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Biopsychosocial-Spiritual; End of Life; Spirituality; Holistic Care; Terminal Illness; Quality of Life

The biopsychsocial-spiritual model of care is the modern humanistic and holistic approach, which served as the structure for understanding the needs of the dying patients, alongside the existing contemporary medicines in clinical practices. This model becomes essential in modern palliative end-of-life care as the core concept of health in medical science, is not only the absence of physical illness, rather it require the treatment of the bio-psychosocial-spiritual sufferings that produces stress, depression, anxiety in the course of illness. Unlike the existing biomedicines that limited its attention on the treatment of physical pain and symptoms, the biopsychosocial-spiritual model of care viewed illness within the context of a complex interplay between biological, social, psychological, and spiritual factors that needs holistic approach of care [1, 2]. Moreover, looking at the present scenario of health system, mainly the palliative end-of-life care in the country, there is an emerging need in developing a treatment policy focusing on the humanistic and holistic approach of care for the well-being of the whole. The one reason as stated by Narayanasamy & Sulmasy [3, 4], the contemporary medicine limited itself within the finitude human bodies that left the mental well-being unconcerned, iniquity and disharmony of mind, which were the bi-products of terminal illness are also left untreated and beyond reach by contemporary medicines. This becomes the underlying factor for the failing of contemporary medicines and other biomedicines in not fulfilling the main objective principles of palliative end-of-life care, which is quality of life. The goal of end-oflife care is to focuses on healing the whole person, through integrating biological, psychological, physical, and spiritual care for quality of life, rather than focusing on the length of life and its prolonging process in medical treatment and therapeutic plan [3-6].

However, looking at the present scenario of India health care system as a whole, the palliative end-of-life care is visible as one among the most neglected area of care, and not even an existing model of health care in some part of the sub-continent. Moreover, among the few palliative end-of-life care centers, the effectiveness in its functioning and in delivering quality of life, is still in its minimal level. People still die with unfulfilled wishes, without meeting their primary needs, and without experiencing meaning in sickness and in dying. The absence of meaning-making policy and quality of life violates the objective principles of World Health Organization, on effective end-of-life care. Thus, concerning the challenges that evolve within the present scenario of palliative end-of-life care in the country, the present study is form with an emphasis to holistic care for the well-being of the whole. The study is through literature review, with philosophical inquiries on the available sources. Moreover, the aim of the propose study is also to dig out the underlying factors for the failure or ineffectiveness of palliative end-of-life care in delivering quality of life, and to let the doctors, nurses and other caregivers to be effective communicators and ethical practitioners of the art and sciences of modern holistic medicines.

The biopsychosocial-spiritual model of health

At the initial stage of its development, the biopsychosocial-spiritual model of care was widely understood as biopsychosocial model, which was a part of critical medicine propounded by George E. Engel during the late 1970s. Engel sought for the evolvement of medical sciences from molecular, biological into biomedical, to create a room for the treatment of the social, psychological, and behavioral dimension of human illness. Feeling the needs for humanistic and holistic view on illness, Engel approach was to focuses on the well-being of the whole, rather than a mere focus of medical science’s towards physical pain and symptoms in clinical practices [7]. The main objective principles of the biopsychosocial model of care is, the medical science should concerned the patient mental well-being alongside the treatment of the bodily illnesses, focusing on comprehensive treatment that is more naturalistic than that of a treatment base on simple analytical method. Most importantly, the transformation of clinical policy and the patient’s role in medical practices from object of investigation to the core subject [8]. However, the absence of spiritual model of care becomes a concern, in spite of biopsychosocial model of care delivering all the necessity domains of life. Thus, it was Sulmasy (an American medical ethicist, and a professor of Biomedical Ethics), who expanded the biopsychosocial model of care into biopsychosocial-spiritual model, with an aim to deliver the quality of life and well-being of the whole in clinical practices.

The biopsychosocial-spiritual is a significant approach to modern health care. Within this model, the biological approach view on the causes and effect of illness, from and within the function of a human body. The psychological and social are the two factor that investigate on the causes of illness through human emotional turmoil, negative thinking, and socio-economic condition, poverty, cultural issues, modern technology, and how religion/religiosity had an influences on individual’s health. Spiritual model of care on the other hand, concerns a person’s relationship with the transcendence being, as sickness interrupted the existing relationship of a person towards its biological, social, psychological, and spiritual domains of life. Spirituality restores the effected relationship, restoring the wholeness of life in a person. Thus, the biopsychosocial-spiritual is an approach that acknowledged spirituality as the underlying dimension of care that enables the whole person treatment in caring the terminally ill patient, for the well-being of the whole [4, 9, 10].

