The results of the literature review and the background contextual review of contemporary spirituality have provided the basis to reflect upon the ways in which spirituality is operationalized in palliative care both in clinical practice and research. From this deliberation, and drawing upon the wide-ranging discourses and studies of spirituality, a conceptual model will be proposed that will attempt to explain what constitutes the spirituality of patients and how it relates to what may be considered the internal and external reality of the person including mental phenomena (e.g. beliefs), personal and social experiences (e.g. illness), and practices and behaviours (e.g. meditation).
The purpose of this account is not to provide a comprehensive unifying theory of spirituality in the context of palliative care but rather an
adequate account for the practical purposes of understanding and responding to the spiritual needs of patients. The model will therefore provide the conceptual apparatus and mechanisms missing from much of the current research and provide a conceptual platform upon which to develop methods of clinical assessment. If academics and clinicians do not articulate what they know about spirituality in the lives of patients and how they know it, or explain how and why palliative care should
recognize and respond to spirituality, then attempts to develop knowledge and improve practice may be hindered.
One approach to this task is to adopt the strategy of the modeller who aims “…to gain understanding of a complex real-world system via an understanding of simpler, hypothetical system that resembles it in relevant respects.”183 Models are ideal representations of phenomena that illustrate a system’s essential properties, functions and relationships. Constructing a model of spirituality enables us to go beyond the problematic
epistemology of this term to open up a means of exploring how it might operate in a real-world context. The model provides a systematic way of discussing the features and characteristics of spirituality and enables its resemblance with empirical observations and practical knowledge to be tested.
One of the earliest models of spirituality developed for a healthcare context is that proposed by Farran and her colleagues who use a functional definition of spirituality operating through seven major dimensions such as belief and meaning, authority and guidance, and ritual and practice. These dimensions are set within a context of universal events and experiences (such as health, illness, pain and suffering), which provide the possibility for expanded or limited spiritual functioning and spiritual growth.184 Models of spirituality have also been developed explicitly for palliative care. Kellehear’s model is focussed on the need of patients to find meaning beyond their suffering through situational,
moral–biographical, and religious transcendence.103 Wright proposes an inclusive model of spirituality based on a synthesis of ideas that includes activities of ‘transcending’, ‘connecting’, ‘finding meaning’ and
‘becoming’ that operate through the dimensions of the self, others and the cosmos.104
These examples of spiritual models demonstrate some of the potential that these techniques may have for understanding the spirituality of patients and developing the practice of palliative care. They also illustrate some of the limitations evident in these examples that are substantially descriptive schemes, or descriptions of models, that rely largely on assertion and provide little in the way of explicit propositions, descriptive adequacy, causal reasoning or consideration of the wider context. There may remain methodological advantage here, but what is lacking is any substantive theoretical contribution or a conceptual model of the whole within which specific spiritual phenomenon and causes can be located and explained.
The method of model building to be adopted here is to construct and analyse a minimal abstract and indirect representation of the way that spirituality potentially operates in the life of a patient. It aims to achieve similarity with the real-world phenomenon reported in the literature that is associated with spirituality. The model will therefore aim to be an
adequate representation of the significant features of spirituality within the palliative care context. This implies certain conditions must apply to the model such as the need to take account of progressive disease. The strategy of modelling therefore provides a method of theoretical investigation, which Weisberg argues happens in three stages:
In the first stage, a theorist constructs a model. In the second, she analyzes, refines, and further articulates the properties and
dynamics of the model. Finally, in the third stage, she assesses the relationship between the model and the world if such an
assessment is appropriate. If the model is sufficiently similar to the world, then the analysis of the model is also, indirectly, an analysis of the properties of the real-world phenomenon.185(p.208)
The starting point for the proposed model is to set out the intended scope of the phenomenon of spirituality that will be explicated as the elements of the model are articulated. Spirituality, or the ways in which people relate to and seek an ultimate or sacred reality, is part of our mental, personal and social life: it is both experienced and expressed, it refers to both the tangible and the immaterial. In relation to palliative care
spirituality narrates and interprets illness and dying: it is manifest in treatment decisions and in the experience of care, it provides a way of engaging with ultimate reality and facing mortality.
The physical world behind human experience is accessible to rational inquiry, and this should be pursued to develop a scientific understanding of the scientific questions about spiritual phenomena (such as the effect of prayer on the pain pathways). Spirituality also exists in a wider life-
context: it has rich personal, social, cultural, historical textures that
contribute to a holistic understanding and require other forms of enquiry, methods and explanations such as the theological or philosophical. Dupré considers how we understand human behaviour as a complex feature and capacity of human life and argues that, “Without in any way refusing the extraordinary range of knowledge that science has provided for us, there are subject matters that require a more synoptic and
integrative vision than the analytic methods of science allow”.186(p.185)
Spirituality is a complex feature and capacity of human life, and
consequently a Synoptic Model of lived spirituality is proposed (Figure 2) based upon the key features of spirituality explored in Chapter 2. It aims to be realist in the sense that it includes both observable entities, such as practices and disease, and unobservable entities that purport to have causative effects, such as the abstract objects of belief and the content of
values. Where this model differs from others is that spirituality is a feature and capacity of the system as a whole in which people express and
experience spirituality individually, through others and through ‘objects’ that effect and mediate spirituality in the world.
Figure 2: The Synoptic Model