Sunday, September 05, 2004

What is Spiritual Distress?

Not too long ago, the words “religion” and “spirituality” had the power to turn my stomach and throw a wall up in my mind to any further communication with the source of the words. But working with people who are dying can have a profound effect on people. Well, at least it has on me. I still do not consider myself “religious.” I do not follow any doctrinated religion, but I have a stronger sense of and acceptance for the presence of a spiritual side to myself.

One of the components to working with people who are dying is a spiritual aspect to their care. In nursing, we have what are referred to as "care plans" and "nursing diagnoses." These diagnoses are not based entirely on biological processes happening on a physiological level in the patient. Nursing diagnoses are more interdisciplinary. They take into account the person as a whole.

At my job, we have a care plan specifically created for “Dying Patients.” The last nursing diagnoses listed in the care plan is “Spiritual Distress, Actual or Potential.” On the care plan, the nurse is to select which diagnosis is appropriate for each specific patient. At first, I ignored the spiritual distress diagnosis, partly out of discomfort and partly out of uncertainty as to how I was to assess whether or not the patient was spiritually distressed. Then I started to realize the great resource that the hospital’s chaplain services is. Once I started utilizing their services, I felt comfortable selecting spiritual distress as a diagnosis and then wrote in “Referred to chaplain services” as my intervention. Lately, I have once again dropped using this diagnosis. I am not sure why. If I knew that I was going to die soon, I would certainly be experiencing spiritual distress. But what does this mean?

I found a spiritual distress care plan
online that is helping me understand this better.

It states that spiritual distress is evidenced by:

-Questioning the credibility of my belief system.
-Demonstrating discouragement or despair.
-unable to practice usual religious rituals.
-ambivalent feelings (doubts) about beliefs.
-Expressing that he/she has no reason for living.
-Feeling a sense of spiritual emptiness.
-Showing emotional detachment from self and others.
-Expressing concern, anger, resentment, fear - over the meaning of life, suffering, death.
-Requesting spiritual assistance for a disturbance in belief system.

I don’t necessarily agree with all of these assessments as evidence of spiritual distress. Some of these symptoms seem more like signs of depression. And detaching from others to some degree is a normal part of the dying process.

There are some better websites on dealing with spiritual distress of dying patients. See...

Spiritual Distress of Dying Patients

Nurse Practitioner's Approach to Spiritual Distress

How Do Nurse's Provide Spiritual Care?

In the latter website, the author states:

“Govier (2000), has identified the five R's of spiritual care:

-Reason and Reflection - A desire to search for, or find, meaning and purpose in one's life; the will and reason to live; to reflect and meditate on one's existence (may be enhanced through art, music or literature)

-Religion - A means of expressing spirituality through a framework of values and beliefs, often actively pursued in rituals, religious practices and reading of sacred texts; religion might be institutionalized or informal

-Relationships - A longing to relate to one's self, others and a deity/higher being (may be expressed via service, love, trust, hope and/or creativity) ; the appreciation of the environment

-Restoration - The ability of the spiritual dimension to positively influence the physical aspect of care (certain life events can be detrimental, resulting in spiritual distress) “


When I told my mother I was interested in working with people who are dying, she was surprised. “But you aren’t religious. How are you going to support them when they want to pray?” It is actually just by nature of my not having any one religion that I feel unbiased enough to support any patients with any religious beliefs. I do not judge their beliefs nor try to impose my own.

I quote that same article:

"Govier (2000) cites a study by Amenta and Bohnet (1986) that suggests the use of four tools to help nurses implement spiritual care:

-Listening in an authentic manner;
-The actual presence of the nurse;
-The ability of the nurse to accept what the patient says; and
-The use of judicious self-disclosure"

I have struggled with trying to figure out what it means to assess that a patient is in spiritual distress and I’ve pondered what I could possibly do about it. And have realized only recently that this job has awakened me out of my own state of spiritual distress in a way. I do meditate for a moment or two before entering my patient's room so that I am fully present with them. I strive to listen to my patients with a peaceful and open heart.

I became conscious of these behaviors through lectures by Christine Longaker. She was talking about caring for people who are dying. These behaviors were suggested outside of a spiritual or religious context. That may have been the only reason I was able to hear them at that time. But in striving towards this goal of being at inner peace when working with these patients, even I – being the semi-agnostic that I am – now realize I have been addressing spiritual distress without even being consciously aware of what I was doing.

