Development of a Spiritual Care Model for

People at the End of Life in Thailand

Assis. Prof. Dr Raweewan Pilaikiat, RN, MSN, PhD

Faculty of Nursing, Naresuan University,
Phitsanulok, Thailand
1
Background and significance
• Spiritual care (SC) has been recognized
as being intimately connected to palliative
care.1
• SC encompasses assisting a patient in
finding answers to spiritual questions or
dealing with spiritual distress or crises;2
responding to patients’ spiritual needs;3
and promoting spiritual comfort and well- 2

being of patients.4
• Many health care organizations globally
have promoted SC,5, 6 and nursing
research focused on SC has been
conducted since 1983.7
• These investigations have revealed that
nurses are the health care team members,
who are the most advocates of recognizing
patients’ spiritual needs, providing spiritual
care, and serving as role models in the 3
care for dying people.8
• Judeo-Christian and Moslem studies have
shown that nurses provide SC
interventions through religious practices
such as facilitating and conducting prayer,
reading the Bible or Quran, facilitating
consultations with religious leaders such
as pastors or imams, and encouraging
patients’ trust in God/Higher Power.9
4
• Nurses also support nonreligious
practices such as demonstrating a
loving attitude, compassion, and
forgiveness; maintaining and
demonstrating moral and ethical
behavior; and providing counseling
and reassurance.9
5
• Facilitators that have been found to
influence nurses’ provision of SC
consist of nurses’ personal and
professional life experiences,6, 10
spiritual self-awareness,6, 11 and
perception of SC6 and the availability
of unconstrained quality time and
team support.8 6
• Barriers to delivering SC include high
numbers of patients, high workload, and
low staffing;12, 13 absence of privacy to
provide SC;14, 15 personal religious/spiritual
beliefs and cultural discordance;10, 14
difficulty in documenting patient spiritual
needs and SC;4, 12 lack of education and
training in SC;6, 14, 16 and lack of guidelines
for SC in nursing practice.17 7
• SC becomes more important for people at
the end of life, who might be in spiritual
distress and suffering, which is expressed
by the feeling of anger, meaninglessness,
hopelessness, loneliness, disharmony with
personal beliefs and value systems, and
difficulty accepting meaning in one’s
death.19
8
• People at the end of life may struggle to
find a connection to their spiritual power
amid their pain and suffering.20
• Therefore, nurses have a unique
opportunity to respond to spiritual needs
and to provide SC based on the culture
and belief systems present in the end of
life care setting.21, 22
9
• Although SC is considered an
important feature of holistic
nursing care, health care providers
frequently avoid the topic.3, 5

10
• Nurses frequently avoid this form of care
for reasons including uncertainty about the
meaning of SC;11, 23 a sense of
incompetence due to lack of education24
and minimal clinical experience;25, 26
confusion between the concepts of SC and
psychological care;12, 27 inner conflict due
to differing philosophies about life;28 and
lack of awareness of their own spirituality.28
11
• Moreover, progression in this area of
research has been limited due to
confusion between spirituality and religion,
lack of clarity in expectations about nurses
delivering SC, and inconsistency of the
operationalization of SC.29

12
 Spiritual Care In Thailand

• The concept of humanized health care has been

recognized as a quality health care indicator by
the Thailand Healthcare Accreditation Institute.30
• Since then, several hospitals in Thailand have
established palliative care working groups and
have developed palliative care and end of life
care programs for their patients.30
13
• In 2013, health care partners at the national
level—namely the Ministry of Public Health, the
National Health Security Office, the Thai Health
Promotion Foundation, the Health Systems
Research Institute, the Healthcare Accreditation
Institute, the Thai Palliative Care Society
(THAPS), and the National Health Commission
Office (NHCO) —collaborated to develop the
National Strategic Plan on Health Promotion for
A Good Death 2014–2016.31 14
• Under this policy, palliative care units have
been established at all levels of Thailand’s
health care services by 2015.31
• The new palliative care units will be
dedicated wards for palliative care, and
each unit will be staffed by at least one
trained nurse on a full-time basis.31
15
• Therefore, many groups of health care
providers in Thailand will be placing more
emphasis on palliative care and SC for
people at the end of life, providing care
intended to help their patients to pass
away naturally and peacefully, with human
dignity.31
16
• Thailand is a stronghold of Theravada
Buddhism, and 94% of the population
is Buddhist.
• Buddhists do not believe that life
begins with birth and ends with death.

