Early in his career, hospitalist Richard Bailey, MD, encountered a widow from the inner city with no family. She was blind, and had been weakened and debilitated by a very challenging hospital course with many iatrogenic complications. “I was first struck, walking into her room,” recalls Dr. Bailey, “that she had a Bible on the table next to her bed. While making conversation, I mentioned this and instinctively asked her if she needed someone to read it to her. She smiled, and asked if I would oblige. I closed the door, sat down, and read her some of her favorite passages. This went on for several days until I went off service.”
Now medical director of Inpatient Care and Hospitalist Services at Saint Clare’s Hospital, a Catholic hospital in Wausau, Wis., Dr. Bailey says he is not an overtly religious person and that his spiritual life is rather private. “But I do like to have that depth of connection with my patients,” he says.
So if a patient or a family member asks him to pray with them, Dr. Bailey does so. “I cannot separate my humanness, which includes spirituality, from my work,” he explains.
When faced with serious or life-threatening medical conditions, patients and their family members are more likely to invoke their faith to cope with the attendant anxieties.
William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for Sentara Medical Group in Hampton, Va., believes that joining his patients in prayer, when asked, “helps develop a better relationship with the family and patient.”
Many Americans tend to “live in the here and now,” notes Carol R. Taylor, RN, MSN, PhD, director of the Center for Clinical Bioethics at Georgetown University. “They usually do not ask the bigger questions so long as life is good. But when life as we know it is threatened by illness, the bigger questions can become very important: ‘Is there anything beyond the here and now? And if so, where do I stand in relation to that God or higher power?’ ”
Prayer is a common response when patients face perilous medical situations.
“The vast majority of patients who are feeling imperiled due to a severe diagnosis or potential mortality is going to be praying,” says Stephen G. Post, PhD, professor and associate director for educational programs, department of bioethics at Case Western Reserve University, Cleveland. “In a way, you can’t get away from those requests.”
Are hospitalists and their institutions fully equipped to respond to the spiritual aspect of caregiving? Some researchers note that biomedicine often regards faith and spiritual world views as relevant only when they obstruct implementation of scientifically sound medical care.1 Studies have also shown healthcare professionals are less likely than their patients to actively practice a religion.
“There’s very often a mismatch between patients and families who would value that intervention and our comfort in being able to be responsive,” says Dr. Taylor, who is also an assistant professor of nursing.
Dr. Taylor and other bioethicists increasingly urge medical practitioners to include spiritual needs when they take a patient’s history. Timely referrals to chaplaincy services, knowledge of the dominant faiths and ethnic traditions in their hospitals’ catchment areas, and improvement of interpersonal skills can allow hospitalists to compassionately and ethically address their patients’ spiritual concerns.
Need to Do a Better Job
The holistic view of medicine defines health as a multidimensional construct that includes the physical, emotional, and social aspects of the patient. This view should be matched with a holistic approach to healthcare delivery that encompasses patients’ subjective illness experience, says Dr. Post.
Dr. Taylor concedes that the medical community’s recognition of patients’ spiritual needs is growing. And yet, she says, practitioners are not held accountable for delivering spiritual care, “which I think is a failing of healthcare as it is practiced today.”
Many reports have indicated patients are unhappy with the low referral rates to pastoral clinical care, adds Dr. Post.2
Incorporate a spiritual-needs assessment when taking each patient’s history upon admittance, the two bioethicists agree. This assessment usually takes the form of questions such as:
- What is your source of strength?
- Is spirituality/religion important to you? (If the patient answers “yes,” proceed to the next question.)
- How would you like us to facilitate your needs?
- Would you like a referral to pastoral care?
Once patients indicate they would like to speak with a chaplain, referral to appropriate clergy trained in pastoral care is essential.
“All physicians need to be respectful of these kinds of appeals,” says Dr. Post. “But they should feel free to make a referral to those who are, in fact, competently trained to deal with this specific area of life.”
While opposed to professional separatism, Dr. Post does argue for keeping “friendly, knee-high white fences” between physicians and pastoral counselors to maintain professional boundaries.3
Marc B. Westle, DO, FACP, president and managing partner of Asheville Hospitalist Group, PA, in North Carolina, agrees with this approach. “As a professional, I completely respect and empathize with the patient’s and the family’s spiritual needs as part of the total care of the patient,” he says. “Just as in other areas where I may not have expertise, I refer to our in-house professionals. We have an excellent chaplaincy service that we involve all the time, on a routine basis.” He says the chaplaincy service at Mission Hospital is in-house 24/7, just as the hospitalists are, and make rounds as the physicians do.
Availability of trained clergy differs from institution to institution, notes Dr. Taylor. She recently visited a metropolitan research institution where the two staff chaplains estimate there are nearly 1,000 daily patient contacts. With this many patients flowing through the facility, the chaplains rely on medical staff to triage patients’ and families’ needs so they can be referred to families who will benefit most from their help. In busy urban hospitals, pastoral coverage may not always be available, and the burden of addressing spiritual requests can fall to the hospital medicine team.
The Comfort Zone
The question of whether to pray with a patient or family member depends on the physician’s comfort with doing so.
- Rule No. 1 when it comes to the question of prayer with/for a patient or family: Clinicians should never proselytize or initiate the prayer. This can constitute a serious breach of professional boundaries.4
- Balancing the need to support patients’ emotional needs while respecting one’s integrity can be difficult. If a physician feels comfortable, it is appropriate to pray with a patient. Or, a physician can offer to sit quietly while a patient prays. If uncomfortable with this scenario, offering to keep the patient in your thoughts is one way to still be supportive while maintaining the integrity of your beliefs.3
“I think most physicians try to be very sensitive to these matters,” says Dr. Post.
Dr. Westle notes he has provided more companionate care (“hugging family and patients, sitting and talking about the good old days”) than spiritual guidance.
“Some patients and families feel supported simply by their doctor or nurse joining in a moment of silence or even holding hands during a spoken prayer,” adds Dr. Taylor. “Some of us are better than others at identifying and responding to spiritual needs. But I do think it’s a shared responsibility. The more people we can engage in identifying and responding to spiritual needs, the better patient, family, and medical team will be served. Hospitalists are in an excellent position to identify those needs because of their everyday contact. And if they simply make the right referrals, they’ve done a really good job.” TH
Gretchen Henkel writes frequently for The Hospitalist.
- Barnes LL, Plotnikoff GA, Fox K, et al. Spirituality, religion, and pediatrics: intersecting worlds of healing. Pediatrics 2000 Oct;106(4 Suppl):899-908.
- Post SG, Puchalski CM, Larson DB. Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics. Ann Intern Med. 2000 April 4;132(7):578-583. Comment in: Ann Intern Med. 2000 Dec 5;133(11):920-1; Ann Intern Med. 2000 Nov 7;133(9):748-9.
- Kwiatkowski K, Arnold B, Barnard D. Physicians and Prayer Requests. Fast Fact and Concept #120. Available at www.eperc.mcw.edu/fastFact/ff_120.htm. Last accessed April 5, 2007.
- Taylor C, Lillis C, LeMone P. Fundamentals of Nursing: The Art and Science of Nursing Care, 5th ed. 2005. Philadelphia: Lippincott, Williams & Wilkins; 2005.