Spirituality

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.



MSOP Report III.

Association of American Medical Colleges,

Christina Puchalski MD 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

George Ann Daniels MS, RN

– Islam (Muslims)

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

• 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

George H. Gallup International Institute.

“Spiritual Belief and the Dying Process:

Christina Puchalski MD 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 6. Social

summary 7. Spiritual

2. Physical 8. Practical

3. Psychological 9. Anticipatory planning

4. Decision making for death

5. Communication









EPEC- AMA

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



 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 Faith, Belief, Meaning

I Importance and Influence

C Community

A 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

 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

 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

• 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



 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

 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

• 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.





MSOP Report I,

Christina Puchalski MD 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.