Why doctors need to consider spiritual health

Near the end of her talk to medical students and staff at the University of Pennsylvania's medical school last week, Christina Puchalski showed a picture of her 93-year-old father awaiting hernia surgery a year ago.

A stream of medical students and residents, all intent on getting him efficiently to the operating room, had asked him a lot of questions very quickly.

Suddenly, he turned to her and said, "Chrissy, take me home."

Puchalski, a palliative-care physician and expert on infusing science-based medicine with spirituality, gave her father's surgeon, Juliet Lee, a helpless look.

Lee shooed everyone else away, pulled the curtains around the bed, and sat beside the patient, holding his hand silently, as though she had no place to go. She listened to him and then invited the former opera singer to sing. He chose "O sole mio."

That was what he needed. "I'm ready," he said. Today, Puchalski reports, he is doing well.

Puchalski, who directs George Washington University's Institute for Spirituality and Health, was in Philadelphia last week to talk about how doctors who are attuned to spiritual health - what gives life meaning - can engage in a "healing relationship."

She emphasized how important it was for doctors to develop the skill her father's surgeon demonstrated, the ability to sit quietly and listen.

Though doctors clearly must focus on providing good clinical care, Puchalski said knowing what mattered to patients spiritually was essential for making the best medical decisions. She used the example of an 88-year-old woman with aggressive breast cancer. Initially, she chose surgery and chemotherapy, but after a discussion about how much her independence mattered to her, she picked treatment that would better preserve her quality of life.

Puchalski's definition of spirituality goes well beyond religion. It includes whatever it is in people that makes them seek meaning, purpose, and transcendence. That might include aspects of relationships with family, society, or nature that feel significant and sacred.

Palliative-care doctors are now required to take a spiritual history when they meet new patients. "It's really an invitation to a patient's inner story," she said.

Doctors and other members of Puchalski's care team ask patients about spiritual beliefs and practices and how they would like to have their spiritual needs addressed.

Spiritual distress is common among patients with life-threatening illnesses like cancer, Puchalski said.

"Spiritual distress," she said, "should be treated the same as any other medical problem."

Some anguish is based in religion, she said. Patients say, "God has abandoned me" or, "Why would God take my child? That's not fair." Other types of emotional pain, such as despair or grief, have spiritual dimensions without necessarily being overtly religious.

Doctors may recommend patients join support groups or try meditation or therapies aimed at forgiveness or gratitude. But Puchalski emphasized that the most important thing they could do would be to listen.

She talked about working with a woman who was dying of lung disease. The woman and her husband were fighting when an already stressed Puchalski came to visit them one day. She left the room to take a deep breath and compose herself, then walked back in. "What's really going on here?" she asked.

"I'm really afraid she's going to die choking to death," the husband said, "and she's afraid of that, too."

Like other medical schools, Penn has taken numerous steps to help doctors in training learn the softer skills of medicine, said Horace DeLisser, associate dean for diversity and inclusion who also directs a course on doctoring relationships. The school offers a session on "Faith, Death, and Meaning" and teaches students about the health beliefs of Jehovah's Witnesses. Students can shadow a chaplain. They are required to follow a patient for a year and a half and must talk about spirituality with the patient.

Puchalski's lecture was part of an annual series on religion and medicine named for Thorne Sparkman Jr., a retired Penn physician and medical school instructor known for his emphasis on humanism and communication skills.

Doctors, who are taught to be goal-oriented and efficient, can find it very hard to just listen to people who are suffering deeply. They have to learn to be comfortable with unknowns - both for the sake of their patients and for their own well-being.

Puchalski thinks doctors who lose sight of what drew them to medicine - often this is the desire to help people - are at higher risk for emotional problems and suicide themselves.

"Resist the urge to fix," Puchalski told her audience. "Resist the urge to lead.

"You want to just listen to where the patient is, which means we need to unlearn some skills for this conversation," she said.

"Deep listening helps that patient heal with us."

sburling@phillynews.com

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@StaceyABurling