Transcript Spirituality and Health Care

Spirituality: Faith and Healthcare
Presented by Chaplain Dana Bratton
“We are not human beings having a
spiritual experience. We are spiritual beings
having a human experience.”
-Teilhard de Chardin
Presentation Outcome Goals
Participants will be able to:
 Define spirituality and religion, and have
awareness of the benefits of spirituality in the
care of patients, especially patients at the end of
life as based on the examination of research.
 Identify what spiritual needs are, and how to
respond to spiritual and emotional needs.
 Recognize that one’s own spirituality might affect
how one might relate to, and provide care to
patients. Develop awareness of personal issues
that might hinder one from providing spiritual
care.
 Have the ability to assist with the faith of others
without proselytizing
 Have spiritual assessment tools
 Identify chaplain’s role as part of the health care
team and in the spiritual care of the hospice
patient
 Identify other areas of available support for
spirituality in patient care.
Definitions
1) Spirituality
 Spirituality refers to a belief in a higher power, an
awareness of life and its meaning, the centering of a
person with purpose in life. It involves relationships with
a higher being, with self, and with the world around the
individual.. Spirituality implies living with moral
standards.
“The spirit of a human is his essence, that part of him or
her that is not visible. The part that does not die but is
immortal. Webster defines spirit as “ a life giving force”
and as the “active presence of God in human life.”
(National Center of Continuing Education, Inc. Death and Dying, pg. 23)
MSOP Report III regarding spirituality
Spirituality is recognized as a factor that contributes to
health in many persons. The concept of spirituality is
found in all cultures and societies. It is expressed in
an individual’s search for ultimate meaning through
participation in religion and / or belief in God, family,
naturalism, rationalism, humanism and the arts. All
these factors can influence how patients and health
care professionals perceive health and illness and
how they interact with one another.
Christina Puchalski MD
MSOP Report III.
Association of American Medical Colleges,
1999
2) Religion
 Religion is an organized and public belief system of
worship and practices that generally has a focus on a
god or supernatural power. It generally offers an
arrangement of symbols and rituals that are meaningful
and understood by it’s followers.
“Religion is primarily a set of beliefs, a collection of
prayers, or rituals. Religion is first and foremost a way of
seeing. It can’t change the facts about the world we live
in, but it can change the ways we see those facts, and
that in itself can often make a difference.” (Harold
Kushner)
Major World Religions
– Christianity
 Catholic, Lutheran, Presbyterian,
Methodist,Nazarene, Episcopal
 Baptist (largest protestant denomination in US)
 Non-denominational
 Other Western faiths
– Judaism
 Reform, Conservative, and Orthodox
– Hinduism
– Buddhism
– Islam (Muslims)
George Ann Daniels MS, RN
Spirituality
 Spirituality fulfills specific needs
– Meaning to life, illness, crises, and death
– Sense of security for present and future
– Guides daily habits
– Elicits acceptance or rejection of other
people
– Provides psychosocial support in a group
of like-minded people
– Strength when facing life’s crises
– Healing strength and support
George Ann Daniels MS, RN
Spiritual Care
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Practice of compassionate presence
Listening to patient’s fears, hopes, pain, dreams
Obtaining a spiritual history
Attentiveness to all dimensions of the patient and
patient’s family: body, mind and spirit
• Incorporation of spiritual practices as appropriate
• Involve chaplains as members of the
interdisciplinary healthcare team
George Ann Daniels MS, RN
A More Compassionate Model
of Care
Focus on The Whole Person
Physical
Emotional
Social
Spiritual
Christina Puchalski MD
Bio-Psycho-Social-Spiritual
 Schools of Medicine have been slow to
recognize & appropriate this model of
whole person care.
 The Nursing profession has long
recognized the spiritual aspects of patient
care.
 Chaplains and clergy have often assisted
patients with the spiritual aspects of illness
and the search for meaning & purpose.
George H. Grant,M.Div., PhC.
