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Religion and Spirituality in Healthcare Settings - Clinical Departments

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					Religion and Spirituality in
   Healthcare Settings


   R. Neal Axon, MD, MSCR
            MUSC
             2012
     Demand for Religious and Spiritual
                Support?
•   Williams JA, et al. Attention to inpatients religious and spiritual concerns. J Gen Int
    Med. 2011;11:1265.

     – 41% of inpatients desired a discussion of their
       religious or spiritual concerns while hospitalized
     – Only half received such discussions
     – Patients who had discussions of their R/S concerns
       had higher patient satisfaction
                     Learning Objectives
•   Knowledge
     – Summarize results of empiric research on the effect of religion, spirituality, and prayer
       on health outcomes.
     – Recognize common health beliefs causing confusion and/or conflict in healthcare
       settings.

•   Skills
     – Demonstrate how to obtain a spiritual history using the "FICA" method.
     – Discuss strategies for managing conflicts that arise between patients/families and
          healthcare providers over religion and spirituality.

•   Attitudes
     – Attach value to the role that religion and spirituality play important patients' coping with
         and recovery from illness.
     – Approach issues of religion and spirituality with heightened sensitivity.
Module 1: Evidence
            Evidence for Spirituality Effects (1)

• Some studies show that regular religious attendance is
  inversely proportional to mortality
   – Chida Y, Steptoe A, Powell L. Religiosity/spirituality and mortality. A systematic
     quantitative review. Psychother Psychosom. 2009; 78(2):81-90

• Religiosity/spirituality may have a favorable effect on survival.
   – Williams D, Sternthal M. Spirituality, religion and health: evidence and research
     directions. Med J Aust. 2007; 187(7):421

• Taking a spiritual history indicates to the patients that the
  physician is concerned with the whole patient.
   – D’Souza R. The importance of spirituality in medicine and its application to clinical
     practice. Med J Aust. 2007; 186(10 Suppl):S57-9
          Evidence for Spirituality Effects (2)

• What has the science shown regarding the effects of prayer?
  – 4 possible mechanisms by which prayer can improve
    health: relaxation, positive emotion, placebo, supernatural
    intervention
       • Jantos M, Kiat H. Prayer as medicine: how much have we learned? Med J Aust.
         2007; 186(10 Suppl):S51-3
          Evidence for Spirituality Effects (3)

• What has the science shown regarding the effects of prayer?
  – Prayer as an adjuvant treatment:
     • In one study: CCU course score was lower in the prayer
       group than the usual care group. LOS were not
       different.
       • Harris W et al. A randomized, controlled trial of the effects of remote, intercessory
         prayer on outcomes in patients admitted to the coronary care unit. Arch Intern
         Med. 1999; 159(19):2273-8.

   – Overall review article showed no benefit to intercessory
     prayer.
       • Roberts L et al. Intercessory prayer for the alleviation of ill health. The Cochrane
         Collaboration. The Cochrane Library. 2011.
     Can a physician be spiritually neutral?

• Physicians should remain spiritually neutral:
  – Scheurich N. Reconsidering spirituality and
    medicine. Acad Med. 2003; 78:356-360.
• It is not possible for physicians to remain
  spiritually neutral:
  – Hall D, Curlin F. Can physicians’ care be neutral
    regarding religion? Acad Med. 2004; 29.677-79.
          Discussion Questions
• How should physicians assess the spiritual
  needs of their patients?
• Is it OK for doctors to pray with their patients?
  If so, under what circumstances?
• What have been your experiences with
  physician/patient prayer?
   How to obtain a spiritual history
• FICA
  – F = Is faith in God important to you?
  – I = What impact does your faith have on your life?
  – C = How important is your faith community to
    you?
  – A = How can I can assist you?
Guidelines for providing respectful spiritual care

