Spiritual Domain Important in Palliative Care: A Case Study

CLEVELAND, Ohio—The importance of the spiritual domain in comprehensive patient care was emphasized during the care of Mrs. S, a 64-year-old woman with renal cell carcinoma with bone metastasis, Cathy Palcisco, LISW, said at a symposium on palliative medicine held at the Cleveland Clinic Foundation.

This patient was being cared for at home, but she refused to enter hospice care. She felt that she did not need it, Ms. Palcisco said. At the same time, the nurses caring for Mrs. S felt frustrated because they were having difficulties connecting with her.

Ms. Palcisco, acting on the suggestion of the nursing staff, paid a visit to the patient. When she was led to the patient’s bedroom, Mrs. S resisted meeting her, announcing instead, “I don’t need you. I’m not afraid to die. Who sent you here?”

Ms. Palcisco explained to Mrs. S that she worked as part of an interdisciplinary team at the Cleveland Clinic Center for Palliative Medicine. Her role was to listen to patients and family and help with any nonmedical needs. She then asked Mrs. S about the source of her strength.

Mrs. S immediately credited her family and God as the source of her strength. “My family helps,” she said. “God helped.” In the conversation that followed, Ms. Palcisco affirmed Mrs. S’s relationship with God and with her family. But she also gently asked about her use of the past tense in her statement “God helped.” Although defensive at first, Mrs. S reluctantly admitted that, in the early stages of her illness, God had answered her prayers for more time and continued independence. Lately, however, it seemed that her prayers had gone unanswered.

Again, very gently, Ms. Palcisco questioned Mrs. S about her prayers and hopes, and learned that it was not death Mrs. S. feared so much as abandoning the care of her family. She needed assurance that her adult children and her husband would be okay without her.

With Ms. Palcisco’s help, Mrs. S was able to affirm the positive growth she had seen recently in her son and daughter, and express confidence that these positive changes would remain. But she worried greatly about her husband, a man who couldn’t talk about his feelings.

Ms. Palcisco agreed with the patient that that aspect of Mr. S probably wasn’t going to change, but perhaps there was something Mrs. S could do. Perhaps Mrs. S could review with her husband their life together and give him some specific things to remember. Mrs. S agreed to do this. Three days later, she died.

The tears the family has shed have been “very healing,” Ms. Palcisco said. Mr. S has been able to talk about his feelings and go on with his life.

The hospice team credits Ms. Palcisco for this especially pivotal visit. She said that she “didn’t play chaplain” but that her counseling skills as a social worker allowed her to give Mrs. S the help she needed.