Spiritual care defined
Spiritual care is recognizing and responding to
the multifaceted expressions of spirituality we
encounter in our patients and their families. The
purpose is to determine the nature of a person’s
relationship to God and other people, and to
give the person the opportunity to accept
spiritual support. Themes such as the search for
meaning, feelings of connection or isolation,
hope or hopelessness, and fear of dying are all
clues that a person is struggling with spiritual
issues.
Chaplain Loyal Ward
Research in Spirituality and Health
Medical Compliance: Study of Heart
Transplant Patients at University of
Pittsburgh
• Those who participated in religious activities and
said their beliefs were important showed:
- better compliance with follow-up treatment
- improved physical functioning at the 12-month
follow-up
- higher levels of self-esteem
- less anxiety and fewer health worries
Hams, RC et.al. Journal of Religion and Health. 1995: 34(1) 17-32
Christina Puchalski MD
Research in Spirituality and Health
Immune System Functioning: Study of 1,700 older
adults
• Those attending church were half as likely to have
elevated levels if IL-6
• Increased levels of IL-6 associated with increased
incidence of disease
• Hypothesis: religious commitment may improve stress
control by:
- better coping mechanisms
- richer social support
- strength of personal values and world-view may be
mechanism for increased mortality observed in other
studies
Koenig, HG et.al.
Christina Puchalski MD International Journal of Psychiatry in Medicine. 1997 27(3) 233-250
Research in Spirituality and Health
Coping: Pain questionnaire by American
Pain Society to hospitalized patients
• Personal Prayer is the most commonly used
non-drug method for pain management:
- Pain Pills
82%
- Prayer
76%
- Pain IV med
66%
- Pain injections
62%
- Relaxation
33%
- Touch
19%
- Massage
9%
McNeil, JA et al.
J of Pain and Symptom Management. 1998: 16(1) 29-40
Christina Puchalski MD
Research in spirituality and health
Coping: Bereavement
• Study of 145 parents of children who died of cancer:
- 80% reported receiving comfort from their
religious beliefs one year after their child’s death
- those parents had better physiologic and emotional
adjustment
- 40% of those parents reported strengthening of
their own religions commitment over the course of
the year prior to their child’s death
Cook. J Sci Sudy of Religion. 1983: 22:222-238.
Christina Puchalski MD
Research in spirituality and health
Coping: Study of 108 women undergoing
treatment for GYN cancers
• When asked what helped them cope with their
cancer, the patients answered:
- 93% their spiritual beliefs
- 75% noted their religion had a significant place
in their lives
- 49% became more spiritual after their diagnosis
Roberts, JA et.al. American Journal of Obstetrics and Gynecology.
1997. 176(1) 166-172
Christina Puchalski MD
Gallup survey key findings
Reassurances that gave comfort
89% Believing that you will be in the loving
presence of God or a higher power
87% Believing that death is not the end but a
passage
87% Believing that part of you will live on
through your children and descendants
85% Feeling that you are reconciled with
those you have hurt or who have hurt you
Christina Puchalski MD
George H. Gallup International Institute.
“Spiritual Belief and the Dying Process:
A Report on a National Survey,” 1997.
Americans have long recognized the healing
power of faith and prayer.
82%: believe in the healing power of prayer
64%: feel MDs should pray with those patients who request it
63%: want MDs to discuss matters of faith.
Almost 99% of MDs say religious beliefs can make a
positive contribution to the healing process. Yet, until
recently, most medical studies failed to consider the
impact of spirituality in disease prevention or the healing
process. Faith was the forgotten factor that was relegated
by healthcare providers to the chaplain's office.
CMDS
 Fortunately, there is change.
Scientists are realizing what people
already know, that a personal
spiritual relationship helps us make
sense out of illness. It gives hope. It
changes health-related behavior
and thus reduces the risk of
disease.
 But faith has an even greater
impact. Studies have revealed that
faith improves the immune system,
enhances healing, reduces
complications during major
illnesses and much more.
