritual care at all levels throughout the organization.
  2. Relationship and connectedness: Providing care within the context of mutual, respectful, and genuine relationships.
  3. Identifying and meeting spiritual needs: Recognizing choices, preferences, and needs of older people, identified, documented, and shared by the care team.
  4. Ethical context of spiritual care: Establishing an ethical framework to ensure spiritual care respects and upholds the rights of older people.
  5. Enabling spiritual expression: Implementing individualized activities and interventions to encourage finding meaning, purpose, connectedness, and hope.

The Spiritual Needs Model for Long-term Care Facilities

Evaluation of elderly-centered care services is approached from four perspectives:
1. Meaningfulness: Whether the elderly can reestablish a new balance in their lives and cope with illnesses and functional deterioration in old age.
2. Transcendence: Whether the elderly can find the foundation of their existence, beliefs, faith, and aesthetics.
3. Values: Whether the elderly can be understood, affirmed, respected, and maintain their autonomy.
4. Psychosocial Identity: Whether the elderly feel loved and cared for, possess positive thoughts about themselves, and have the feeling and ability to forgive others.

So then, how can spiritual care be implemented in long-term care facilities? Fang Liu pointed out five important driving forces: (1) active participation of the organization's senior management, (2) close alignment of values embraced and practiced by staff, (3) staff education and training, (4) integration of spirituality with related philosophies/models, and (5) cultivation of a culture that recognizes and responds to the needs of spirituality.

Lastly, Fang Liu emphasized that all members of the geriatric or palliative care team can provide spiritual care through activities such as sensitive and respectful interactions, empathic communication, reminiscence, mindfulness and meditation, and therapeutic life review. Spiritual care is optimized when a holistic organizational approach is taken, building trusting relationships and providing the elderly with opportunities to connect with family, friends, and nature, ensuring they feel safe and can engage in meaningful activities or give back to others.

~ to be continued~