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Addressing Spiritual Care: Calling for Help

From the First Baptist Church, Rochester, MN, and The Royal Marsden Hospital, London, England.

Address reprint requests to C. John Steer, First Baptist Church, 415 16th St SW, Rochester, MN 55902; e-mail: john{at}firstb.org

Here's the Case

Sally, a young mother of two young children, underwent a routine mammogram, leading to a diagnosis of a resectable breast cancer. A mastectomy, radiation therapy, and adjuvant chemotherapy were provided with the intent to cure. Unfortunately, recurrent breast cancer became apparent 2 years later, and she died after another 2 years of therapy.

Discussion

Oncologists recognize that a diagnosis of cancer challenges a patient and family in many ways: physical, psychological, practical, and spiritual. While most oncologists have an understanding of how to address the first three issues, they may be less likely to know how to ask for help with the fourth. Using the above scenario as background, this article offers advice on when and how to call on the services of a religious minister or a chaplain.

Spirituality, a cardinal feature of human life, relates to an individual's capacity to seek meaning and purpose in life. It allows a person to be able to see beyond the present situation, to have faith, to be able to worship, and to be able to love and forgive other individuals.^1-3 Cancer commonly affects the spiritual dimension of patients with cancer. Religious beliefs and practices, a subset of the spirituality domain, play a significant part in the way that some patients cope with their disease and how they make sense of what is happening to them.

A physician or health care professional who shows interest in spiritual care expresses concern for the "whole person" who has cancer. The simple screening question, "What role does faith play in your life?" could be all that is needed to assess the dimension of faith in a patient, and to point the way for future support.

Physicians should have the same confidence in referring their patients to clergy as they do in referring them to other colleagues. The first step is to understand the distinctions between clergy and chaplaincy.

Clergy Versus Chaplaincy

Local church clergy and hospital chaplains often have similar training, although the former primarily serves a local congregation, whereas the latter serves the wider and more transient community of a hospital. Most clergy have a master's degree from an accredited seminary and are in good standing with their denominations. After graduation, they often go through the procedures of placement in a local church. The majority of hospital chaplains in the United States were previously church pastors or sisters in a religious order. Having decided to pursue chaplaincy, they follow the requirements established by such professional chaplain associations as the Association of Professional Chaplains, for Protestants; the National Catholic Association, for Catholics; or other organizations for other faith traditions. Hospital chaplains generally must have four units of clinical pastoral education, which often involves a 1-year program of intensive training in the hospital setting. They usually are ordained, or licensed, by their denomination or church. After being employed as a chaplain for a year, they can apply to be a board-certified chaplain. Hospitals accredited by the United States Joint Commission on the Accreditation of Healthcare Organizations require their chaplains to be certified. Recently, it has become more common for seminarians to go straight into chaplaincy after graduation without serving time in a church environment. However, some denominations still require a chaplain to serve a period of time in a local church, before they can be endorsed for chaplaincy.

In lieu of such training, hospital chaplains and some clergy have the skills and competence to deal with spiritual issues that arise when cancer, one of the most terrifying words in the English language to the layperson, is diagnosed. Such support can provide a path to understanding and acceptance, and can provide spiritual, emotional, and social support.

Specific Aspects of the Case

We will use the case summarized in the Here's the Case section to illustrate when in the course of cancer care spiritual support might be helpful.

Abnormal mammogram.
When Sally was informed by her physician that her mammogram was abnormal, a follow-up appointment for a second consultation could not be made for 2 days. Those 48 hours seemed like an eternity to Sally and her husband. If Sally belonged to a church or other faith community, the involvement of her pastor may have been comforting at a time like this. Often, such a referral would come from the patient herself, her family, or a member of her church. If a physician or nurse knows of a patient's church affiliation, they can encourage her to call her pastor with a phrase like, "I know your faith is important to you, would it be helpful to call your pastor to let him know what has happened?" A referral for professional chaplain support at this stage could be helpful but might be hampered by a variety of reasons, including: (1) the uncertainty of the diagnosis, (2) the desire to not prematurely scare the patient, (3) the need to obtain other evaluations, (4) the time needed to arrange consultation, and (5) obtaining the patient's permission to make such a referral.

Cancer diagnosis.
Spiritual support may help a patient adjust to a cancer diagnosis by helping to answer the question, "Why me?"⁴

Cancer affects a patient's spiritual dimension in a variety of ways, often adversely. After C.S. Lewis, an articulate atheist turned Christian apologist, had become a devout Christian, he described his experiences following the death of his wife, Joy, from metastatic breast cancer. He wrote, "Meanwhile, where is God?... When you are happy, so happy that you have no sense of needing him...if you remember yourself and turn to him with gratitude and praise, you will be—or so it seems—welcomed with open arms. But go to him when your need is desperate, when other help is in vain, and what do you find? A door slammed in your face and a sound of bolting and double bolting on the inside."⁵

If Sally were like the majority of Americans who say that God is important to them, she may have wanted experienced guidance at this stage of diagnosis. If she were a member of a faith community, involving her own pastor at this stage could be helpful. For some with religious faith, the cancer journey, although frightening, can be spiritually enriching. Values such as hope, faith, and love may develop new meaning. Prayer can be much appreciated, even by nonreligious people. Religious books, like the Bible or Quran, may take on relevance not previously experienced. The simplicity of religious rites, such as sacraments, anointing, and prayer, can be powerful interventions. One way to introduce such a referral is by saying, "Many of my patients find the support of their clergy or rabbi to be helpful; I suggest you call him or her."

