This was my Home Health/Home based Palliative Care Rotation Feedback; It is major part is concerned about how to take spiritual history and how to address spiritual concerns/Cues of our patients

1. Dr.M. Mataro Hingorjo
Resident Year 04
Family Medicine AKU Karachi Sindh
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2. 
 Rotation in final year residency
 Three days in a week for one month
 Once per week : Saturday Cover
 My Rotation period: February 2015
 Supervisor: Dr. Faizan Qaiser, SMO, Family Medicine Department
Introduction: Rotation
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3. 
 Any diagnostic, therapeutic, or social support service provided in the
home
OR
 Home health care offers the opportunity to provide care that takes into
consideration patients’ home lives, living situations, chronic illnesses,
and functional limitations and aims to deliver patient-centered care.
Introduction: Home Health
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4. 
 Hospital Inpatient Referrals
 Palliative Care Referrals from oncology/palliative care clinics
 Geriatric Clinic Referrals
 Consulting clinic Referrals
 Self Referrals
 Patient to patient Referrals
 Hospice/Nursing homes
 Follow up Visits
Types of Referrals
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5. 
What is Palliative Care?
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6. 
 88 year old lady, diagnosed patient of CA Endometrium, known to
palliative care services for past 06 months
 HBPC physician called by family to Visit
 As she has become more irritable and screams at times…….!!
 Patient says, She feels that some body is calling her ,She is afraid of that
 She further says she is angry with God
 How will you approach to that patient?
 How will you counsel the family?
Patient Problem
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7. 
 Whole Person Approach/Respect humanity of each individual
 Multifactorial Pain = Suffering
 Physical/Emotional/Psychological/Social/Spiritual
 All dimensions should be treated equally
 Team Approach= Multiple expertise
 Respect for dignity and inherent value of each
human being
Bio Psycho-socio-spiritual Model
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of palliative
care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904.
7

8. 
 Spirituality is the aspect of humanity that refers to
 the way individuals seek and express meaning and purpose of their
existence
 the way they experience their connectedness to the moment, to self, to
others, to nature, and to the significant or sacred
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of palliative care: The Report of the
Consensus Conference. J Palliate Med 2009; 12(10):885-904. 8
Spirituality: Meaning?

9. 
 meaning: activities, values that are meaningful but don’t define ultimate
purpose/value in life
 Ultimate Meaning: values, beliefs, practices, relationships, experiences,
that lead you to the awareness of the sacred or significant, to sense of
ultimate purpose
halski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of palliative care: The Report of
the Consensus Conference. J Palliate Med 2009; 12(10):885-904. 9
Meaning v/s meaning

10. 
 Interventions, individual or communal, that facilitate the ability to
express the
 integration of the body, mind, and spirit
 to achieve wholeness, health, and a sense of connection to self, others,
and[/or] a higher power.
American Nurses Association, & Health Ministries Association. (2005). Faith and community nursing:
Scope and standards of practice. Silver Spring, MD: American Nurses Association.
10
Spiritual Care

11. 
Cues Spiritual Diagnosis
“My life is meaningless”
“I feel useless”
Existential
Why would God take my
life… its not fair”
Anger at God or others
“I want to have a deeper
relationship with God”
Concerns about relationship with
Higher being
“I am not sure if God is with me
anymore”
Conflicted or challenged belief
systems
Spiritual, Religious And Existential Aspects Of Palliative Care, Journal Of Palliative Medicine 2005 11
Spiritual Cues in the History

12. 
Cues Spiritual Diagnosis
“Mere liye kuchh naheen bacha dunya meen” Despair/ Hopelessness
“Mere apne kaise chhor sakta hoon” Grief/loss
“I do not deserve to die painfree” Guilt/shame
“Meen sab ko maaf karta hoon, mujhe bhi maaf
kiya jae”
Reconciliation
“Meen is halat men ibadat naheen kar sakta dr
sahib”
Religious specific
“What if all that I believe is not
true”
Religious/Spiritual
Struggle
12
Spiritual Cues In History

