SAN FRANCISCO – Medicine shrinks from caring for the spiritual needs of dying patients, even though spirituality is what most people yearn for most at the end of life, Franciscan Brother Daniel Sulmasy, a physician and philosopher, told an audience at the University of San Francisco April 28.
Doctors tend to ignore spiritual care or back away from it out of fear of inadequacy or invading patients’ privacy, Brother Sulmasy said. Often they think they are helping, but underserve patients by turning spiritual questions into technical problems, he said.
For dying patients, the impulse is the reverse, he said: The terminal patient whose spiritual life is outstanding despite great physical distress reports having an outstanding quality of life.
The split is so large that a new model for medical education may be needed, he said. The model would integrate biological, social and spiritual issues in training doctors.
Doctors should be mindful that patients’ spiritual questions are fundamental – deeper than the biological, moral and ethical issues that concern clinicians and hospital ethics advisory boards, said Brother Sulmasy, who holds the Sisters of Charity chair in ethics at St. Vincent’s Hospital in New York.
“Spirituality is incredibly important in the care of patients and it’s shocking how we do wind up ignoring so much of it,” he said.
Brother Sulmasy opened his talk with the case of a 54-year-old man, Mr. “W.” Dying of cancer, the patient was Christian and believed in the possibility of miracles, but also accepted that God might not grant one in his case. In reviewing the transcripts of interviews with the patient’s caregivers, Brother Sulmasy found that despite the patient’s outspoken spirituality his spiritual care fell short.
Mr. W’s belief in miracles caused some confusion for the medical team. As a result he was transferred to a nursing home rather than to hospice care, where he would have received better treatment for his pain.
“It was stunning the way this man was treated,” Brother Sulmasy said. “There’s nothing that says the patient who believes in miracles is ineligible for hospice, but somehow the hospice care team felt that belief was an issue.”
A chaplain, though, had correctly diagnosed the underlying problem. As Brother Sulmasy paraphrased the chaplain: “When I look at a patient I look at the primary, core spiritual need. Is it a request for meaning to try to determine what their life meant? Or are they looking for validation of their life? Or trying to reconcile broken relationships?”
Meaning, value and relationship are the ingredients of spiritual health and become urgent in the last months of life as patients strive for dignity and hope despite losing their productivity and appearance, Brother Sulmasy said.
“People who were able to find meaning in their illness, meaning in their dying, are people who understand what it is to hope in a deep way,” he said.
He stressed how important it is for dying patients to reconcile relationships with family, friends and God. “The brokenness of their bodies reminds patients in a deep way about the brokenness of their relationships,” he said. “They’re looking perhaps to express their own forgiveness of someone who had hurt them or to try to be reconciled to those they had hurt, to try to bring families and friends together in ways that arise as they’re dying in a very salient way.”
Brother Sulmasy displayed a detail from a Giotto painting of the dying St. Francis of Assisi. The detail shows a monk kissing the saint’s stigmatic wounds. It is part of a scene in which St. Francis is dying at home surrounded by his friends and watched over by God. The scene embodies the three ingredients of spiritual health for the dying person – meaning, value and relationship.
“You see a picture of somebody who is surrounded by people who love him, who are supremely present to him, who care about him … as a whole person,” he said. “They are praying with him, engaged with him as a whole person in this experience.
“I think this is death with dignity,” Brother Sulmasy said. “If it was possible in the 14th century, why isn’t it possible for us in the 21st?”