CMDS
Clinical Questions
• Does spirituality play a role in end-of-life care?
How?
• Should nurses address spirituality with their
patients and how?
• What is the role of the interdisciplinary team with
respect to the needs of the patient?
• How does paying attention to patients’ spiritual
needs help with delivery of compassionate care?
Where does spirituality fit?
 Patients may have
coping mechanisms
related to their belief
 May be supported by
a community of caring
others.
 May feel themselves
to be in the company
of God who gives
them peace and
comfort.
George H. Grant,M.Div., PhC.
Spiritual Needs
• May be dynamic in patient
understanding of illness
• Religious convictions / beliefs may
affect healthcare decision-making
• May be a patient need
• May be important in patient coping
• Integral to whole patient care
Christina Puchalski MD
Five basic spiritual needs of every
person:
 A meaningful philosophy of life (values, and
moral sense).
 A sense of the transcendent (outside of self,
view of God and something beyond the
immediate life, having hope.)
 A trusting relationship with God (faith).
 A relatedness to nature and people (friendship).
Experiencing love and forgiveness.
 A sense of life meaning.
Needs
The need for meaning and purpose
 The search for meaning is one of the
primary motivators that keeps us going.
When a person comes to a place where
his or her life makes no sense, and the
seems to be no meaning or purpose,
depression and indifference set in.
 If the person can find no help for meaning
and purpose in the future, he or she longs
for death.
National Center of Continuing Education, Inc. Death and Dying, pg. 24
Man’s Search for Meaning
Victor Frankl
 Sometimes external circumstances in our life
situation are beyond our control.
 Frankl maintains that the attitude we choose to
take toward our life situation is within our control.
 The spiritual journey relates to our inner struggle
to shape our attitude toward illness and even
death itself.
 A relationship with God gives meaning to life.
George H. Grant,M.Div., PhC.
Where do we find hope?
 Ultimately from our faith or understanding of our
relationship to a higher power.
 The belief that a higher eternal power is in
control provides meaning and purpose to any
situation.
The need for love and relationships
 We were created with this need. Humans
are social beings.
 The emotional need for love and
relationship is met in the context of
significant human relationships.
 The spiritual need for love and fellowship
is met only through a personal relationship
with God.
National Center of Continuing Education, Inc. Death and Dying, pg. 24
Three kinds of love
 Eros -If you satisfy my needs then I will love you.
A physical love.
 Phileo - a brotherly love, a friendship live. I love
you because of what you have or who you are.
This may be conditional love also, because
things might change.
 Agape – God’s kind of love. I love you, in spite
of …, I love you no matter what. Not deserved,
not earned. Freely given. Unconditional.
Unconditional love
 Important for the dying person because he
or she is no longer in a position to earn
love. Therefore it is important to
encourage and support the person’s belief
in and relationship to God who offers
unconditional love. Examples of how a
person might experience this might be
through prayer, and the appropriate use of
Scripture.
National Center of Continuing Education, Inc. Death and Dying, pg. 24
The need for forgiveness
 Guilt is one of the biggest burdens in our lives. It
results from the failure to live up to expectations,
either our own or those of others.
 True guilt may come as a result of rebelling against
the belief in God, and the consequences of that
rebellion.
 A sense of forgiveness within the context of one’s
faith, often brings a sense of inner peace for that
person in their relationship with God, self, and
others.
National Center of Continuing Education, Inc. Death and Dying, pg. 25
Forgiveness results in:
 Less anxiety and depression
 Better health outcomes
 Increased coping with stress
 Closeness to God and others
 Resolves guilt
 Restored relationships
“Beware lest anyone resist the grace of God and a root of
bitterness spring up in you and many be defiled”
Hebrews 12:15
Christina Puchalski MD
Sharing the patient’s faith
 Ask questions. Allow people to discover the truth for
themselves by stimulating their thinking through
questions, which is much more powerful than having
them simply listen to your thoughts.