1.   Health care professionals should seek a basic understanding of patients’
     spiritual needs, resources, and preferences
2.   Health care professionals should follow the patient’s expressed wishes
     regarding spiritual care
3.   Health care professionals should neither prescribe spiritual practices nor
     urge patients to relinquish religious beliefs or practices
4.   Health care professionals who care for the spiritual needs of patients
     should seek to understand their own spirituality
5.   Participation in spiritual care should be consonant with professional
     integrity
Module 2: Cultural Competence
U.S. Religious Landscape
                         Percent
   CHRISTIAN                78.4
     Protestant             51.3
     Catholic               23.9
     Mormon                  1.7
     Jehovah’s Witness       0.7
     Other Christian
      denominations          0.9
   OTHER RELIGIONS           4.7
   Jewish                    1.7
   Buddhist                  0.7
   Muslim                    0.6
   Hindu                     0.4
   Other faiths              1.2
   NOT AFFILIATED           16.1
                            *Source: Pew Forum on Religion
                            and Public Life, 2008
   Trends in U.S. Religious Groups
• Decline in Protestantism

• Shifts in Catholicism

• Influx of other faiths

• Increase in “Unaffiliated Religious”
                      U.S. Religious Landscape Survey. Pew Forum on Religion and Public Life,
                      2008
Common Themes: Religious Rituals
•   “Last rites” …Roman Catholicism
•   Founded 1st Century CE, Jesus Christ
•   > 1 billion followers worldwide
•   Leadership by Pope (Benedict XVI)
•   Last Rites
     – Sacraments
          • *Penance
          • Eucharist as Viaticum
          • *Anointing of the Sick
              Common Themes: Fasting
•   Judaism:
•   Origins over 3,000 years ago
•   Covenant between God (Yahweh) and Abraham
•   Prominent Jewish movements:
      – Orthodox-
      – Conservative-
      – Reform-
•   Synagogue as center of faith community:
•   Fasting days:
     –   Yom Kippur- The Day of Atonement. The holiest and most solemn day of the Jewish year.
     –   Pesach – Passover. Celebration of the exodus of the Hebrews from their enslavement in Egypt.
     –   Fast of Gedaliah- Death of the last governor of Judea after the Babylonians burned the First Temple in 586 BCE.
     –   Asora B'Tebet- A fast day commemorating the beginning of Babylonian siege of Jerusalem
     –    Shiva asar B'Tammuz- A fast day commemorating the first breach in Jerusalem's walls by the Babylonians
        Common Themes: Refusal of
           Medical Procedures
•   Jehovah’s Witnesses
•   Founded 1872
•   Estimated 6 million adherents worldwide, 1 million in U.S.
•   Doctrinal leadership from the Watchtower Society, Brooklyn, NY
•   Best known for beliefs against blood transfusion

     – Biblical verses cited:
          • Genesis 9:4 "But you must not eat meat that has its lifeblood still in it."
          • Leviticus 17:11-14 "For the life of a creature is in the blood, and I have given it to you to make
            atonement for yourselves on the altar; it is the blood that makes atonement for one's life.
            Therefore I say to the Israelites, "None of you may eat blood, nor may an alien living among you
            eat blood."
          • Acts 15:29 "You are to abstain from food sacrificed to idols, from blood, and from the meat of
            strangled animals... You will do well to avoid these things.”


                           Panico ML, et al. When a patient refuses life-saving Care: Issues Raised when Treating Jehovah’s
                           Witnesses. Am J Kidney Dis. 58(4):647-653.
                           Woolley S. Jehovah’s Witnesses in the emergency department: what are their rights?. Emerg Med J
                           2005;22:869–871.
        Common Religious Practices by Denomination
               Dietary                        Blood Transfusion Last Rites /       Organ Donation Autopsy
               restrictions/                                    Prayers?
               Fasting
Buddhism       NA                             Yes                Mantras recited   No            No
Catholicism    Fasting as a religious         Yes                Yes               Yes           Yes
               discipline, meatless
               Fridays

Hinduism       Variable, frequently           Yes                No                No            Not favored
               observe vegetarian diet
               Fasting during Shivaratri



