When Christina Puchalski, M.D. ’94, FACP, FAAHPM, was a medical student serving in a hospital ward, she went to visit a terminally ill patient. “I couldn’t find her; she was not in her usual room, which was right next to the nurses’ station,” Puchalski, professor of medicine at the GW School of Medicine and Health Sciences (SMHS), recalled. “Somebody said, ‘Oh, we moved her down the hall because there’s really nothing more we can do as she is dying.” Puchalski found her patient lying quietly in a four-bed room; the other three beds were empty. She sat with her patient in silence, held her hand, listened deeply to her patients fears, beliefs, and hopes.
That story exemplifies what the GW Institute of Spirituality and Health (GWish) aims to prevent. “Henri Nowen describes deep listening as a form of spiritual hospitality by which we “invite strangers to be friends, to get to know their inner selves more fully, and even to dare to be silent with them” —to be fully present to their suffering,’” said Puchalski, founder and director of GWish. “Spirituality can help transform suffering into hope, aloneness into being loved, emptiness into wholeness. It is with all of our relationships with our patients that there can be opportunities for this healing, even when death is near. This is the mission of GWish.”
Puchalski added that GWish programs address the clinicians as well as the patients. “Clinicians need to be aware of their own spirituality to be able to be fully present to patients and to continue to find meaning in their own professional lives,” she explained. To accomplish this the institute offers courses and programs for medical students and clinicians to raise awareness of spirituality as essential in the provision of compassionate person-centered care.
GWish, the first university-chartered institute of its kind, “works toward a more compassionate system of health care by restoring the heart and humanity of medicine through research, education, and policy work focused on bringing increased attention to the spiritual needs of patients, families, and health care professionals,” explained Puchalski.
Since its establishment in 2001, the organization has become a global leader in promoting compassionate approaches to patient care. Puchalski, for example, developed a spiritual history tool — FICA, or Faith/Beliefs, Importance, Community, Addressed in Care or Action — to be used in clinical settings and medical schools, including SMHS. Since 1992, Puchalski has also championed the development of spiritual care curricula for use in medical schools, when she created the first course in the subject. More than 75 percent of schools now teach students how to address spirituality with their patients, particularly with those who have a serious illness and suffer from existential, religious, or spiritual distress.
As Jeffrey S. Akman, M.D. ’81, RESD ’85, vice president for health affairs, Walter A. Bloedorn Professor of Administrative Medicine, and dean of SMHS, explained, “In perfect alignment to the school’s mission, GWish works toward a more compassionate health system by restoring the heart and humanity of medicine through research, education, and policy work.”
This year, GWish marked a milestone: its 15th anniversary. To commemorate the occasion, as well as punctuate the annual three-day Spirituality and Health Summer Institute, GWish welcomed members of the community, including political and academic luminaries, to a special dinner. The dinner also included the presentation of the inaugural GWish Excellence in Interprofessional Spiritual Care Award.
“I think 15 years is amazing,” said Kathryn M. Braeman, chair of the GWish Advisory Board, as she welcomed guests to the event. “[Dr. Puchalski] has been a pioneer in creating awareness of the importance of spirituality in health. While others looked at individual body parts, many of them important — the kidneys, the brain — she looked to the whole person. She is a visionary on a national and global scale.”
Thanks to Puchalski’s and GWish’s efforts, spirituality is now recognized as a vital contributor to health and an essential element of whole-person care — a prominent theme throughout the evening. In addition to Braeman’s introduction, GWish friends and supporters, such as Jim Blatt, M.D., associate professor of medicine and medical director of the Clinical Skills Center at SMHS, lifted their glasses for a series of toasts. One toaster, Rev. Susan Donham, chaplain fellow in palliative care at Johns Hopkins Hospital, noted that Puchalski and GWish’s “insistence on clarity, on completeness and consensus on the meaning and integration of spirituality as a linchpin in health care is what makes our every encounter with each patient human.”
Grateful patients Rev. Albert Swingle, D.Min., and his wife, Nancy, confirmed that sense of humanity in delivering their toast to Puchalski. “We were amazed when we learned that you were concerned about our spiritual wellbeing as well as our physical wellbeing,” Nancy said. “We are truly blessed to have had you as our primary care doctor.”
