The Role of Spiritual Care in Comprehensive Integrative Pain Management (CIPM)

This online and downloadable resource was developed as part of the ongoing work of the Alliance to Advance Comprehensive Integrative Pain Management. This was a collaborative effort among the Spiritual Care subgroup members that initially met in 2018-19 after the second Pain Policy Congress. These members came back together recently to update and complete this piece so that it can be shared more widely.

Authors: Christina Puchalski, MD, Bonnie Sakallaris, PhD, RN, Matthew J.Taylor, PT, PhD, C-IAYT, Juliana Lesher, M.Div., Ph.D., BCC, Mindy Wallace, DNP, MSN, CRNA, DAIPM, Amy Goldstein, MSW, Col. Kevin Galloway, BSN, MHA (RET)

All patients in an integrative pain practice should have their spiritual care needs assessed and receive spiritual care as needed and desired. Evidence in multiple studies demonstrate that patients want this care and that addressing spiritual needs improves physical, functional, and emotional outcomes.^1-5 Many national and international guidelines have  been developed for addressing spiritual care as part of whole person care. ^6-12  The clinical models described in these guidelines are based on addressing spirituality as part of wellness but also identify spiritual distress as part of symptom management.¹² In these guidelines spirituality is defined broadly as a “dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices.”⁶ Religion is one type of expression of spirituality and it relates to the participation in beliefs and practices of a community of faith, and usually focused on a relationship with God or a higher power. ¹³ Spirituality has been demonstrated to impact health outcomes including pain, pain interference, pain catastrophizing, quality of life, and has been associated with decreased mortality and morbidity.^14-16  Studies also demonstrate association of spiritual distress with worse quality of life, physical pain, depression and anxiety.

The experience of pain involves multiple signals influenced by the biochemical pain pathways, cognition, emotions, environments, and behaviors.  Each of these pathways can reduce or increase the experience of pain.¹⁵  The experience of chronic pain is multi-dimensional, including physiological and existential suffering, such as questioning why I have to go through this  painful existence.¹⁷ It is not surprising then that studies have shown that prayer was either the primary or second most frequently used coping mechanism to deal with pain.¹⁵  The need for intervention in the spiritual or existential dimension of pain appears to be common across nationality, belief systems, and cultures.^17-22 There is significant evidence documenting spiritual pain and its relationship to other forms of pain as well as the influence of spiritual distress and spiritual coping on the pain experience.^23-25 Spiritual pain can be defined as pain deep in the soul. It is one dimension of what is now understood as the multi-dimensionality of pain. The National Comprehensive Cancer Network (NCCN) and National Consensus Project for Quality Palliative Care (NCP) have developed spiritual distress diagnosis (Table 1).^8,26

Recommendations are for attending to all dimensions of patient’s distress and wellness including spiritual distress and wellness.^2,27 Therefore comprehensive care requires the evaluation, assessment, and inclusion of spiritual care in the plan of care. The consensus-based guidelines have agreed that all healthcare practitioners should be involved in spiritual care.^28,29

The practice of spiritual care is based on a generalist-specialist model of care called the Interprofessional Spiritual Care Model.³⁰ ‘Spiritual care involves the assessment and treatment of spiritual distress, support for spiritual resources of strength and in-depth spiritual counselling when appropriate’.³¹  Clinicians address spiritual concerns, do spiritual screening or histories to assess for spiritual distress and work with spiritual care specialists such as chaplains, pastoral counselors, or spiritual directors in treating and attending to  spiritual distress.  Health care chaplains have the skill and expertise to assess and address the spiritual and existential issues frequently faced by pediatric and adult patients with acute or chronic pain or receiving palliative care. Chaplains play a strong role as professional members of the health care team.  Spiritual care is best provided in an interdisciplinary, team-based care environment with strong ties to the communities they serve.^29,32  In the community setting the spiritual care expert may be clergy, pastoral counselors or spiritual directors.

Spiritual care builds on the relationship between clinician and patient and is facilitated by the practice of compassionate presence.²⁹ Spiritual care or “treatment” is individual, dependent on the patient’s beliefs, culture, and values.²⁹ Spiritual care may include such practices as reflective listening, guiding first person ethical inquiry, and being present to patients.  Treatment options might include referral to spiritual care professionals, art therapists, meaning-oriented therapy, meditation.  If the patient identifies specific spiritual or religious practices that are important to them, then encouraging those practices might be appropriate, such as reconnecting with nature, prayer, meditation, community support, rituals. Part of positive coping strategies might include spiritual coping strategies such as meditation or re-establishing priorities.^15,28,29,33

The outcomes of spiritual care are the individual’s ability to understand their suffering at a deeper level, while making some sense of the pain experience, and to give the experience a meaningful place within the overall context, direction, or purpose of their life. Accompanying a patient in the midst of their suffering may help that patient cope better with their overall condition.  Eric Cassell has noted “Transcendence is probably the most powerful way in which one is restored to wholeness after an injury to personhood. When experienced, transcendence locates the person in a far larger landscape.”³⁴

Offering spiritual care supports outcomes that can include peacefulness, a sense of coherence, and less depression and anxiety, as well as improved pain management. The acknowledgment and inclusion of spiritual care in the CIPM definition represents a significant milestone in understanding the complexity of pain care while also satisfying the preferences of those living with pain.

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