Islam          Pork, blood, intoxicants       Yes                Shahadah recited Yes            Yes, if required
               prohibited
                                                                                                 by law to
               Daily fasting during                                                              determine cause
               Ramadan
                                                                                                 of death
Judaism        Kosher dietary laws            Yes                No                Variable      No
               Multiple fasting days
               during traditional festivals




Reformed       Occasional fasting as a        Yes                Yes               Yes           Variable
               religious discipline
Christianity
Module 3: Conflict Resolution
                                             Case 1
•   Mr. W is a 63 year old male with a past medical history of hypertension, type 2 diabetes, and
    hyperlipidemia who suffered a devastating hemorrhagic stroke approximately 2 years ago. During an
    initial 3 month hospitalization, Mr. W. had tracheostomy tube and gastrostomy tube placement.
    While the tracheostomy was subsequently removed, he has remained bed-bound and dependent
    on tube feedings for nutrition. Mr. W. is cared for by a devoted but overwrought wife who is the only
    person who can communicate with her husband by interpreting his various grunts and garbled
    attempts at speech.
•   Eighteen months ago, Mr. W. developed a stage 4 sacral decubitus ulcer and chronic osteomyelitis,
    so a chronic indwelling foley catheter was placed to minimize urine soiling of the wound bed.
    Subsequently he has had 5 hospitalizations for pyelonephritis and urinary tract infections. Two of
    these episodes were severe enough to require ICU hospitalization.
•   Mr. W. was readmitted to the hospital again last night with another apparent case of urosepsis. He
    did not initially respond to crystalloid infusion, so pressor support was begun in the ICU. Despite
    this, Mr. W. had a PEA arrest. He was intubated, and CPR was performed. Mrs. W. was allowed to be
    present in the ICU during the resuscitation attempt, and she has now been moved to an anteroom
    do discuss Mr. W.’s case. In in the treating team’s opinion, Mr. W’s chances for a meaningful recovery
    are quite dismal, and this poor prognosis is presented to his wife with a recommendation to
    withdraw life support.
•   Despite having just witnessed a grizzly resuscitation, Mrs. W. volunteers that her husband would
    “Want everything done.” She states that she believes in MIRACLES.
   How to obtain a spiritual history
• FICA
  – F = Is faith in God important to you?
  – I = What impact does your faith have on your life?
  – C = How important is your faith community to
    you?
  – A = How can I can assist you?
                                           Case 2
•   Mr. M. was a slightly built 69 year old immigrant from Sudan. He worked in a convenience store
    where he stocked shelves and operated the cash register provide money for his family back home.
    According to emergency room records, a man entered the convenience store and attempted to
    shoplift several items—Mr. M struggled with the thief, and in so doing, fell and suffered a tibial
    plateau fracture. He was taken to the hospital, treated, and then discharged home,
•   In a matter of days, he was rehospitalized in the MICU with acute respiratory distress syndrome
    (ARDS), sepsis, and acute renal failure. After 3 few weeks of diligent searching, several cousins and
    nephews were located in a neighboring state.
•   Upon their arrival, a dismal prognosis was presented, and discussion held as to the presence of Mr.’s
    previously voiced opinion regarding resuscitation or withdrawal of life-sustaining therapy. The
    assembled family stated that they could not make any decisions, and requested that no changes in
    therapy be made until Mr. M’s brother arrived from Sudan in three to four days—they believed he
    would best know what Mr. M would want.
•   And, since Mr. M was a devout Muslim, the family assured the team that Allah would provide all the
    answers—maybe not now, but certainly with time. And, they wanted his bed turned towards Mecca
    five times a day for prayers, and they wanted to rub religious oil over his body, oil brought from
    Sudan. In the eyes of the medical staff, this was certainly not appropriate in the sterility of the ICU.
    Thus the lines were drawn between medical staff and family.
       4 Foundational Principles
• Respect for Autonomy

• Beneficence

• Non-maleficence

• Justice
                                            Case 3
•   Ms. M was a 34 year old female admitted to the hospital with a coronary cusp abscess, acute aortic
    regurgitation likely secondary to subacute bacterial endocarditis, and septic emboli.