Citing Richardson the main reason for Indian health care system as a whole, and palliative end-of-life care at particular, fail in delivering quality of life is visible in unavailability and the absence of the biopsychosocial-spiritual model of health care. The only existing model of care that viewed illness within the context of the complex interplay between biological, social, psychological, and spiritual factors that frames an individual response, to create an account for their response and to an understanding of their illness, in the face of medical helplessness. Moreover, a mechanism that comforts an individual mind against suffering, gave hope when cure is not possible, and delivers meaningful and peaceful death, which the contemporary medicines and other biomedicines cannot offered. Spirituality and faith at this point had a greater impact on how to cope with illness and suffering, providing hope in the midst of despair. The biopsychosocial-spiritual model of health care also plays an important role in bereavement policy, an antidote that gives comfort to emotional pain and suffering of separating from life and loved ones. Thus, even in medical health science spirituality and its byproduct ‘meaning-making’ becomes vitally significant, providing the ability to make up personal mindset, feeling or emotion especially, when death becomes unavoidable, in the last hours of one’s life. Victor Frank beautifully wrote, “Man is not destroyed by suffering; he is destroyed by suffering without meaning.”

The biopsychosocial-spiritual approach of health care, like any other models of modern scientific medicines, is purely base on scientific aspect of medicine, and more significant as it is a broader approach of care towards human behavior and diseases. At present, the biopsychosocial-spiritual model of care took its particular shape in medical science, as the medical and psychological work together having their primary focuses on incorporating ‘person-centered’ approach to palliative end-of-life care patient, alongside the symptom control and pain management to achieved quality end-of-life care. The core concept of this model of health care is on the emphasis of the importance of ‘spirituality’ as resources for coping mechanism against existential suffering, negative emotional outcomes, and sought for genuine holistic care that addresses the whole person of patient’s relational existence, and his/her relationship with the transcendence being.

Moreover, as stated by Moss & Dobson, the biopsychosocialspiritual model is a scientifical approach to care, which is a part of critical medicine in clinical practices. It not being a mere philosophical approach, does not proposed dualistic approach to mind and matter, it rather, sought for the biological, psychological, social, and spirituality are inseparable from the whole, they interacts with one another to promote the other aspects of a person, to deliver quality of life, and to find meaning in suffering. However, when someone face end of life, delivering meaning and peaceful experience in clinical practices stand still as the hardest task of the care providers, but as Puchalski says, spirituality is the only option and an important solution to this approach. On the other hand, citing Sulamasy & Ramsey, the underlying reason for the absence of the spiritual model of health care in the country, is the concept of people and contemporary medicines confining themselves within the modern scientific medical realms and human bodies, which has no room for any other approach to care outside of its realm. Moreover, the contemporary scientific medical sciences, inferiorities the involvement of the spiritual model of health care, though knowing the fact that, it can contributes the whole person treatment and deliver the needs of the whole person in palliative endof- life care, mainly in the face of medical helplessness.

The general concept of people as a whole towards spirituality is, in relationship with religion, which make oneself to misunderstand the term ‘spirituality’ in most cases. It is important to understand what spirituality is and is not, to do away with the confusion, in regards to its concept, objective principle, and meaning, mainly in clinical realms. The meaning and concept of spirituality differs in religion and in health science. Spirituality in itself is a broader term with several meanings concerning to its roles and functioning, existing within and outside the socio-religious realms. Thus, spirituality cannot be confuses with religion, which is merely an outward expression of a particular belief system of people or community, consisting a specific set of belief and practices related to particular faith. Spirituality on the other hand, is a mechanism that provides autonomy over individual’s own understanding and interpretation of soul and spirit, generate inner peace, and unlimited universal experience of the individual. Most importantly, spirituality is search for ultimate/transcendent meaning, even to those who are not with any particular faith or belief system/ religion, and is not confine only within the existing socio-religious practices. However, religion is an approach that makes one to access to the sacred/divine, which is God or absolute truth, which generally, offers moral and ethical code of conduct through scriptures and theological teachings.

Spirituality as an important structure of care, focus on the perception of the individual’s, in regards to the thoughts and feelings towards his/her being and purpose in life. Unlike the concept of existing religions, the ultimate aim of spirituality is to find deeper meaning of life, hope, comfort, and inner world of the human soul, deliver inner peace, when cure is not possible in the course of illness. The objective of spirituality is base on the five important principles of life; the meaning in life, interrelatedness, wholeness, morality, and awareness of the transcendent being. Citing Narayanasamy, the term spirituality is mostly presented in a linguistic pattern that is rich in metaphor, which has the characteristic that influence ones culture, philosophy, religion, and history. Many health literatures also highlighted spirituality and affirmed its significant role’s towards positive health outcomes, quality coping mechanism with terminal illness, and the central propounding aspect of the existence of many.