Puchalski then addressed the attendees, thanking them for their support, before turning the podium over to U.S. Representative Fred Upton from Michigan’s 6th District.
Upton explained that GWish’s mission is close to his own life. “I’m here in large part because of my wife, Amey, who was a chaplain at Wesley Theological Seminary [in Washington, D.C.] and at Alexandria Hospital for a number of years, and I heard so many of these compassionate stories,” said Upton, who went on to discuss his efforts with the government to prioritize health research.
Keynote speaker Robert Boisture, president and CEO of the Fetzer Institute, likewise praised GWish’s mission and its overall impact on health care and humanity.
“We’re here to celebrate a wonderful cause,” said Boisture. Those in attendance, he explained, though they may come from a variety of backgrounds, cultures, religions, and countries, share a passion. “The common denominator, I think,” he said, “is compassion, is opening our hearts to the pain and suffering of the world with hope and a commitment to try to do something about it.”
What’s crucial, he added, is understanding the necessity of spirituality when dealing with patients who deserve to be treated with dignity. “At the end of the day, the most important thing is to honor [each person’s] sacred dignity as a human being and to be present with them and their family members as they live, and hopefully flourish, with long and healthy lives, but also as they come to terms with the mortality each of us faces.” He emphasized the transformative role of spirituality in health and society, particularly in helping people find healing, hope, and compassion, as well.
With that kind of compassion in mind, GWish presented its first Excellence in Interprofessional Spiritual Care Award to Betty Ferrell, Ph.D., M.A., FAAN, FPCN, CHPN, director and professor in the Division of Nursing Research and Education, Department of Population Sciences, City of Hope Hospital.
“I don’t at all take this lightly, this recognition, because I know I’m in a room of many kindred spirits and people who are dedicated to ideas about love and spirituality,” Ferrell said, thanking Puchalski and the organization. “I think for many of us in the room, there is the work we are asked to do every day, but deep within us there’s the work that we were born to do, the work that’s our passion.” That’s the work, she said, that GWish does.
GWish Summer Institute: Spirituality and the Standardized Patient
The standardized patient, a 70-year-old man named John, had been diagnosed with cancer, he told the interprofessional team — chaplains, a physician, social workers, nurses, a psychiatrist — at GWish’s first-ever standardized patient session during the 2016 GWish Spirituality and Health Summer Institute. The Summer Institute, currently in its eighth year, features panels, open and round table discussions, and lectures on interventions and models of generalist-spiritual care from experts, as well as faculty development experts and SMHS leadership such as Benjamin Blatt, M.D., professor of medicine; and Eduardo M. Sotomayor, M.D., director of the GW Cancer Center and professor of medicine at SMHS.
The standardized patient session, designed to allow groups to develop a whole-person assessment and treatment plan, was a “chance to learn what it is to work as interdisciplinary teams to address all the needs of patients,” said Summer Institute co-director Rev. George Handzo, BCC, CSSBB, director of health services research and quality at HealthCare Chaplaincy Network and president of Handzo Consulting. Participants were split into small groups, each with their own “patient.” Together, they worked to identify spiritual issues affecting their patient’s understanding of their illness, diagnose spiritual distress, and determine ways to help their patient deal with that distress.
In John’s case, his team listened carefully to his story, drawing out potential sources of distress and attending to his end-of-live concerns. John’s cancer had progressed; radiation and chemotherapy were no longer feasible treatment options; and he had four to six weeks left to live. “I don’t want to be a burden on people,” he added.
The retired Naval Intelligence officer had just three goals for those final weeks: to attend the wedding of his daughter, and only child, in San Francisco; to complete his novel on the Cold War; and “do something” with his collection of American and Soviet medals, worth $10,000. Complicating matters, however, were John’s physical limitations and his reluctance to disclose his prognosis to his daughter. “She doesn’t know the dimensions of the disease,” he confessed.
The group, discussing John’s options with each other and with him, explored what they could do to support him and make him feel comfortable. Suggestions included a Skype or Facetime call between John and his daughter, with counselors or spiritual advisors present on both ends. Asking John’s college-age helper, who helped maintain the lawn of his Silver Spring, Maryland, home and bought his groceries, to help with the novel was another possibility. Finally, one of the social workers on the team volunteered to help with the medals.