•   She had 2 young children, 4 and 8 years old. She was a devout Jehovah’s Witness, as was her boyfriend.
    Antibiotics were started, and Cardiology and Cardiothoracic Surgery consulted.

•   Cardiothoracic surgery was willing to perform abscess drainage and an aortic valve replacement, in spite of
    the great risk, but wanted Ms. M to agree to receive blood transfusions if necessary.

•   Ms. M refused, and was advised there was a high likelihood she would die without surgery, but she still
    refused to go against her religious beliefs. The Cardiothoracic surgeon then refused to do surgery and
    signed off of the case.
Guidelines for providing respectful spiritual care

1.   Health care professionals should seek a basic understanding of patients’
     spiritual needs, resources, and preferences
2.   Health care professionals should follow the patient’s expressed wishes
     regarding spiritual care
3.   Health care professionals should neither prescribe spiritual practices nor
     urge patients to relinquish religious beliefs or practices
4.   Health care professionals who care for the spiritual needs of patients
     should seek to understand their own spirituality
5.   Participation in spiritual care should be consonant with professional
     integrity
               So What Now?
• Enhance your own practice
  – Incorporate guidelines for spiritual care
• Add to your teaching repertoire
  – Teach residents and medical students how to
    obtain a spiritual history
• Continue the discussion
  – Engage local chaplains and religious leaders
                                 References (1)
•   Williams D, Sternthal M. Spirituality, religion and health: evidence and research directions. Med J
    Aust. 2007; 187(7):421
•   Chida Y, Steptoe A, Powell L. Religiosity/spirituality and mortality. A systematic quantitative review.
    Psychother Psychosom. 2009; 78(2):81-90
•   D’Souza R. The importance of spirituality in medicine and its application to clinical practice. Med J
    Aust. 2007; 186(10 Suppl):S57-9
•   Jantos M, Kiat H. Prayer as medicine: how much have we learned? Med J Aust. 2007; 186(10
    Suppl):S51-3
•   Harris W et al. A randomized, controlled trial of the effects of remote, intercessory prayer on
    outcomes in patients admitted to the coronary care unit. Arch Intern Med. 1999; 159(19):2273-8.
•   Roberts L et al. Intercessory prayer for the alleviation of ill health. Cochrane. 2009
•   Scheurich N. Reconsidering spirituality and medicine. Acad Med. 2003; 78:356-360.
•   Hall D, Curlin F. Can physicians’ care be neutral regarding religion? Acad Med. 2004; 29.677-79.
•   Borneman T, Ferrell B, Puchalski C. Evaluation of the FICA for spiritual assessment. J Pain Symptom
    management. 2010 Aug; 40(2): 163-73
•   Winslow GR, Wehtje-Winslow BJ. Ethical boundaries of spiritual care. Med J Aust. 2007 May
    21;186(10 Suppl):S63-6.
                                References (2)
•   Panico ML, et al. When a patient refuses life-saving Care: Issues Raised when Treating Jehovah’s
    Witnesses. Am J Kidney Dis 2011; 58(4):647-653.
•   Woolley S. Jehovah’s Witnesses in the emergency department: what are their rights?. Emerg Med J
    2005;22:869–871.
•   DeSpelder LA, Strickland AL, eds. The Last Dance: Encountering Death and Dying, 5th edition. Mayfield
    Publishing. Mountain View, CA. 1999.
•   Multifaith Information Manual, 5th edition. Ontario Multifaith Council. Toronto. 2009
           Internet Resources
• Center to Advance Palliative Care
  (http://www.capc.org/support-from-
  capc/capc_publications/)
• American Association of Hospice and Palliative
  Medicine (http://www.aahpm.org/)
• The Association of Professional Chaplains
  (www.professionalchaplains.com)

				
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