 Don't react negatively to objections. Realize that
expressing doubt is actually a good thing because it
means that someone is genuinely thinking about an
issue. Expect emotions such as anger and hostility to
surface during an exploration of faith as people wrestle
with the most important issues in life. Don't take
objections personally as people go through this
process. Express your disagreements with respect,
affirming the value of the people with whom you speak
and leaving the door open for further discussions.
Sharing the patient’s faith
 If the patient expresses a need for assist with their
spiritual situation, a chaplain should be made available.
In the effort to assist the patient to understand their faith,
the chaplain might ask these questions: "Who is God?,"
"Who are We?," "Who is Jesus?," "What Did Jesus Do?,"
"What Can We Not Do?," "What Do We Have to Do?,"
and "What Does God Promise to Those Who Believe?.”

 Don't discount the beliefs or experiences of
others. Show respect for them. Simply ask people to
evaluate how their current belief system is working in
their lives. Don’t proselytize. When appropriate, sharing
your own testimony can be powerful.
Question: Should nurses talk about
religion or spirituality with patients?
 A. You may say no, because a nurse can not
be expected to be conversant with all
religions.
 B. You may say no, because the nurse may
be an atheist or non-believer. (Though I’ve
met very few nurses who are.)
 C. You may say no, that would be an
unethical intrusion into the privacy of the
patient.
 D. But the answer is yes, particularly when
there are indications of patient interest or
need.
The nurse’s role in spirituality
 Define your own philosophy of life and death.
What do you believe? What does human life
mean to you? What does death mean? Is there
life beyond? Is there a God? Is there a Heaven
and a Hell?
 You must be comfortable and confident in what
you believe in order to help others. Or you will
be threatened and fearful when confronting
death and dying in your patients.
 Identify your emotional and physical limitations.
National Center of Continuing Education, Inc. Death and Dying, pg. 29
Ethics & professional boundaries
 Spiritual History: patient-centered
 Recognition of pastoral care professionals as
experts
 More in-depth spiritual counseling should be under
the direction of chaplains and other spiritual
leaders
 Praying with patients:
You can, if the patient requests, or make a
referral to pastoral care for chaplain led prayer.
9 dimensions
of patient assessment
1. Illness / treatment
summary
2. Physical
3. Psychological
4. Decision making
5. Communication
EPEC- AMA
6. Social
7. Spiritual
8. Practical
9. Anticipatory planning
for death
Approach to
spiritual assessment
 Suspect spiritual pain
 Establish a conducive
atmosphere
 Express interest, ask specific
questions
 Listen for broader meanings
 Be aware of your own beliefs
and biases
EPEC- AMA
A Spiritual Inventory might
include questions about:
 The patient’s perception of what is going on.
 What gives meaning and purpose to life?
 How, or whether belief and faith enter in.
 Love: By whom do you feel loved-accepted?
 Forgiveness--need it? Do you need to grant it to
others?
 Prayer--What do you pray for?
 Quiet and meditation--What helps get you on
center?
George H. Grant,M.Div., PhC.
Spiritual assessment
 Meaning, value – personal, of the illness
– burden, control, independence, dignity
 Faith
 Religious life, spiritual life
 Identify areas of spiritual crises. Would
pastoral intervention be needed or desired
– their own pastor or the hospital or
hospice chaplain?
EPEC- AMA
Spiritual assessment
 Spiritual assessment should, at a
minimum, determine the patient’s
denomination, beliefs, and what spiritual
practices are important to the patient.
 This information assists in determining the
impact of spirituality, on the care and
services being provide, and will identify if
further assessment or services are
needed.
Chaplain Loyal Ward
Spiritual Assessment
 An integral part of a patient’s initial assessment
should include data about the patient’s spiritual
and religious beliefs.
 Several tools exist for spiritual assessment.
 Spiritual care needs to be individualized, with
the patient given the opportunity to participate
George Ann Daniels MS, RN
 Open ended questions that are specific
regarding beliefs can be helpful. A formal
assessment guide can provide a review of
the strength and meaning of person’s
religious practices that can open the door
to helping the person establish a
meaningful relationship with their higher
power.
