by Wayne Jonas
CHAPLAINCY
When my patients seek the spiritual dimension of healing, I may ask if they would like to see a chaplain. Surveys report that most hospitalized patients, and many with serious illness, would like an existential or spiritual discussion with their physician or a visit with a religious professional—but rarely do medical professionals ask patients about their spiritual needs. To help remedy this situation, internist and palliative care physician Dr. Christina Puchalski, founder and director of the George Washington University Institute for Spirituality and Health and author of Making Health Care Whole: Integrating Spirituality into Patient Care, trains health care practitioners in how to discuss spirituality in health care. Her yearly course for physicians and other health care professionals teaches them how to integrate patients’ spiritual beliefs into their care, address sensitive medical issues that seriously ill patients face, and support health care professionals in providing compassionate care. In other words, it seeks to get health care practitioners and the health care system to take the nonphysical, inner aspects of healing seriously—to recognize and ask patients about the mind and spiritual dimension of their lives.
I am fortunate to be surrounded by people in my family who do look at the spiritual dimension. They have taught me the healing power of attending to the mind and spirit in health care. My father was a chaplain who spent a large part of his career working in hospitals. He was one of the first chaplains to get formal training in hospital chaplaincy—called clinical pastoral education (CPE)—and brought this training into the military. As a young boy, I recall asking him why he, a minister, went to work every day at a hospital, where doctors worked. I thought ministers were supposed to work in churches.
“Why do I work in a hospital?” he replied. “Because that is where a lot of suffering is. I work in a hospital to help alleviate suffering and to heal.”
That stuck with me. I wanted to know more. So, before medical school, I decided to do five months of training as a hospital chaplain student. That taught me a lot about healing.
I remember the first patient I was assigned to as a student minister. He was a seventy-three-year-old man dying of metastatic lung cancer and on a morphine drip for pain. He had requested a visit from a chaplain and was willing to see the “student chaplain” first. I was all of twenty-one years old, nervous as a cat, with no idea what I was going to say. When I entered his room, I was relieved to see that he was asleep—apparently sedated by the morphine. Thinking I was off the hook, I sat next to his bed and began to softly read a few prayers. After a few moments, he opened his eyes to look at me. Then he reached his hand over and placed it on my hand and said, “Son, you are going to be okay.” Not only was my cover blown, my most basic assumption about healing was flipped on its head—he was healing me! In the spiritual dimension, healing emerges in the space between people—in the collective mind—and its benefits can go either way.
After getting her first breast cancer and recovering from it, my wife also shifted her life focus from being a lawyer to getting a degree in pastoral care. She then worked in a chaplain’s counseling center for the military. I was amazed at the stories I heard from her of the spiritual struggles faced by service members and their families. She heard stories with a view of suffering they did not tell me about as a doctor in the clinic. She also told me about healings I had not known were happening to my patients. I looked for the physical causes of their suffering to prescribe a treatment. But with this focus I often totally missed other influences that perpetuated their suffering—influences that my wife was picking up on. The wounding of the cancer and its treatment had awakened her intuitive skills in listening and spiritual care. In recent years our daughter Maeba has enlightened me about the power of the spiritual dimension to heal. After earning her M.Div. degree from Yale Divinity School, she did an additional year of formal CPE training at Yale University Hospital. Prior to becoming a chaplain, she did premedical training and worked in medical research at Johns Hopkins. She also worked in Nepal at a school run by Buddhist nuns and at a clinic in Ethiopia treating children. These experiences and her formal trainings enable her to see the whole person—spiritual, psychological, and physical—and the ways they are linked.
One evening, Maeba was called to visit a man hospitalized for uncontrolled high blood pressure. He was on multiple medications, yet his blood pressure remained dangerously high. After she sat and talked with him for a while, he told her it was the anniversary of the death of his wife, whom he had loved deeply. Maeba prayed with him, holding up the joy of his and his wife’s love and the deep sorrow of his loss to clear view. He began to cry, and she sat with him while he mourned. That night his blood pressure returned to normal, and he was discharged the next day. The mechanisms responsible for this are likely explainable. The catharsis of his weeping and the social witness of my daughter likely reduced the stress hormones that were raging through his body and elevating his blood pressure. How often these types of biological healings occur through the spiritual dimension is unknown. Although hospitals with full-time chaplains will chart their visits along with all the other health care professionals, it is rare that those notes are followed or “measured” as drug treatments are. Sources like the Journal of Pastoral Care & Counseling are full of case studies like this. How often doctors and nurses read them, much less use these visits in an integrative fashion to heal, is unclear. Thus they remain invisible to most of us health care.