Cancer treatment.
Cancer treatment may be experienced, in part, in the spiritual dimension. Values such as fighting, endurance, or penance, may be elicited.

Cancer can threaten the patient's and their family's sense of identity. Sally's operation and subsequent chemotherapy changed her body and her understanding of herself as a woman. Treatment can lead to changes in social roles, family function, physical strength, and body appearance that, in turn, challenge a person's self-image and sense of worth. This was illustrated by Dole⁶ who wrote, "The family doctor had asked me to see [a woman] because she was isolating herself from her husband and becoming a recluse. I observed a photograph on the piano of a voluptuously beautiful bathing belle, and remarked what a lovely daughter she had. It was, she pointed out tearfully, actually a photograph of her taken a year before! ‘I am not me anymore,’ she said, ‘and I can't make sense of it all.’"

Change of body image and questioning of identity is also addressed by Aldredge-Clanton⁷ who wrote of a 40-year-old woman in the midst of aggressive treatment for leukemia lamenting, "When I look in the mirror, I don't see myself anymore," and of a man who cried out, "My cancer took my manhood away." Aldredge-Clanton goes on to say, "Accepting an altered body image may be extremely difficult. Feeling less attractive may cause people to feel less lovable and thus to face social and sexual rejection. They may suffer distress from knowing that they no longer look the way they want to look. Treatments for prostate, gynecological, breast, and colon-rectal cancers especially threaten a person's physical and sexual image."

These problems may be addressed, in part, from a spiritual dimension. As such, the oncologist can stimulate spiritual support in a variety of ways. The physician can check in with the patient by asking, "How is the treatment affecting her in herself?" or "What sense does she make of the experience?" Additional support can take many forms. Some churches have parish nurses. They are often RNs, and are usually female. They can be invaluable in listening to a patient talk about their concerns and the purpose and meaning of life. If the patient is hospitalized, many religious groups have members who will to go to the hospital. Such visitation may be co-ordinated and assessed by the hospital chaplain. Members of the religious group may provide childcare and meals for the family while the patient is recuperating.

Treatment completed.
Spiritual support may help patients express joy and thanksgiving, as well as deal with the anxiety that frequently accompanies successful completion of cancer therapy. A telephone call from a chaplain or minister every 2 weeks during this time can pick up on any stress or anxieties that the patient may have.

Cancer recurrence.
For many patients, cancer recurrence can be a more demanding time than when the cancer is first diagnosed. At the initial diagnosis there are a number of clinical options that bring hope of a cure, but when the disease reappears, the options for treatment are fewer, and the treatments are often more demanding. Some patients may have internalized a bargain with God or some other sense of supernatural deliverance that now is challenged.

Support of hope is an important clinical goal—not "false hope" based on untruth, but realistic hope for achievable goals.⁸ Spiritual support may help the patient find hope. Finding hope in the midst of tragedy is a clinical skill. While most chaplains have received some training in this, it is not often a part of the routine training of most clergy. While community clergy may be highly skilled, they may be as overcome as the patient and family. Professional chaplains may be useful in that they are trained to be present during spiritual suffering. Mother Theresa once said that the worst disease in the world was not leprosy or tuberculosis but the fear of being unwanted, unloved, or abandoned. By simply being there, the chaplain can help relieve spiritual pain that otherwise is, by definition, refractory to analgesics, sedatives, or antidepressants. "Suffering is not a question which demands an answer, it is not a problem which demands a solution, it is a mystery which demands a presence."⁹

Professional chaplaincy can be introduced with a phrase like, "I can see how distressed you are and I'd like to ask the chaplain who works with me to see you. She has experience and training beyond what I can offer. Many of my patients have found her to be helpful."

Terminal illness.
When it becomes clear that death is inevitable, spiritual needs may increase. Patients like Sally frequently need increased help and support. Support may be needed with practical things like planning for the patient's death (funeral arrangements, care of survivors) as well as more transcendental questions ("How will I be remembered?"; "What was my life worth?"; "Is there life after death?") Questions like, "What are you afraid of?" or "What do you expect to happen to you once you die?" can open up whole areas of conversation that can bring comfort and hope. Because spiritual support is a routine and expected component of comprehensive care during the last months of life, hospice care requires the participation of trained chaplains. Issues that need to be addressed include the future care of the patient's children (and their memories of the patient) and the importance of listening and recording the stories of the patient's life.¹⁰ Key issues to communicate between the patient and her loved ones, such as, "I love you," "Forgive me," "I forgive you," "Thank you," and "Good-bye" need to be sensitively explored.¹¹

Summary

The comprehensive care of a patient with cancer requires attention to the spiritual dimension of illness. A large majority of patients report that faith provides emotional support, social support, and a root to meaning, all of which help them cope with the diagnosis and treatment of cancer.¹² The oncology team will want to ask the question, "What support does this patient have as they face this disease?" Asking this question of the patient makes them aware that their physician is interested in their whole being rather than just the site-specific tumor. Oncologists should remember that "The most precious possession any human being has is their spirit, their will to love, their sense of dignity and personality. Though technically we may be concerned with tendons, bones and nerve endings, we must not lose sight of the person we are treating."¹³

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

NOTES

Authors' disclosures of potential conflicts of interest are found at the end of this article.

REFERENCES

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7. Aldredge-Clanton J: Counseling People With Cancer. Louisville, KY, Westminster John Knox's Press, 1998, p 96

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13. Yancy P: Soul Survivor. London, England, Hodder and Stoughton, 2001, p 75

Submitted June 29, 2004; accepted September 20, 2004.

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