Chaplain Loyal Ward
Spiritual History
• Taken at initial visit as part of the social
history, and at follow-up visits as appropriate
• Recognition of cases to refer to chaplains
• Opens the door to conversation about values
and beliefs
• Uncovers coping mechanism and support
systems
• Reveals positive and negative spiritual coping
• Opportunity for compassionate care
Christina Puchalski MD
Taking a spiritual history. . .
 S Spiritual Belief System
 P Personal Spirituality
 I Integration in a Spiritual Community
 R Ritualized Practices and Restrictions
 I Implications for Health Care
 T Terminal Events Planning (advance
directives, DNR wishes, DPOA etc..)
George H. Grant,M.Div., PhC.
Assess for spiritual activities
 Religious denomination (past or present)
Where do you go to church when you are
able?
 Activity level Do you go all the time?
 Prayer / scriptural resources Do you read
your Bible? Do you pray much?
Assess for spiritual crises
 Search for meaning or purpose in one’s life.
 Loss of a sense of connection with people or
God.
 Feelings of guilt or unworthiness
 No relationship with God
 Anger, denial, and bitterness expressed toward
self, others, or God. Questioning of faith
 Desire for forgiveness
 Sense of abandonment by God
Spiritual Assessment Tools
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SPIRIT
FICA (Pulchalski 1999)
LET GO (Storey and Knight 1997)
Nurses and MDs should know the patient’s
personal values and wishes. The patients
religion is specified in the medical record.
“The secret in the care of the patient is in
caring for the patient.”
 Francis Peabody
FICA assessment tool
F
I
C
A
Faith, Belief, Meaning
Importance and Influence
Community
Address
Christina Puchalski MD
The HOPE Questions
 H: Sources of hope, meaning,
comfort, strength, peace, love
and connection
 O: Organized religion
 P: Personal spirituality and
practices
 E: Effects on medical care and
end-of-life issues
LET GO
 Listening to the patient’s story
 Encouraging the search for meaning
 Telling of your concern and acknowledging the
pain of loss
 Generating hope whenever possible
 Owning your limitations
Spiritual History
F
Do you have a spiritual belief? Faith? Do
you have spiritual beliefs that help you cope
with stress? What gives your life meaning?
I
Are these beliefs important to you? How
do they influence you in how you care for
yourself?
C
Are you part of a spiritual or religious
community?
A
How would you like your healthcare
provider to address these issues with you?
Christina Puchalski MD
Ritualized Practices and
Restrictions
 Patients may
especially value the
rituals of their faith
community:
 Anointing (last rites)
of a dying person
 Scripture
 Prayer
 Communion
George H. Grant,M.Div., PhC.
Spiritual needs neglected
 Why? Many people have not recognized their
own spiritual needs, and thus are uncomfortable
in assessing them in others.
 Religion is often considered a private matter and
one not to be discussed.
 It is important in medicine to assess a person’s
physical situation related to his bowel
movements or his or her sex life. Aren’t these
private matters as well?
 Should a nurse be interested in spiritual needs
in their patients? Yes.
National Center of Continuing Education, Inc. Death and Dying, pg. 26
Patient care is done by a team of
interfacing disciplines
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Medical specialties
Nursing and allied health professions
Psychology
Pastoral care/health chaplaincy
Philosophy: bioethics
Community services: faith or need based service
groups
 Hospice and parish nursing
Each discipline contributes a special perspective
on human experience, which when taken
together, can lead to a general understanding of
the healing process.
Chaplain Loyal Ward
Four resources
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The therapeutic use of yourself. We affirm to
each patient that he or she is worthy of our
time and involvement, relating in a supportive
caring way.
The use of prayer when appropriate. Dialogue
within the context of your own religious beliefs
about your concerns for the patient.
When appropriate, the use of Scripture. They
are God’s communication to us. Teaching to
live in harmony with God, ourselves, and
others.
