Palliative care is a discipline that is devoted to the holistic care of the patient with a progressive, life-threatening illness. As palliative care seeks to provide the best possible quality of life in the face of death, it is essential to provide comprehensive care not only in the physical, emotional, and psychological sense, but also to attend to the spiritual needs of the patient (Cohen et al., Reference Cohen, Woodward and Ferrier1996; Davies et al., Reference Davies, Brenner and Orloff2002; Seccareccia & Brown, Reference Seccareccia and Brown2009; Sinclair et al., Reference Sinclair, Mysak and Hagen2009). Therefore, it is important that the palliative care physician be cognizant of the important role of spirituality for these patients and hence, address spirituality when interacting with patients and their families (Marr et al., Reference Marr, Billings and Weissman2007; Puchalski et al., Reference Puchalski, Ferrell and Virani2009; Seccareccia & Brown, Reference Seccareccia and Brown2009; Sinclair et al., Reference Sinclair, Mysak and Hagen2009; Surbone & Baider, Reference Surbone and Baider2010).
Although many studies have acknowledged the importance of establishing a relationship between spirituality and palliative care, there is an absence in the literature that specifically addresses the perspective of palliative care physicians and how the palliative care setting has impacted the clinician's own spirituality and spiritual growth (Boston & Mount, Reference Boston and Mount2006; Sinclair et al., Reference Sinclair, Raffin and Pereira2006). “Spirituality” is one of those terms commonly used and acknowledged but it is used without a universal understanding of its definition (Bash, Reference Bash2004; Chochinov & Cann, Reference Chochinov and Cann2005; Martsoff & Mickley, Reference Martsolf and Mickley1998; McSherry & Cash, Reference McSherry and Cash2004; Sulmasy, Reference Sulmasy2001). Sinclair et al. (Reference Sinclair, Raffin and Pereira2006) looked at the development of spirituality within a palliative team setting and discovered that palliative care served as a potent catalyst for reflection about spirituality. Many other studies have established the important role of spirituality in palliative care — often being described as a dynamic relationship, interchangeably influencing each other (Millison, Reference Millison1988; Seccareccia & Brown, Reference Seccareccia and Brown2009). Individuals involved in providing palliative care are granted a true sense of the spiritual impact of caring for the terminally ill as well as a sense of wisdom and awe in bearing witness to patients' journeys (Seccareccia & Brown, Reference Seccareccia and Brown2009).
The primary objective of this study is to explore and describe how the practice of palliative care by physicians has influenced their own spirituality and personal spiritual growth. Within the concept of spirituality, this study also seeks to further explore and describe how palliative care physicians define spirituality; how spirituality influences the care they provide to their patients; and how spirituality influences self-care practices. This information is particularly relevant by identifying strategies to better optimize the delivery of multi-dimensional care to patients at a critically sensitive period—that of the end of life.
METHOD
Study Design
This study employed a qualitative descriptive approach to explore the experiences and perspectives of palliative care physicians in order to create a description of how providing palliative care has influenced their own spirituality (Sandelowski, Reference Sandelowski2000). The individual experiences of the palliative care physicians were explored and summarized to create a lived experience of their spiritual journey and growth through their interactions with their patients and the patients' families. An interpretative, low inference approach was used to lessen the potential for any of the investigators' preconceived ideas to influence the data, which could occur if a conceptual framework were employed.
Participants
A purposeful sample of palliative care physicians who practiced in the central west region of Ontario, Canada were identified as the study population. Inclusion criteria included physicians who had been providing palliative care for at least one year, and who were able to communicate proficiently in English and provide informed consent. Other members of the interdisciplinary teams, including palliative care fellows and residents, were excluded in order to increase homogeneity of the sample. Ethics approval for this study was obtained from the McMaster University Research Ethics Board, Hamilton, Ontario, Canada.
Data Collection
Palliative care physicians who expressed an interest in participating in the study were identified according to their responses to the letter of invitation to participate in the study. The identified physicians were then contacted by an investigator (AP) who scheduled and conducted a semi-structured, in-depth interview. The interview explored what spirituality meant to the participant, how their practice of palliative medicine influenced their spirituality, and how their spirituality influenced their professional practice. The interview also examined how participants' spirituality influenced their self-care practices. Interviews lasted ~ 45–60 minutes and were held at a time and location based on the availability and preference of the participant. Each interview was digitally recorded.