DAVID
Sometimes healing is, as in the Beauty Way, for the collective mind and not just an individual patient. Once Maeba was called to do a baptism of a premature baby born to a drug-addicted mother who, after the birth, walked out of the hospital without a word. The baby was on life support; he was so underdeveloped he could not live on his own. It took social services several days to track the mother down to ask permission to take him off life support after it became apparent he was not going to make it. When they finally got the mother on the phone, she refused to give the baby a name, but did give permission to take him off life support—and then asked that he be baptized. Several of the nurses caring for the abandoned baby were distraught. Not only did he not even have a name, but the mother’s only indication of her desire to love the baby—her parting request—was to have the baby baptized. Chaplain Maeba was called in to baptize the baby before he died. The only witnesses were the nurses and one of the doctors who had cared for him and tried to save him. As Maeba prepared the water and the ceremony, she asked the baby’s name. The nurses gathered, and, after consulting together, decided to name him David.
The ceremony began. Each caregiver was offered a chance to hold their hands over the water to bless it with their healing touch. “David,” Maeba said, “I baptize you in the name of the Father, and of the Son, and of the Holy Spirit,” and because of the special circumstances in which she was baptizing a motherless child, she added, “One God: Mother of us all, amen.” As the water was placed on the premature infant, the group began to spontaneously weep. This collective catharsis lasted several minutes. The ventilator was then turned off and the baby died. A deep sense of peace emerged, even as everyone grieved David’s death. After a silence that under any other circumstances would have seemed long and awkward, but in this context was to be cherished, one of the neonatal ICU nurses commented, “I needed that. For all the little Davids who die here.” There was a collective deep breath. She had spoken for all. Despite his short life, his unfortunate circumstances, and his major woundings, David was among the beloved, and it healed them all.
It is not just patients who need mental and spiritual healing. In many ways, the nurse in the neonatal ICU was speaking for all health care—practitioners and patients. Physicians and nurses report the highest rates of burnout of any profession. Nearly half of all physicians have burnout—defined as lack of enthusiasm for work, feeling apathetic, and becoming more callous toward people. The highest rate of burnout is among physicians and nurses in primary care—those at the fro
nt lines of health care—where it affects more than 50%. These physicians also have high rates of substance abuse—nearly 15%. Rates of burnout in primary care have risen nearly 20% in the ten years since 2007. As a hospital chaplain, Maeba found that her spiritual care was frequently needed by the staff. This led her to hold a monthly breakfast for the staff of the pediatric ICU.
The causes of burnout are many: excessive workload, clerical burden, inefficiency in our health care system, loss of control over medical decisions, and difficulties in work-life balance. Burnt-out physicians and nurses are not the best healers.
But the primary cause of burnout is, in my opinion, the erosion of meaning. This arises from the lack of opportunity for physicians and nurses to care for themselves and patients in all their dimensions. The imbalanced focus in medicine on the physical aspects of disease, along with the economic and administrative forces dominating medicine, squeeze out the dimensions of healing that they know produce benefit for patients and would allow them to heal the whole person. Those in primary care who see the decline in patients’ health and well-being year after year—when they know what could keep them well—bear the heaviest burden. The discouragement of burnout is magnified when they see that the patient’s environment, the social and emotional factors, lifestyle and behavior, and the inner dimensions of the mind and spirit also need attention—but they do not have the time or tools to attend to them.
Unfortunately, this discouragement begins in medical school. Medical students in their first year have high levels of altruism and empathy. This empathy drops lower with every year of training, from the time they enter to the time they are licensed four years later. It continues as they get into practice and find that health care is not designed to help patients heal and stay well, and it does not provide the primary tools they need. Our “health care system” is a triple oxymoron—it produces only about 20% of the public’s health, it is difficult for those working in it to deliver compassionate care, and it is not an integrated system. No health, no care, and not a system!
Health care needs a new way of thinking and a new design. It needs to shift its economic incentives toward prevention and whole person care, even as the industry profits from doing the opposite. Physicians and nurses need new types of skills and tools for the clinic and hospital. Patients need to expect—even demand—something different from what they are getting from health care. Health care needs to bring healing together with curing. Health care needs a miracle.
MIRACLES
Miracles happen. Most people know this. Many can describe miracles—small or large—that they have seen or experienced in their lives. Miracles in healing are those recoveries that modern science cannot explain. That does not mean they are not explainable. But usually scientists and physicians don’t bother to try. They are considered too hard to investigate. Adding the mystery of a miracle to the uncertainties of science makes it even harder. Our research at Walter Reed on how laying on of hands works—through electromagnetic frequencies coming off the hands—explained Susan’s boost in energy after I tried it. At least part of why the Marines with PTSD got better with healing touch is explainable—even if from placebo effects. But that does not mean these healings are any less miraculous. In his encyclopedic book The Future of the Body, Michael Murphy documents instances of unexplained healing from all over the world—including the meticulous documentation by the Catholic Church of the rare dramatic miracles from visits to Lourdes in France. While more than seven thousand healings from visits to Lourdes have been reported, the church has verified only about seventy as major, unexplained, miraculous healings. These types of miracles are just the dramatic ones that, although they provide evidence that truly mysterious healing can happen, also distract us from the more common and less dramatic miracles seen in health care every day—that is, if we look.