Referrals to clergy and chaplains
National Center of Continuing Education, Inc. Death and Dying, pg. 27-28
Life Goals
 A meaningful life
 A peaceful, dignified death
“There is a time for everything, and a
season for every activity under
heaven: a time to be born and a
time to die….”
Ecclesiastes 3:1-2
Questions asked by dying and
chronically ill patients
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•
•
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Why is this happening to me now?
What will happen to me after I die?
Will my family survive my loss?
Will I be missed? Will I be
remembered?
• Is there a God? If so, will He be there
for me?
• Will I have time to finish my life’s work?
Christina Puchalski MD
“The uncertainty is not the dying, it’s the
preparation. We need to know how to deal
with the inevitable deaths of loved ones and
friends and patients.
Death is the last enemy, but one that
need not be feared.”
Billy Graham Death and the Life After
Conspiracy of silence
 Reluctance to discuss death and dying
 Cultural practices regarding truth telling
 MD and patient each wait for the other to initiate
discussion. Even more so in the case of family
members.
 Avoidance: “I’m healthy. I’m busy. No time. My
family will take care of it.”
 Discussing specific treatments and procedures
instead of confronting the issue of impending
death
Medical team’s responsibilities
 Initiate discussion of end-of-life issues
 Help patients articulate their goals for care
– Clarify treatment preferences
– Uncover personal values
 Establish and maintain caring, trusting
relationship
 Acknowledge importance of spiritual
dimension in the dying process
End-of life discussions: how
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Establish rapport and a caring relationship
Ask about death-related beliefs and concerns
Take time to listen
Communicate empathy and respect
Be nonjudgmental
“Put your house in order because you are going to
die; you will not recover.”
2 Kings 20:1
End-of life discussions-how
 Become aware of patient’s cultural, ethnic,
religious background
 Be honest and compassionate
 Silence is a powerful tool
 Any person on the team- doctor, nurse,
social worker, may recommend and refer to
chaplains or other clergy or other team
members.
End-of-life discussions when?
 Urgently :
– Imminent death
– Patient talks about dying
– Questions about hospice or palliative care
– Recent admission for severe, progressive illness
– Severe suffering and poor prognosis
– Initial assessment when coming on hospice
Quill 2000. JAMA 284:2502
Initiating end-of-life
discussions - when?
 Routinely when:
– Discussing prognosis
– Discussing treatment with low probability of
success
– Discussing hopes and fears
– MD would not be surprised if patient died in 6-12
months
Quill 2000. JAMA 284:2502
A Shift of focus:
from the biomedical
to the psycho-social-spiritual
 For many patients facing serious illness
or the end of life, the focus shifts from
the biomedical to the spiritual.
 When symptom management and pain
control are appropriately provided,
patients are set free to address their
“final agenda.”
 This may be seen as the last chapter in
one’s spiritual journey. (Mary Levine)
George H. Grant,M.Div., PhC.
Spiritual Issues
The struggle with serious illness is ultimately
a spiritual struggle.
 Suffering
 Meaning and Purpose
 Loss or Abandonment
 Guilt or Shame
 Trust
 Reconciliation
 Hope
Christina Puchalski MD
Spiritual Identifiers in Dying Patients
• Is there purpose or value to their life?
• Are they able to transcend their suffering?
• Are they at peace with themselves and
others?
• Are they hopeful, or are they despairing?
• What nourishes their personal sense of value:
prayer, religious commitment, personal faith,
relationship with others?
• Do their beliefs help them cope with their
anxiety about death and with their pain, and
do they aid them in attaining peace?
Patients raise spiritual questions
 Who am I, now that I am sick or dying?
 What is the meaning of my life when I am no
longer productive and independent?
 Where am I connected to others who value me
and see me as a person of worth?
 What is my relationship to God and am I going to
Heaven?
 What do I now value most in the time that is left
to me?
George H. Grant,M.Div., PhC.