Data Analysis
The audiotapes of each interview were transcribed verbatim with all identifying information removed from the recordings in order to preserve participant confidentiality. Each interview transcript was then independently reviewed and coded by the two investigators. Analysis occurred concurrently with data collection. Therefore, the data collection and data analysis had a synergistic relationship with one another (Miller & Crabtree, Reference Miller and Crabtree1992). The thematic content analysis was an inductive process in which themes were generated from the data as they arose (Sandelowski, Reference Sandelowski2000). A summary table was constructed for each participant summarizing the themes identified by the investigators. This summary table was returned to the study participants for review and feedback. Any changes or additions made by the participants were included in the final coded summaries. The final summary tables were reviewed to identify overarching patterns and themes that emerged from the data.
The two investigators (AP and KB) independently read each transcript and were able to collaborate and reach a consensus regarding the coding of the data. Additionally, an independent reviewer was consulted to resolve any further differences in the coding.
To support the interpretations drawn from the interviews, short examples of typical statements from the study participants are included in the text serving as referential adequacy. The quotes are presented in italics and their sources identified with a number corresponding to each of the participants (PC 1 – PC 6). Some of the quotes have been edited minimally to ensure readability while maintaining and preserving authenticity.
RESULTS
Letters of invitation were sent to all physicians practicing palliative care within the central west region of the province of Ontario (N = 14). Six of the fourteen potential participants volunteered to participate in the study. Of the six participants in the study, the majority were female (n = 5), practicing in palliative care an average of 16 years (range 13–20 years).
Four major concepts regarding spirituality in palliative care were established: concept of spirituality, influence of practicing palliative medicine on personal spirituality, influence of spirituality on the practice of palliative medicine, and influence of spirituality on self-care.
The Concept of Spirituality
When asked to define spirituality, several different perspectives were introduced and discussed by the participants. In particular, a number of the participants talked about the relationship of spirituality with religion as being divided into two separate entities: “Spirituality is like the hand, religiosity like the glove so they take similar shape… but they are not the same. And religiosity is… a more structured way to deal with the issues at hand that spirituality deals with.” (PC 5) Similarly, another participant commented: “I kind of automatically divide it into two parts. The part that has to do with organized religion and then the part…that doesn't have a place, necessarily, in organized religion.” (PC 1)
For some participants, the notion of spirituality was conceptualized as a relationship between authenticity and sense of self: “[Spirituality] helps you to connect to your authentic self.” (PC 5) Furthermore, another participant remarked: “I think spirituality is the part of the person that calls them to be who they are.” (PC 2)
Influence of Practicing Palliative Medicine on Personal Spirituality
All participants felt that practicing palliative medicine had influenced their spirituality, albeit in different ways individually. One theme common among participants was that palliative medicine provided a level of emotional nourishment within a unique, spiritual context that is unlike any other specialty or profession: “Palliative care prompts me to think about spiritual things and a large part comes from what I've seen, what I've been part of in my work and what I bear witness to.” (PC 3) In addition, by engaging with patients dealing with end-of-life issues, physicians report an increased cognizance of the presence and role of spirituality in providing compassionate care for these patients: “I think I am more aware of [my spirituality] in palliative care just because you are confronted with mortality all the time… you think about these courageous battles… the dignity they show and everything. And you think about your own situations and how you would be.” (PC 4) Many participants felt that practicing palliative medicine influenced the development and growth of their own personal spirituality: “I am much less stuck in rigid definitions of spirituality… bearing witness has made me much less certain… I dwell a lot more in the grey and I think I'm much better able to receive what people tell me when I am going in with greater uncertainty…I just don't think there are absolutes.” (PC 3)
Many participants mentioned how they felt that a strong sense of spirituality stimulated a reflection on how their individual self is able to relate to other individuals and their surroundings: “if I look at my own spirituality… how am I connected to others, this world, the other world, you know… it's a concept of connectedness. And I think ultimately spirituality revolves around that which helps me feel connected.” (PC 5) The importance of self-reflection particularly in a context of having a life-threatening illness was relevant for many physicians: “When I was in my [former specialty], short of a particular patient who had an end-of-life issue…I would not likely think about these bigger…issues. As opposed to in palliative care where virtually every day…those types of [life and death] questions cross your mind…it does facilitate self-reflection.” (PC 5)