13. 
 Physical: Progressive Disease, Worsening Symptoms
 Psychological: Stress, Depression, Psychosis
 Social: Good Family support, Wants to see her grand children living in
USA before death, Worried about her husband
 Spiritual: Distress, Angry with God, feels relief with Tasbih, thinking
about Khana Kaaba, Worried about death, wanted to discuss death with
family/Alwaiz
13
Back To Our Patient: Issues

14. 
 Impaired ability to experience and integrate meaning and purpose in
life through connectedness with self/others, art, music, literature,
nature, and or a power greater then oneself/some one significant
Clinical Spiritual Distress
Nanda-2007
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of palliative
care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904. 14

15. 1. What is the reason of fear?
2. What do u think, who would be calling you?
3. Do you think of Death at times?
4. Which feelings surface when you think about your death?
5. Know for sure where you are going when you die?
6. Satisfied with ultimate destination?
7. If you could choose, how would you like to die?
8. Which way of dying is the most unacceptable to you?
9. Which person most difficult to leave behind when you die?
10.Which things most difficult to leave behind?
11.Adequate preparations regarding your own death and burial?
Discussing Death
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of
palliative care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904.
15

16. 
1. Good relationship with God/Some one significant
2. Clear conscience
3. Hope
4. Meaning
5. Purpose
6. Life concluded with no loose ends
7. Prepared for the transition
The Dying Person: 7 Basic Spiritual Needs
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care
as a dimension of palliative care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904. 16

17. 
 Define Goals of Treatment to patient and family
 Family support
 Compassionate presence and follow up
 Reflective listening/query about important life events—spirituality as connection
 Support patient sources of spiritual strength and note in chart
 Explore sources of hope/meaning
 Connect patient to community spiritual resources
 Referral to chaplain/Alwaiz/Pandat or other spiritual care professional/Spiritual
Leader
 Self practiced spiritual rituals
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a
dimension of palliative care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904. 17
Management: Interventions by Physicians

18. 
 Every patient should be screened for spiritual distress
 Clinicians should include a spiritual history as part of the routine
history
 Spiritual issues, distress, resources of strength should be identified and
documented in patient chart and followed up appropriately
 Spiritual Care Provider should be the integral part of healthcare team
and should be the trained in clinical spiritual care
Recommendations
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of
palliative care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904. 18

19. 19

20. 
 82 year old lady, known Hypertensive, Diabetic, diagnosed patient of
Renal Cell CA, S/P nephrectomy, mates in urinary Bladder/bones (S/P
radiotherapy, Chemotherapy, S/P cystoscopy)
 Referred to Home Based Palliative Care Team in late February 2015 for
pain management at home
Patient Problem
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21. 
 Patient is more sleepy
 Not eating/drinking
 Altered mentation
 Changes in breathing patterns/ slow and fast breathing
 Unstable Oxygen saturation
 Talking with someone who is already dead
 Blood Pressure changes (some times high/some times low)
 Calling kids
All for past one day………….!!!
Complains
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22. 
 Family is in panic state
 They want their patient back in baseline status
 Not properly counseled by primary physician
 We were having first encounter with patient and family
Issues
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23. 
 Increased pain
 Changes in blood pressure, respiratory rate, oxygen saturations and heart rate
 Continued loss of appetite and thirst and difficulty taking medications by
mouth
 Decline in bowel and bladder output
 Changes in sleep-wake patterns
 Temperature fluctuations that may leave the skin cool, warm, moist, or pale
 Constant fatigue
 Congested breathing
 Disorientation or seeing and talking to people who aren't there
The Period of Transition
American Cancer society 23

24. 
Breaking Bad News:
The SPIKES Protocol
 SETTING UP the interview
 Assessing patient’s/Family’s PERCEPTION
 Obtaining the patient’s/Family’s INVITATION
 Giving KNOWLEDGE and information
 Addressing the patient’s/Family’s EMOTIONS
 STRATEGY and SUMMARY
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25. 
 25% Psychiatric morbidity is found in Palliative Care physicians
ABC of Palliative Care 25
House Keeping