On the other hand, it is important to identify how spirituality helps people cope with illness and dying, for the deeper understanding of its role in palliative end-of-life care. Spirituality as a mechanism provides hope or helps people to find hope in the midst of medical helplessness, and despair occurs in the course of serious illness. Especially, for those with no healing possibilities, spirituality becomes the only resource that deals effectively with physical and medical adversity, traumatic and stress events mainly related to health-disease issues. Thus, when medical sciences fail in providing the patient needs, spirituality becomes an essential structure for palliative end-of-life care that constituted as a coping mechanism towards illness of all stages. Looking at the scenario of India at present, regardless of its socio-cultural and religious differences, spiritual model of health care is the needs of the hours. It attains the needs of the patient to a heart level, helps patients to overcome major issues like depression, distress, anxiety, stress, and mood-disorder that the contemporary medicines neglected in clinical practices, in most cases. Moreover, citing Anadarajah, Narayanasamy, and Daaleman & VandeCreek, as a structure of care, spirituality has the possible ability to heal, promote quality of life, improve experience of patient’s emotional and cognitive judgments, deliver healthy personal lifestyle with existential meaning, improve the quality of being logical and consistent, and ensure the support and involvement within the community. Most importantly, spirituality establishes personal relationship with the divine being.

Spirituality is an unavoidable model of health care, alongside the contemporary medicines in palliative end-of-life care to deliver holistic care for the well-being of the whole. It is significant as it gear-up the terminal ill patient in transforming their emotional state, making the patient to feel the necessities’ of their active role towards the challenges of living and dying. In the course of illness, spirituality is the one important factor that reduces the disease risk, by enhancing the mental ability to deal with the situation that enhances the patient physical condition. Spirituality also serves as a dynamic mechanism in discovering ‘self’ and a search for meaning that positively affects patient life expectancy, and influence an individual experiences in many ways. However, though spirituality is a source of strength and helps patients to cope with their vulnerable situation, it is visible as the most neglected area of care in the country. Thus, its positive attributions in coping with terminal illness cannot be experience by patients in Indian palliative end-of-life care, which remain the greatest challenges within the health care system of the country.

Spirituality and life limiting medical illness

In contradicting with the common concept of many, health is not the absence of illness alone, rather the well-being of the whole person that seek for the deliverance of the biopsychosocial and spiritual treatment, alongside the bodily symptoms. The objective of palliative end-of-life care is to achieve quality of life, delivering whole person treatment through holistic care, pain and symptom control, avoiding inappropriate prolongation of death and dying. Most importantly, meeting the spiritual needs adequately that would alleviate the burdens, helps in finding inner peace, restore and strengthen patient relationships with his/her loved ones. According to Manitoba’s Spiritual Health Care Partners, spirituality is the core component for good health. The growing impacts of spirituality towards chronic or terminal illness can be visible in three main ways; helps the dying individual to understand his/her sickness, loss, and recovery; play a vital role in patient decisionmaking in regards to treatment and plan; and helps in building quality relationship between patient and the health care providers. At this point, the Indian health care system and its government need to accept the fact that, spirituality is central to terminally ill patient, which is even recognize by many medical practitioners. Spirituality is a mechanism that transforms the dying patient in many ways, provides hope, factor that contributes health, and becomes a part of total existence for the dying individual, when cure is not possible in clinical practices. In the study “The essence of spirituality in terminally ill patients”of Chao and colleagues, the essence of spirituality is visible in communion with self, in regards to self-identity, wholeness, and inner peace, and with others, concerning love and reconciliation. In its broader sense of its existence and functioning, spirituality is also in intimate relationship with nature, environment, and with the transcendent being, helping oneself to be inspire, creative, faithful, source of hope, and gratitude. Thus, spiritual as a structure of care in clinical realm had greater impact in health with positive outcomes, play its significant role in coping with terminal or incurable diseases like cancer and HIV. Moreover, looking at the findings of many researchers, it is noticeable that unlike those with less or without the involvement of spiritual activities, the individual/terminal patients with adequate spirituality or higher level of relationship with the transcendent being had minimum risk concerning depression, anxiety, and feeling of hopelessness that usually produces trouble mind. It also helps the palliative patient to construct meaning and purpose in regards to the sufferings and pain associated with illness that construct or facilitate coping and acceptance in the course of illness through faith and hope.