Unresolved issues and fears
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Old feuds or broken relations
Last visits, seeing people for the last time
Lifetime project
Unfinished business
Funeral plans
Financial plans
Need to forgive or be forgiven
Loss of control and dignity
Loss of relationships
Being a burden
Physical suffering
Spiritual Coping
• Hope: for cure, for healing, for finishing
important goals, for a peaceful death
• Sense of control
• Acceptance of situation
• Strength to deal with situation
• Meaning and purpose: in life in midst of
suffering
Christina Puchalski MD
Spiritual Care for the dying
•
•
•
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Practice of compassionate presence
Listening to patient’s fears, hopes, pain, dreams
Obtaining a spiritual history
Attentiveness to all dimensions of the patient and
patient’s family: body, mind and spirit
• Incorporation of spiritual practices as appropriate
• Involve chaplains as members of the
interdisciplinary healthcare team
Christina Puchalski MD
Community support
 Sources of assistance
 Church
 Disease support groups
 Hospice
 Social groups
 Friends, neighbors, and employment
peers
Nurses must be compassionate and
empathic in caring for patients… In all
of their interactions with patients they
must seek to understand the meaning
of the patients’ stories in the context of
the patients’ beliefs and family and
cultural values…. They must continue
to care for dying patients even when
disease-specific therapy is no longer
available or desired.
Christina Puchalski MD
MSOP Report I,
Association of American Medical colleges, 1998
Grief
 An emotion or complex of emotions we
experience when we lose someone or
something we value.
National Center of Continuing Education, Inc. Death and Dying, pg. 37
Assessment of the Meeting of
Spiritual Needs
• Does the health care provider listen to their
beliefs, faith, pain, hope or despair?
• Are patients able to express their spirituality
through prayer, art, writing, reflections, guided
imagery, religious or spiritual reading, ritual,
or connection to others of God?
• Are referrals made to chaplains, counselors,
or spiritual directors when appropriate?
George Ann Daniels MS, RN
Case 1: Clarifying religious statements
by patients
Mr. R is a 77 year-old, white, retired mechanic who
has class II congestive heart failure and coronary
artery disease that cannot be revascularized. After an
emergency department visit for an exacerbation of
congestive heart failure, his physician raises the issue of
a DNR order. The following conversation occurs:
Physician: “In your situation, CPR is very unlikely to
succeed. What do you think about what I have said?”
Mr. R: “Well, I want you to do what you can. I trust that
God will decide when it’s my time.”
Case 2: Responding to religious reasons for
rejecting the physician’s medical
recommendations
Mrs. M is a 72 year-old black woman with chronic
obstructive pulmonary disease who has been receiving
mechanical ventilation for 2 months because of acute
respiratory distress syndrome and multiorgan failure.
Believing that Mrs. M now has only a 1% chance of being
successfully extubated, her physicians begin to discuss
limiting life-sustaining interventions. Mrs. M is unable to
participate in these discussions. She had previously
indicated that her husband should act as her surrogate
but did not provide specific directives for her care. Mr. M
and their 2 children insist that mechanical ventilation be
continued, believing that God will answer their prayers
and work a miracle.
General Recommendations
Consider spirituality as a potentially
important component of every patient’s
physical well-being and mental health.
Address spirituality in your initial
assessment; continue addressing it at
follow-up visits if appropriate. In patient
care, spirituality is an ongoing issue.
Respect patient’s privacy regarding
spiritual beliefs; don’t impose your beliefs
on others.
Christina Puchalski MD
General Recommendations, cont…
• Make referrals to chaplains, spiritual
directors, or community resources as
appropriate
• Awareness of your own spirituality will not
only help you personally, but will also
overflow in your encounters with those for
whom you care.
Christina Puchalski MD
Religious Beliefs Related to
Health Care
 What are the health related beliefs of
these major religions?
– Buddhism
– Christianity
– Hinduism
– Judaism
– Islam
– Atheism
That’s your homework. Thanks and may God
bless your ministry in caring for people.