There has been an interesting side effect for me. I have become much more open to picking up whatever bits ring true for me from any religion. Having grown up Catholic and thinking of myself as a “recovering Catholic,” references to Christianity have been the strongest triggers for my animosity and walls. But I am even finding myself able to appreciate writings that come from Christian sources, such as the quote below, that I heard while watching a movie this evening:

"Lord, make me a channel of Your peace,
that where there is hatred, I may bring love,
where there is wrong, I may bring the spirit of forgiveness,
where there is discord, I may bring harmony,
where there is error, I may bring truth,
where there is doubt, I may bring faith,
where there is despair, I may bring hope,
where there are shadows, I may bring light
and where there is sadness, I may bring joy.
Lord, grant that I may comfort, rather than to be comforted,
that I may understand, rather than to be understood
that I may love, rather than to be loved.
For it is by forgetting self, that one finds
it is by forgiving, that one is forgiven
it is by dying that one awakens to eternal life."
- Saint Francis

2 comments:

Jennynyc said...

This post makes me reflect back on an eye-opening experience I had while working as an inpatient psychiatric hospital social worker. An older, white, Christian man came in (somewhere between middle-aged and elderly) after a failed but very serious suicide attempt. He had bought a train ticket out of his state, got onto the train, and taken many pills. When he awoke, he was mentally confused and was being asked to leave the train. He was taken to our hospital and almost died. It turned out that he was a prominent person in a conservative state with a loving family and friends who were terrified that he was missing and were completely shocked to receive our call. About a dozen of his loved ones immediately flew out to support him and arrived at our hospital ward. I was responsible for the “family meeting.” I gathered all of us together with chairs in a circle in a room. Then I attempted to assist them in communicating with one another. I kept hitting a wall. No one wanted to talk about what had happened, and they were instead discussing track meets and the like! When I would try to address what had brought us all together, they made it clear that they did not want to discuss it and did not appreciate me bringing it up. I was baffled at the degree of avoidance, especially because it was clear that this man was so loved and cared about. I felt more and more helpless myself, not knowing why my usual skills at facilitating communication weren’t working. Finally, I decided to stay completely quiet and let them talk themselves out about irrelevant topics. This took awhile, and then the room became quiet. Without a word, they joined hands, including myself, in the circle we were all sitting in and bowed their heads. Each of them began crying and sharing their shock and grief at having almost lost their loved one. They did this in a way that was completely open, as if they were thinking their deepest thoughts alone. All comments were addressed to God. By the time it was over, they had made their loved one aware of how much they cared and how they would do anything to help him no matter what his problems. When hands were released, and they raised their heads, the emotional tone became casual and pleasant, with no references to the shared prayers. From that experience, I learned how important the spiritual assessment of a case is. I felt grateful to be part of such an amazing way of addressing a family crisis, a barely averted tragedy.

Anonymous said...

I know this post is old, but I caught it in a Google Search.

I arrived at a hospital this morning to visit my grandma in ICU. When I got up there, a nurse was at her bedside and a red light flickered on her monitor. Her heart rate was critically low and the death rattle was still strong. We expected it to happen at some point, but apparently this state happened quickly ...shortly before we made it up. She was dying/going right there in front of our eyes. I asked if I could talk with her....and yes, I was encouraged to do so...to hold her hand, to give her permission to go. My mother was on her other side and told her, as well. I told her I loved her (as I had numerous times the prior day and reflected on good memories with her..or TO her..she was not able to speak, but knew we were there by opening her eyes (death stare) and squeezing my hand. She also tried to move towards me when I spoke in prior days.

Anyway...it was not more than a minute or so and she was gone. Just like that.

She waited for us to get there. You cannot tell me she did not. What are the odds of this happening on THIS timing? AND...with the experience I experienced, you CANNOT sit there and tell me there is not a God. I always had a HUGE fear of death. You could NOT get me within 20 feet of a body at a visitation. I FEAR(ed) it. PHOBIC-LIKE. But today....today changed things to a degree. I have a completely different outlook. It doesn't mean I like it, but it means that I saw a MIRACLE. Just as birth, death is a miracle. It's God. If my sense of this would've been stronger, *I* would've seen "the light" my grandma was seeing, as well. And no...I am not a "Bible Thumper". I do not attend church (not for a good 10 years?), but I've given birth. I've seen how the body functions to make life happen. I've seen our environment work in a perfect system (trees take in CO2 which we give off, give off O2 that we take in, for example)....a perfect but complex system called EARTH. And now I've seen death as it happened. It's WAY beyond what Man can make. It's a miracle. Everything about LIFE is a miracle...this is no coincidence. This is GOD.