However, the unavailability of spiritual psychotherapy as a part of health care systems in the country makes palliative end-of-life care scenario unfruitful for many, greatly affecting its effectiveness. The absence of holistic care becomes the underlying reason for why India is consider a country not to die, and one among the worst place to die, representing a scenario of care where the wishes and voices of the dying patients are not perceive and listened. On the other hand, maximum of the existing literatures and documents concerning the role of spirituality in palliative end-of-life care, affirmed spirituality as an important factor for coping, and the common needs of the palliative care patients as a whole. The studies discover that, 41-94% of the patients who encounter terminal illness with healing impossibilities want their physicians to address their spiritual needs for peaceful death. Moreover, even around 49% of non-religious patients, with incurable diseases also feel the importance and the necessities of spiritual assessment by their health care professionals in a polite manner, to discover greater amount of one’s own value and meaning. Another study of Awasthi, and Koenig and colleagues on “Mental Well-Being” also shows the importance of spirituality in medical related illness, decision making in regards to treatment plan, and in emotional support of the patient and family. It not only controls the depression rate, but also delays one’s possible condition of physical disability that usually developed in the later part of terminal illness and a mechanism having the ability to heal and improves ones health. Citing Holloway and colleagues, as a structure of care, spirituality provides a context in which people can make sense of their lives, cope with incurable illness, explains their situation, sources of hope, and to maintained inner peace even to the last hours of dying against the existential challenges.

Critical analysis on spirituality and its role in meaningmaking

Disharmony of mind, despair, hopelessness, sadness, anxiety, guilt, regret, and anger on self and others, are the outcomes of terminal illness that patients usually experience in the course of their illness, which becomes the underlying feelings for the emerging needs of spiritual psychotherapy in clinical practices. Moreover, physicians and the existing scientific medicines helplessness towards incurable diseases, is also the core reason to the search for alternative care and treatments, in palliative end-of-life care, with its principle objective to deliver holistic care for the well-being of the whole and quality end of life care. At present, when cure is not possible, spiritual psychotherapy is the only option the medical sciences had, to cope with those unwanted outcomes in end of life experience. The reason for spirituality being a reliable model of care in the face of medical helplessness is the quality that spirituality possesses in its characteristics, which is the ability to cope with; alienation, loss, dissonance, and the ability to deliver; inner peace, meaning, purpose, forgiveness, reconciliation, self-actualization, selfexploration, balancing life, and mental well-being. On the other hand, the increases of depression, stress, and emotional pain, experience by terminal ill patients also gave rise to the urgent needs for this model of care in clinical realm. These characteristics make spirituality ‘the central’ to the dying patients, as recognized by many experts.

In the findings of Nwogu, Puchalski, Leyla & Fatemeh, Manitoba’s SPHCP and Balboni & Puchalski, spiritual psychotherapy is the one mechanism that decrease the fear of death, giving the dying patient the ability to confront his/her critical situation, and enhancing the patient sense of comfort to experience meaningful end of life live. Spirituality on the other hand, is identify as the universal characteristic to terminal illness, which relate human terminal illness or cancer to the transcendent being for meaning making process, and provided an assessment to dying individual and their connectedness to self, with others, and with the sacred being. Many studies also stated that, strong sense of spirituality help in producing positive heath, to adjust with their illness, gives sense of control over sentiment in difficult situations, mental well-being, the source for understanding human existence, and the reason to live, with meaning in dying. Citing Puchalski , in its infancy, healing is the sole aim of every patient in the course of illness, however, when cure is uncertain, quality of end life with peaceful and meaningful life experience becomes the only option. At this point, spirituality plays an important role in meaning making, and restoration of hope in the last hour’s experience of the dying patient. On the other hand, Park & Folkman, Breitbart et al., and Koenig emphasis, the vital role of spirituality in clinical practices, and the core aspect to palliative end-of-life care, providing the dying patient to experience a sense of self-awareness with deeper meaning of life, reducing suicide risk, substance abuse, and serve as an interpretive framework for patient suffering.

Moreover, the recent analytical studies of, Rego & Nunes, Leyla & Fatemeh, and Puchalski, also propose spirituality as reliable scientific model of health care, with less negative effects, the source of effective coping mechanism, and self-esteem for patient, physician, family, and other care providers. Spirituality as a structure of care, offer a personcentre care therapy, even in the face of critical medical diagnosis. It provides an optimistic worldview towards one’s existence, and with terminal illness, it strengthen care providers and patient that build trust. Thus, physician and the patient can come together for fruitful treatment plan, ensuring the treatments in accordance with patient’s choice, value, and belief in the clinical practices.