17
• Rather, a person has several lives based
upon the acts committed (karma) in
previous lives,32 and the feeling of
peacefulness before death will lead to a
good rebirth for the next life.33
• The belief in the law of karma helps
Buddhists to do a goodness or practice
meritorious acts in daily life.
18
• During time at the end of life, Buddhist
patients and family members can request
to meet a monk for merit making, need to
say meaningful words or ask for
forgiveness from their loved and significant
people, and desire to do something such
as meditation to help them pass through a
peaceful death.33
19
• Therefore, health care providers and
family members have a responsibility to
take on the role as spiritual guides, which
includes helping a patient to accept death
as a part of life, helping a patient engaging
in meritorious acts prior to death, and
promoting a peaceful mind of the patients
through meditation to be reborn into a
good next life.33
20
• The nursing profession in Thailand
has recognized SC as the central
paradigm of palliative care nursing
practices36 and the most important
area for improving current end of life
nursing care in Thailand.37

21
• Moreover, spiritual nursing care has
been determined to be one of the
competencies of registered nurses by
the Thailand Nursing and Midwifery
Council.38

22
• However, nurses feel that SC is
subjective and difficult to integrate into
their daily practice because they lack
adequate knowledge of how to provide
SC for people at the end of life.33

23
• To improve the quality of holistic nursing
care and SC in Thailand, health care
providers need more information and
guidance on how to provide SC and more
support in dealing with spiritual issues
among people at the end of life.

24
Objective

• To develop a Spiritual Care Model to

guide health care providers in Thailand in
the delivery of spiritual care practices for
people at the end of life.

25
Development of a New
Spiritual Care Model

26
 Existing Spiritual Care Models

• Most previous SC models were developed

from Western Judeo-Christian backgrounds,
and the goals of these models were to guide
health care providers to apply spiritual theories
and concepts in patient care and to integrate
the concept of spirituality into their practices.40

27
• There are two existing SC models, which
illustrate the theoretical frameworks of SC for
people at the end of life: the biopsychosocial-
spiritual (BPS) model of care41 and an inpatient
spiritual care (ISC) implementation model.39

28
The BPS model of care

29
• According to the BPS model of care 41 everyone has
a spiritual history.
• For many people, this spiritual history is not specific
to the context of an explicit religious tradition but
rather relates to one’s philosophical principles or
significant experiences as an individual, accumulated
over one’s lifetime.39
• This spiritual history helps shape each person to be
a whole person, especially when confronted with life-
threatening illness, which strikes each person in his
or her totality.
30
• The totality of a person includes not only
biological, psychological, and social aspects,
but spiritual aspects as well.39, 41
• These aspects are distinct dimensions of a
person, and no one aspect can be separated
from the whole. Each aspect can be affected
by a person’s history and illness and can
interact with and affect other aspects of the
person. 31
The ISC Implementation Model

32
• Based upon the interdisciplinary SC model, 42
a
further model—an inpatient spiritual care (ISC)
implementation model was developed for
implementing spiritual interventions at the end
of life to inpatients.39
• The ISC implementation model indicates that
health care providers such as nurses,
physicians, chaplains, and social workers
should take an appropriate spiritual screening
and history taking from each patient before 33

admission to a clinical setting.

• Based on information from the spiritual history, the
health care provider can identify the presence of
spiritual needs, such as spiritual distress or the need
for external strength.
• Based upon this assessment, the health care
provider can then make an appropriate referral to a
chaplain or other SC provider.
• This model is based on a generalist-specialist model
of care, in which board-certified chaplains are
considered to be the trained SC specialists and
serve as resources to identify other SC providers 34

who might be appropriate for the patient.

 Limitations of the Existing SC Models

• These two SC models discussed here were

conceptualized as holistic care models to
guide health care providers in their efforts at
the end of life.
• However, the implementation of these models
has been limited.
35
 Limitations of The BPS model of care

• The BPS model of care has been used as

conceptual framework for a number of
research studies, but there is limited
information about its applicability to clinical
practice.

36
• While the BPS model of care emphasizes the
spiritual dimension of human experience in an
approach aimed at caring for the whole person,
the main purpose of the model is to generate
testable hypotheses in areas of knowledge where
current gaps exist.41
• This model does not address who should
undertake which responsibilities for SC nor how
SC should be delivered by health care providers.
37
 Limitations of the ISC implementation model

• The ISC implementation model focuses on bringing

together the expertise and experience of the provider
team in the hospital to focus on the delivery of SC.
• The ISC implementation model is strongly focused
on the delegation of SC planning, and, in this model,
the delivery of SC is focused on a SC specialist such
as chaplain.
• The ISC implementation model has the following
limitations: 38
• 1. The model lacks application in different
settings (e.g., home care, community care)
and is difficult to implement in non-Christian
cultures in Asia, Africa, and in native
communities.
• 2. The model is complex and difficult to
practice because of the requirement of varying
degrees of expertise in the SC team.
39
• 3. The chaplain as SC specialist needs to be
involved in patient care, and this model does
not address how other religious traditions,
such as Thai Theravada Buddhism, would
integrate their spiritual leaders into care at the
end of life in the absence of a chaplain.
• 4. This model does not use the rich experience
and expertise of nurses to deliver SC; instead,
nurses are involved only in the spiritual
screening and history at patient admission. 40
• 5. The SC specialist in the ISC implementation
model is the chaplain, but in reality, nurses in
Thailand are the professional group with the most
frequent opportunities to meet and respond to the
spiritual needs of patients and family members.
• 6. Some professions in this model, such as social
workers, do not provide SC for people at the end of
life in countries outside the United States, such as
Thailand.
• 7. The ISC implementation model does not provide 41

any outcomes in regards to the treatment plan.