One of the more common “miraculous” events toward the end of life is someone waking up from a coma or sometimes even coming back from the dead to say goodbye to loved ones. My father’s death is an example. My father was a Christian minister—Presbyterian. He had served for thirty years in the military and been in three wars—WWII, Korea, and Vietnam. He then spent ten years as a hospital chaplain; ten years as a prison chaplain; five more in service to a poor, rural region in central California; and five more serving the destitute in Las Vegas and San Diego.
He was a man of deep faith who sought to emulate Christ. He believed that God works through people. Once I asked him if he had ever been afraid under fire during the wars. He thought carefully, then told a story about how once bullets passed through the poncho rolled up around his waist. He then said, “No. I was never afraid. I felt Christ next to me.”
He and my mother were married nearly sixty years. They had been through the three wars together, moved more than twenty times, and raised four children. They brought their family to Vietnam, Germany, Oklahoma, Texas, California, and New York City—moving almost every two years. They were deeply bonded.
Then, at eighty-six, my dad had a major hemorrhagic (bleeding) stroke and was rapidly dying—falling into a coma within three days. As he lost consciousness, the doctors attempted multiple interventions. They placed intracranial monitors into his head to track the pressure on his brain and catheters to try and drain the blood. “It looks like a crown of thorns,” my cousin said. My father had a tube placed down his nose, and they restrained his arms—splayed out to the sides. “Like he is tied to a cross,” our son, Chris, said. In this very painful situation and before he went completely unconscious, I asked him if he wanted any pain medication or sedation. He said no. All I could give him was water on a sponge. For me this all evoked the image of Jesus on the cross. Meaning drips thickly over events at the end of life. Gradually, the family came in from all over the country to be with him. He continued to bleed into his head, and the coma became deeper. After about six days, when most people had arrived, he was completely unconscious, not responding even to deep pressure on his sternum. We gathered around him. Our youngest daughter Emily sat at his feet and sang to him for hours. We prayed.
In the evening of the sixth day, my mother came up close and kissed him. Suddenly he woke up and asked, “What happened?” My mother told him he had had a stroke and was in the hospital and the family was all around. They kissed again and each said, “I love you.” He then lapsed back into the coma and died the next day. He had come back from a coma to say goodbye to her. A miracle? Perhaps. Explainable? Perhaps. But this kind of happening is not unique. Anyone who has worked in palliative or end-of-life care for a while has witnessed these kinds of miracles. They are more common than the dramatic ones documented in Mr. Murphy’s book—and often more meaningful. “It was a miracle for me,” my mother recounts, even now, almost ten years later.
Palliative care does not just palliate; it heals—socially, emotionally, mentally, spiritually, and often physically. In a meticulous study published in the New England Journal of Medicine, a team led by Dr. Jennifer Temel of the Massachusetts General Hospital randomly divided 150 patients with terminal lung cancer into two groups. One group received standard medical treatment only. The second group was given the option of standard medical treatment plus complete and early palliative care. This care included rapid treatment of pain and distress; psychological, social, and spiritual support, including help with end-of-life decisions; and whole person, integrative care. If the cure-focused treatment was causing more suffering, patients were encouraged to discontinue—the opposite of what usually happens in medicine. Under these circumstances, it was not surprising to find that those in the palliative care group had less pain and less depression and improved quality of life. However, to the surprise of the researchers and the medical profession, when the curative medical treatments were used less often and healing approaches used more often, the patients also lived longer—on average 11.6 months compared to 8.9 months in the curative-only group. It was a small and unexpected miracle. A drug that extended life this long would be ra
pidly approved. It’s still often a struggle to get coverage approved for palliative care.
In America and many other countries, health care does not do dying right. Only about one-third of patients receive formal palliative care, such as the care hospice provides, at the end of life. Few physicians are trained in palliative care, so they don’t know what to do once curative treatments are no longer reasonable. Surgeon and author Atul Gawande described this tragedy in his book Being Mortal: “This experiment of making mortality a medical experience is just decades old. It is young. And the evidence is, it is failing.” The U.S. National Academy of Medicine agrees. In 2014, they published a landmark report, Death and Dying in America, recommending that the principles of palliative care be expanded well beyond the end of life and that all physicians be trained in its principles. Those principles include the “frequent assessment of the patient’s physical, emotional, social, and spiritual well-being.” In other words, healing, as embodied in palliative care, should be part of all health care training.