Spiritual approach to ‘health’ and ‘medical science’ becomes a significant model of care, with the adoption of meaningful and peaceful death, with quality end of life care, by modern medical science in clinical practices. At present, in line with the contemporary medicines, spiritual psychotherapy is a worldwide topic that attracts a growing interest in health and palliative care, affectively implemented into its practices in developed country like, Canada, UK, Australia, and in Iceland. However, spirituality is confine mainly within the socioreligious realms of the people in Indian sub-continent, with a narrow understanding of the term and its contributions to well-being of the whole. Looking at the present scenario, the absence of the spiritual model of health care as a subject of study in medical health science, and the lack of proper knowledge concerning the policy, guidelines, and structure of spiritual model of health care, could be the underlying reasons for the failure of spiritual psychotherapy in Indian clinical practices as a whole. Moreover, unlike any other medical approaches to care, used in the practices of modern medical sciences, spirituality and its components cannot be measure or testable in the medical laboratory, with regard to its quality and quantity, to affirm its effectiveness. On the other hand, as a structure of care and a mechanism to deliver quality of life, spirituality can only be experience personally, which the contemporary medicines which is purely scientific in its approach, finds difficulty in understanding the policy or strategies behind spiritual model of care, to make it as a part of its critical care medicines. Failing to constitute as one among the critical medicines, becomes another reason for the existence of spirituality into a mere theoretical approach to care in the country.

Moreover, spirituality being a broader term in its functions and nature of existence, does not confined within any given tradition or practices, having multiple meanings that vary from one to another, depending on the ethical situation, requirement, and needs of the people. Thus, the lack of clarity over its specific definition creates confusion over its usage, on the other hand, the sensitiveness of medical science in its approaches; also constituted as the one factor over its rejection in clinical practices. At this point, in spite of its emerging needs, another possible reason for the absence of spiritual model of health care in the country could be the fear of misuse and the unavailability of well-trained medical or psychological professionals working in clinical realm, concerning to its therapeutic functioning alongside the contemporary medicines.

On the other hand, the improper functioning of the health care systems in the country, and the negligence of the government towards quality health care, are the two fundamental reasons for the absence of holistic approach to care, mainly to palliative end-of-life care in India. Due to the absence of proper knowledge in understanding the spiritual model of health care, the physicians as a whole in the country view spirituality as a mere philosophical approach to care, and an impractical model of care in clinical health science. However, looking at its origin, spirituality as a model of care was born within the context of medical health science, with the urgent needs of biomedicines, as the need arises for the well-being of the whole. It is pure scientific in its approach to care, comprising of well-defined structure, policy, and guidelines, affirmed and approved by World Health Organization, basing on its effectiveness to terminal illness or incurable diseases. Thus, the WHO, stated good health, is not the absence of physical pain and symptoms alone, rather it sought for the total treatment of the biological, psychological, and spiritual sufferings, along the bodily symptoms, for the well-being of the whole. Focusing the ‘total’ treatment policy, the WHO declared spirituality as an important dimension for quality of life, and an important principle for palliative end of life care.

Yet, the weakness of the contemporary medicines in India, is firmly visible in limiting its functioning and treatments over the bodily-related issues, focusing mainly to do away with physical pain and sufferings, while ignoring the involvements of the other models of care that is not associated with contemporary medicines. However, the one truth, even the contemporary medical sciences and its technologies cannot deny is the effectiveness of spirituality, the only affective mechanism in dealing with terminal and incurable illness, in the face of medical helplessness, which is affirm by many studies. On the other hand, looking at the increasing numbers of terminal ill patients in the country at present, spiritual model of health care is the needs of the hour. The only structure of care that gives; hope when cure is not possible, delivers quality of life, heals the whole person, make dying as natural as birth, and help patient to experience meaning in their sufferings, as it address the various dimensions of the needs of those who are nearing to end of life.

Moreover, as stated by Saad and colleagues, medical system has evolved so as its approaches from disease-centered care to the patientcentered care, and more recently, to person-centered care. These changes enable the contemporary medicines to achieve its crucial role for high standard medical practices. Citing Awasthi, and Boston and colleagues, the greatest challenges in Indian health care system for effective palliative end-of-life care, is offering course on spirituality and its relation to medicine, in Indian medical colleges, training institute, and hospitals, to deliver quality of life for patients, families, and health care providers. However, there is also a danger in fully relying on the assessment of spirituality for healing and well-being. Thus, it is important for the clinicians and other care providers working in palliative end-of-life care need to be mindful of their own choices and consider treatment options from a critical approach.

Acknowledgement

Not applicable.

Conflict of Interest

Author declares no conflicts of interest.

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