•Development of the Buddhist
Spiritual Care Model

42
• Based on the identified gaps of the previous
two models, we propose a new model.
• The new BSCM (Buddhist Spiritual Care
Model) builds upon the strength of previous
SC models and expands on the health care
provider’s role and responsibilities as the
guide and implementer of patient-and-
family-centered SC. 43
• Moreover, we used the four steps of the
nursing process as the guiding principle
for health care providers:
• needs assessment,
• planning of actions,
• activities related to the plan,
• effectiveness of activities.
44
45
• The BSCM is developed based upon a number
of spiritual concepts, such as spiritual history,
spiritual needs, spiritual distress, spiritual well-
being, and spiritual practices.
• We developed the BSCM to help health care
providers to learn and implement SC in their
clinical practice, whether that is an inpatient or
an outpatient setting.
46
• The BSCM could be a guide for health care
providers to provide better SC to people at the
end of life and their family members,
particularly, in the health care teams which
have no SC specialist such as chaplain.

47
• The BSCM could be used to guide health care
providers to implement SC in various cultural
traditions.
• Health care providers include nurses,
physicians, nursing support staff, nursing and
medical students, and physical therapists.

48
The process of SC in this model includes 5
steps:

• 1. Spiritual history taking:

Screening of the person’s background, history,
and the worldview of spirituality, religion, beliefs,
and cultures held among both the patient and
family members.18, 43

49
• 2. Spiritual care assessment:
Assessment of the person’s spiritual needs,
current level of spiritual distress, engagement
with spiritual/religious beliefs, and access to
spiritual resources/supports.43

50
• 3. Spiritual care plan:
Planning of actions for each person, which
includes identifying the person’s spiritual needs,
identifying spiritual goals, and determining SC
activities.

51
• 4. Spiritual care implementation:
Providing of the SC activities related to the
plan by facilitating and guiding the person with
spiritual experiences for learning a new
paradigm of inquiry.43, 44 For example, nurses
help guide the patients to use spiritual
experiences such as listening to Buddha
preaching or meditation in preparation for the
upcoming death and achieving a peaceful
death. 52
• 5. Spiritual care evaluation:
Evaluation of the effectiveness of the recent SC
activities, including outcomes related to the
person’s spiritual well-being, physical and
psychological symptom experiences such as
pain, depression, anxiety, sleep quality, quality
of life (QOL), and self-management related
outcomes such as coping strategies, adaptation
processes, and social support. 53
• In this model, health care providers would
provide SC for people at the end of life and
family members under the ethical
consideration, which includes spiritual self-
awareness, trustworthiness, compassion, and
active listening.
• Health care providers will be able to continue
to develop their own competencies in SC and
their own spirituality through self-reflection,
spiritual self-care, and comparative practices. 54
• During the process of SC planning and
implementation, family members, friends, or
community spiritual providers such as monks,
nuns, SC volunteers, or other people will be
involved in planning and providing SC for the
care recipient.

55
Limitations
• The BSCM has not been tested in any clinical practice,
in either an inpatient or an outpatient setting.
• We are not sure whether this model will be culturally
adaptable or practicable in all types of clinical settings.
• This model is focused on patient-and-family-centered
SC in highly supportive environments and the
application in a health care system that does not support
and integrate SC into its organizational vision will be
difficult. 56
 CONCLUSION

• There are few guidelines or models for provision of

Buddhist SC in clinical practice. Health care
providers need more information and guidance on
how to provide SC as well as more support in
dealing with spiritual issues.
• The BSCM builds upon the strength of previous
existing SC models and uses the four steps of the
nursing process to make SC implementation in
clinical practice feasible. 57
• The BSCM could guide nurses, physicians, nursing
support staff, nursing and medical students, and
physical therapists to provide SC for people at the
end of life and their family members.
• Moreover, the BSCM could facilitate connections and
collaborations between people at the end of life,
health care providers, families, monks, and their
communities to achieve spiritual well-being and
facilitate a peaceful death.
58
 • This paper have been published in
Journal of Hospice and Palliative Nursing
(Volume 18, No 4), August 2016 issues

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Thank you for your attention

Any suggestion or question?

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