Some participants also expressed that they felt that practicing palliative medicine itself was spiritually fulfilling: “In terms of spirituality, I feel that it is actually fulfilled at work, I don't feel drained.” (PC 1) As opposed to feeling burdened emotionally, participants instead expressed a weight being lifted off their shoulders: “I think that our work actually makes us lighter, not heavier.” (PC 2) Similarly, participants felt that their clinical experiences enabled them to gain insight into their own spiritual growth and perceived notions of individual spirituality: “[In palliative care] I felt that I could really view the whole person, including their spirituality and attend to them properly. And at that time I could honour my own spirituality.” (PC 4)
A shared insight among many of the participants was the belief that providing palliative care to their patients provided a changed perspective of their own everyday life and life events: “Palliative care… reorients your life, it makes you so aware of some of the important issues in life, the things you wouldn't guess are important.” (PC 2) Similarly, another participant commented: “It very much influences my philosophy of life in terms of what I think is important and valuable in my outside life based on what I witness in my day-to-day work… we've seen rich people die and we've seen poor people die and I don't see the rich people dying any happier than the poor people…What matters to people who are dying [are] the relationships they've had, the relationships they are in.” (PC 1)
Participants also acknowledged the growth in personal development that has arisen from their clinical experiences in a palliative setting: “I am growing and thinking and changing because of what I have seen in my work life … I have often thought, ‘well, what would I think and feel if I weren't in this field, would I have changed anyway?” (PC 3) Another participant commented: “I think that the type of person we become, we become in response to our patients.” (PC 2)
Influence of Spirituality on the Practice of Palliative Medicine
When asked if participants felt that their spirituality influenced how they provided palliative care to their patients, all participants agreed that their spirituality impacted how they practiced palliative medicine. Participants discussed how they often had rituals or acts that they commonly performed to help prepare themselves to focus their own attention and spiritual energy on the patient: “[Before I] walk in, [I] take some cleansing breaths and center [myself] and create this inner stillness.” (PC 5) This is particularly useful for certain participants in dealing with difficult situations in their clinical practice: “Upon entering…some sort of situation where you feel you need support, guidance, where you may not want to be alone… I imagine there being this higher power above and then connecting to that power…that source is guided by compassion, wisdom, by that which is right, that which is helpful, that which is loved.” (PC 5) Other participants reported that certain practices were routinely performed for the purpose of asking for guidance to deal with certain clinical situations: “when I am washing my hands in front of people, I try and make that a holy act and try and center myself… kind of like a little prayer to give me wisdom and ask for wisdom and guidance.” (PC 4) Prayer was a common practice for many of the participants: “I actually pray before I go into many rooms… ‘Dear God, please help me do something that is helpful for them.’” (PC 2)
Other participants commented on how spiritual readings helped them to find words they wanted to convey to patients and their families: “I have this box of prayer cards… assembled by a [religious] scholar… prayers, meditations, chants, sayings and poems… I was thinking I might try to memorize more of them…sometimes when you feel you need those words you may not be in a situation where you can easily [find them].” (PC 5)
Another theme mentioned among participants was that they felt their spirituality allowed them to be more open or receptive both to their patients and the opportunities that practicing palliative medicine provides: “I am not uncomfortable talking about the broadly spiritual or specifically religious… I freely invite that dialogue.” (PC 3) Being cognizant of the important role of spirituality in palliative care has enabled some physicians to incorporate it into their clinical practice: “I always know about their spirituality… that's always part of my history… what their beliefs are… I think that's really important.” (PC 4)
Influence of Spirituality on Self-Care Practices
This study revealed that nearly all participants took part in a number of different self-care activities that addressed caring for both their physical and spiritual or emotional selves. For many, their self-care activities were influenced by their spirituality and their practice of palliative medicine: “I run because I can, which very few people understand…it is one of those little ways that I honour what you and I bear witness to… All those people can't run, but I can run, and I do…I am completely and utterly blessed to be able to run right now, so I'm sticking to it.” (PC 3)
Other participants mentioned that they kept a journal as part of their personal self-care activities: “I write in the morning… I find if I do, that my day goes so much better…it's like a meditation, you know, all those little things come into your mind…Often I will find that somewhere under the layers there's something I've been thinking about or wondering about…it just makes my mind more of a clean slate to start the day.” (PC 2) Furthermore, journaling was also seen as an important vehicle for spiritual reflection within the palliative care team: “[As a team] we decided we would try [to] keep a record…of special moments…where you had these phenomenal mind-blowing conversations with the patients and [their] families.” (PC 5)
Participants also recognized the importance in obtaining emotional, social and spiritual support from a community of individuals with shared experiences: “I think if there is a message in this [it] is to conscientiously build yourself a network … be aware that wherever you practice it's important to have that network for a variety of reasons and I found it has been very helpful.” (PC 6) Additionally, another participant remarked: “It seems important for me to be in a community of people who do want to think around things that are spiritual.” (PC 3)