In the process of conducting a spiritual history, the team learned that John was Catholic, but he had stopped going to church after his wife’s death. He had trouble, he said, reconciling his wife’s death with the belief in a supportive god. With help from one of the chaplains, who offered to facilitate a meeting with a priest, John was able to reflect on his faith, and he indicated a desire to return to church.
“This is encouraging to me,” said the standardized patient playing the role of John, describing how positively he felt about the experience, particularly the ways in which the team looked to help him accomplish his goals. Expanding on his feedback, he added that he felt the team listened with compassion and followed his needs, not their own, which he found valuable. “I think what we’ve discussed [about my family and faith] is very vital.”
A Panel of Perspectives
During the Summer Institute, attendees participated in a variety of open discussions, but one panel in particular stood out in addressing the need for compassionate care and advocacy.
“There are three leaders here to talk about their perspectives from nursing to medicine to policy,” Puchalski said, introducing the panelists: Ferrell; Marie-Jose Gijsberts, M.D., an elderly care physician based in Amsterdam; and Carol “Sister Carol” Keehan, D.C., RN, M.S., CEO of the Catholic Health Association of the United States.
Ferrell’s perspective — “All we’re asking for is the kind of care that you would want if you or someone you love is very ill” — sparked the first conversation. Her story, she said, began in Washington, D.C., with a young couple in their 20s and their 2-year-old child. The family’s morning had started as it usually did: breakfast at the table, feeding their child, laughing. They got in their cars, one driving directly to work, the other dropping off the child at preschool before continuing on.
“Life was perfect and good,” Ferrell said.
Then each parent got a phone call around 10 a.m. from the school. “‘The gate was left open. Your child walked into the street and was hit by a car. Come to the ED,’” Ferrell recalled. The parents raced through town to get to the hospital, where they found the emergency department in chaos. After 40 minutes, the mother wandered through the hospital to find her son; he was still responsive, but her emotional reaction prompted medical staff to escort her back to the waiting room. Before long, a young physician found both parents in the waiting room.
“‘I’m sorry, your son has died,’” Ferrell related the physician saying. The mother, screaming, started shaking and hitting the physician, who left. An admitting clerk, within 20 minutes, handed the couple a brown bag with their child’s clothing. The parents left, driving home in separate vehicles.
“I share that story and ask the audience two questions,” Ferrell said. “How many of you believe that that story, which is a very real story, is just horrible, unconscionable? The second question I want to ask you, how many of you believe that could happen in a hospital in your community tomorrow? How is it that care we consider unconscionable still exists? What we are all trying to do here is change the story.”
Ferrell, as well as Puchalski and Keehan, who each recalled similar experiences, believe solutions are possible. “Times are complicated, money is short, people are busy, but much of what we are trying to do and advocate for is so incredibly possible and it’s not too much to ask, it’s not,” Ferrell said.
In the spirit of finding solutions, discussion moved to issues of advance directives and spirituality at the bedside. Panelists and participants alike noted the sometimes casual nature surrounding advance directives, which have, the panel said, almost become drive-thru in nature: “Do you want fries with that?” Ferrell joked. As the panel concurred, talking through the answers should be a thoughtful process where people tell their health care team their spiritual values and beliefs.
That idea of a thoughtful dialogue, one that should include an advocate, was reflected in an earlier statement by original GWish board member Judi Teske, who noted that someone needs to link the science of medicine with the art of health care.
“My belief is that we are all physical and spiritual beings. It goes beyond what your religion is, if you have or don’t have a faith community; it’s way beyond that,” Teske said at the 15th anniversary dinner.
“Fully integrating spiritual care is an essential component of whole-person care,” added Puchalski, referring to the role GWish in the establishment of patient-centered training. “It is vital to have physicians and other clinicians trained in interprofessional spiritual care where they learn to address spiritual issues of their patients and to create an environment in which the patient feels deeply listened to and respected. “Ultimately, healing is not just about a patient ‘getting better.’ It’s about transformation — whether the patient recovers or not — and how an entire system can offer the opportunity for patients to heal in his or her own way.”