Rabbi David Albert is a Senior Staff Chaplain at Baptist Health South Florida, a non-profit, faith-based hospital system comprising six hospitals in Miami-Dade County, Florida, in the United States. Originally from South Africa, he is an ordained Orthodox Rabbi and Board Certified Chaplain who has been on staff at Baptist Health South Florida for 10 years.
Click here to access Rabbi David Alberts Power Point presentation titled "Preserving Human Dignity at the End of Life".
I grew up in a society where most of the indigenous population would initially consult a spiritual care giver (called a sangoma or witch doctor). Illness and disease were understood in terms of spiritual imbalance. So I was always exposed to a different model of care and healing.
Obliviously, providing spiritual care today in Miami is very different. Yet, I find that so many of the struggles, dilemmas and concerns people face at the end of life are universal. It really doesn’t matter where one is from or what they believe. The needs and concerns are the same as regarding the need for love, meaning and forgiveness. Was my life significant? Did it have an impact, make an impression? What is the meaning of all this?
Complex decisions about plan of care and types of life saving and life prolonging interventions need to be made. The desire to die in peace and not suffer is a very important concern for most. Of course, in certain circumstances, my role may be limited. Certain ritual needs may need to be administered by an adherent of ones own faith. The circumstances surrounding a patient’s admission to the hospital are endless – suicide, routine surgery, terminal illness, snake bite or plastic surgery – but the message that the chaplain brings by his or her presence is, “I come to offer you my presence and support in your time of need/distress, if you wish, and according to your agenda, not mine.”
I do not work in isolation, but as part of an interdisciplinary team providing holistic care to the patient. This means that a patient is understood to be much more than a physical entity, or than their physical disease, but also has psychological, social and spiritual/existential needs. As the saying goes, “Good doctors treat the disease, great doctors treat the person.”
I also provide emotional and spiritual support to our health care professionals and all employees. I am an active participant in our ethics committee and occasionally I also give presentations.
That is a very interesting question. I mentioned during my introductory remarks at a recent conference presentation that I am an end of life advocate and activist. There is so much that can be done, both medically and psychologically/spiritually, today to help and comfort those who are dealing with chronic illness life and threatening illness, that training and accessing the resources to receive such care should be a high priority.
A society is judged by the way in which they treat their elderly and vulnerable. I am definitely an advocate, ensuring patients and their loved ones receive the compassionate and dignified care that they desire, and deserve. Sometimes loved ones may be making substituted decisions for the patient who is incapacitated and if I feel that those decisions are not in the patient’s best interests, I will advocate on behalf of the patient’s best interests. This may entail enlisting the intervention of the institutional ethics committee and also counseling the health care professionals who may be experiencing compassion fatigue or moral distress. But I am also a counselor, which to me means above all to be a good listener and compassionate presence. How can we best honor and respect the patient’s cultural and religious needs? This applies to so many areas of the patient’s life, from the food they eat, to how they dress, to how they communicate.
Frequently, family members are requested to make heart wrenching, life and death decisions for an incapacitated loved one. I often find myself being approached either by family members, or frustrated doctors and nurses to assist with end of life decision making. Approaching the end of life takes its emotional toll on the patients loved ones.
The tremendous amount of cultural, religious and ethnic diversity in Miami poses many challenges. These factors influence the way people navigate their care, cope, communicate and make health care decisions. This means that I cannot take anything for granted and I need to make a special effort to be culturally sensitive or culturally competent as it is expressed in the medical environment. Culture is frequently a major factor in end of life decision making and bioethics and those of a different culture often have a very different perception and understanding. The attending interdisciplinary team, although being multicultural themselves, nevertheless are all rooted in the medical institutional culture, which often struggles to accept the decisions made by the patient or health care surrogates. An example of this would be where the treating team feels it is appropriate to withdraw life support, whereas the patient and/or family feel that more should be done, and that they are possibly being discriminated against.
One of the more bizarre challenges has been to what extent we can accommodate a patient’s religious rituals. We have many people in the Miami area who emigrated from the Caribbean and who are Santeria worshippers. We have been approached about the permissibility of sacrificing a dove in the patient’s room as a form of healing ritual. For various reasons we are obviously unable to permit this.
Dignity therapy was formulated in response to a number of studies which showed that patients at the end of their lives were facing feelings of despair, loss of worth, loss of hope, loss of dignity. Dignity therapy is also referred to as dignity preservation, because it instills hope and provides a bulwark against threats of demoralization and meaninglessness. It enables and also empowers people to pass on their personal narrative and legacy to their loved ones.
Although I have acquainted myself only recently with dignity therapy, I found a strong correlation between this exciting new intervention and the more traditional “life review” technique that I learned about in my clinical pastoral education (CPE) residency. Although not empirically validated and studied as dignity therapy has been, life review had been used for many years as a form of spiritual intervention with terminally ill and dying patients. People want to know that their life mattered, that it was meaningful in some way. This is accomplished by directing trigger questions such as “What were some of your greatest achievements? Disappointments? Most meaningful moments?”
Other techniques or interventions I also use are prayer/meditation, guided imagery, mindfulness, teachings from positive psychology and Viktor Frankl’s logotherapy, or meaning centered therapy.
The notion of human dignity is very fluid, ambiguous and unclear. Some have even questioned its usefulness in contemporary bioethical and human rights discourses. It also compels us to ask the question “what exactly is this
dignity” that I am preserving?”
The Universal Declaration of Human Rights of 1948 declares in its preamble: “Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world…”
The UNDHR directly links the two concepts together, as if to say, a human being’s inherent dignity is the key principle which infuses and informs their entitlement to basic human rights. The principle of rights infuses the very important bioethical principle of autonomy. No longer is the patient is not dictated to about the plan of care, but actively participates in it. Being an active participant and being given a voice, being informed and asked about his or her preferences in care, affirms the individual’s dignity, sense of worth and value.
I think it gets back to a statement I mentioned earlier: “Good doctors treat the disease, great doctors treat the person.”
I will give you an anecdote. Recently I had to see a specialist and the very first thing he asked me when I entered his office and sat down was, “Tell me a little bit about your family” So we spent the first couple of minutes talking about our families. That made me feel like he was interested in me as a person. He cares about me as a person. That it wasn’t all medical and impersonal.
Spirituality is putting the heart back into medicine. It is the “can” in cancer. It is the care in “health care”. It is reclaiming medicine as an art. It is an acknowledgement of our existential vulnerability and that we – physician and patient – are fellow pilgrims, supporting one another as we pass through the great mystery of life and death.