Books on spirituality appeared to be an important source of spiritual and emotional support for many participants: “Reading around purpose and meaning and suffering … the spirit and the connection with the whole … all [consume] a huge amount of my reading time by choice.” (PC 3) Similarly, another participant commented: “I have a million spiritual books … I have several books that are daily reflections and I use them different years…I read every morning.” (PC 4)
Some participants mentioned that they felt that their practice of palliative medicine facilitated or even led to a return to religious practice: “I have become re-engaged to some degree in religious ritual practices … I actually grew up in [this] tradition … it has really just been literally as we engaged in some of these [spiritual journeys as a team] that I've … become more interested in some of those rituals, the actual religious things.” (PC 5) The interactions that physicians had with their patients appeared to be influential in the development of their stronger relationship with religion: “[A] patient gave me a [spiritual] book…it helped me get back into church … .into organized religion again.” (PC 4)
DISCUSSION
The interviews with palliative care physicians provided a unique, in-depth examination of the spiritual journey that palliative care physicians embark upon during their clinical exposure to patients with life-threatening illnesses. As reported widely in the literature, spirituality was described by participants as a concept of questioning a sense of purpose and meaning of life, striving to experience personal growth and development, understanding one's existence in relation to others, extracting meaning from life experiences, and having a sense of connectedness to others (Koenig et al., Reference Koenig, Larson and Larson2001; Seccareccia & Brown, Reference Seccareccia and Brown2009). Similar to other studies, participants described religion as a separate entity from spirituality which was viewed as a construct more accessible and less structured (Martsolf & Mickley, Reference Martsolf and Mickley1998; Sulmasy, Reference Sulmasy2001).
Similar to the findings reported by Seccareccia & Brown (Reference Seccareccia and Brown2009), palliative care physicians reported not only a need for addressing spirituality for the delivery of multi-dimensional, compassionate palliative care, but also a true desire to reflect upon how their clinical experiences, in turn, positively shaped the growth and development of their own personal spirituality. The participants in this study appeared to have an appreciation for the self-reflection and changing perspectives on life and relationships that resulted from the spiritual growth they had encountered in caring for their patients. Furthermore, participants reported a greater sense of spiritual fulfillment from providing palliative care with a conscious awareness and need not only for addressing the spiritual needs of their patients but their own beliefs as well. This appears to reflect the consensus in the literature that being cognizant of one's spirituality results in healthcare providers being less vulnerable to physical, emotional, and cognitive fatigue in the workplace (Holland & Niemeyer, 2005).
With the widespread documentation of the importance of spirituality as one of the key elements in palliative care, it appears as though there is a need for greater opportunities to allow healthcare providers to engage in the dialogue of spirituality. In fact, several studies have described the need for and development of programs designed to enhance the palliative care health provider's recognition of the spiritual care needs of patients and families (Hickey et al., Reference Hickey, Doyle and Quinn2008; Kelly et al., 2006; Marr et al., Reference Marr, Billings and Weissman2007; Pulchalski et al., Reference Puchalski2008; Surbone & Baider, Reference Surbone and Baider2010; Todres et al., Reference Todres, Catlin and Thiel2005). Although this need has been identified, implementing it into medical school and residency training programs in a way that ensures a high level of spiritual competency upon completion remains challenging (Hickey et al., Reference Hickey, Doyle and Quinn2008; Larson & Pulchalski, 1998; Marr et al., Reference Marr, Billings and Weissman2007). Further research would be ideal in this setting to ascertain how best to educate and support healthcare professionals regarding spirituality.
As for the impact of such spiritual training, Wasner et al. (Reference Wasner, Longaker and Fegg2005) explored the impact of a formalized half-day training seminar for palliative care professionals, which resulted in significant improvements in self-perceived compassion, reduction of work-related stress, and greater job satisfaction. However, although this effect was not maintained at 6 months, it does suggest a beneficial role for increasing opportunities for healthcare professionals to engage in spiritual care training (Wasner et al., Reference Wasner, Longaker and Fegg2005). This can also shed light on the ability of spirituality to promote positive self-care practices in physicians, such as those documented in this study, which include physical exercise, journaling, establishment of a community support system, and the opportunity for positive self-reflection.
It is important to note that the sample size of this study was not balanced in terms of gender, years of practice, or ethnicity, and therefore is not meant to serve as a generalized representation of the opinions of palliative care physicians as a whole. A study sample of larger size would facilitate the opportunity to establish any comparisons between various participant characteristics and the spiritual growth experienced by palliative care physicians.
