Several years ago, a patient at Virtua West Jersey Hospital Marlton, in Marlton, N.J., was diagnosed with metastatic colon cancer with spinal metastases. The patient was septic, bleeding from a spinal wound, and was experiencing kidney failure. Hospitalists recommended stopping treatment and moving the patient to hospice care. The patient’s family refused, and told hospitalists that, according to their Christian faith, suffering was the only true path to heaven. Hospitalists kept the patient as comfortable as possible, but blood pressure problems and hypotension made it difficult for them to administer pain medication.
Hospitalists held numerous meetings with the family and medical and nursing staff to discuss the ethical implications of the situation. Two months later, the patient suffered cardiac arrest and died.
“The medical staff and family were continuously at odds because the patient was suffering so much,” says Marianne Holler, DO, a hospitalist at University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, who was part of the patient’s medical team. “We were never able to discontinue life support throughout [the patient’s] hospital stay.”
Whether planning a routine procedure or end-of-life care, hospitalists may be called into religious discussions with patients, their families, spiritual advisors, and hospital chaplains. While many hospitalists have received ethics and other professional training to prepare them for these conversations, some say the intersection of religion and medicine remains a challenging and multifaceted aspect of their practice.
—The Rev. Peter Yuichi Clark, PhD, Alta Bates Summit Medical Center, Berkeley, Calif.
A Hospitalist’s Belief
Hospitalists’ brief relationships with patients may influence the degree of knowledge they have about an individual’s religious beliefs, says Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif. Over the years, primary care physicians may become less involved with a patient’s acute medical needs as they use hospitalist services to manage their inpatients, Dr. Enderby says. This means hospitalists must discuss patients’ wishes regarding code status and resuscitation, end-of-life care, and other necessary treatments.
When discussing religion and treatment, hospitalists must put aside their personal beliefs, and this may not always be easy, says Dr. Thomas McIlraith, MD, medical director of Hospital Medicine at Mercy Medical Group in Sacramento, Calif. Dr. McIlraith recalls a Jehovah’s Witness patient who cited religious beliefs when refusing a blood transfusion following a massive post-partum hemorrhage. The patient was severely anemic, and her hemoglobin levels plunged dangerously to 2 gm/dL. Leaders from the patient’s church asked Dr. McIlraith to try hemoglobin substitutes, but he was unable to do so because these substitutes still were experimental and associated with significant complications, he says.
Dr. McIlraith had to act fast. He instructed the obstetrician on the case to stop drawing hemoglobin levels; the patient needed every drop of blood she had to carry oxygen. He administered erythropoietin and iron to stimulate red blood cell production. He also put the patient on high flow oxygen to help saturate the plasma. The patient survived without a blood transfusion or significant complications.
“I didn’t think [the patient] was going to make it,” says Dr. McIlraith. “This was a very difficult situation because I knew they would have benefited from a blood transfusion. But, I presented them with their options and respected their wishes.”
Religious diversity can be another challenging aspect of patient care. In its 2008 U.S. Religious Landscapes Survey, the Pew Forum on Religion and Public Life interviewed 35,000 Americans age 18 and older and found “religious affiliation in the U.S. is both very diverse and extremely fluid.” The survey also found “people who are unaffiliated with any particular religion (16.1%) also exhibit remarkable internal diversity.”
Asking questions is the key to understanding a patient’s religious and spiritual needs, says the Rev. Peter Yuichi Clark, PhD, chaplain administrator at Alta Bates Summit Medical Center in Berkeley, Calif., who works closely with medical teams to assess and respond to these needs.
“I don’t assume I know what a patient’s religious needs are—even if I know what religion they profess to be,” Clark says. “Some patients may be very devout but do not practice certain aspects of their religion, while others follow a religion in name only but look for religious support during a time of crisis.”
Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, says it is impossible to predict an individual’s religious beliefs and how that may affect their hospital stay—even when the physician practices the same religion as the patient. For example, Dr. Patel knows that some, but not all, Hindus observe a strict vegetarian diet and that Vitamin B12 deficiencies are more prevalent in vegetarian populations. However, diet may not be the cause of this deficiency if the patient is not a vegetarian. Rather than assume, it’s important to ask Hindu patients if they observe a vegetarian diet, Dr. Patel says.
Some hospitalists find it difficult to engage patients in conversations about religion. In a study published in the June 2007 edition of the Journal of Palliative Medicine, researchers found physicians’ knowledge of factors relating to end-of-life care, which included patients’ religious and spiritual concerns and whether they affect decisions regarding end-of-life care, is poor.1
Hospitalists don’t have much time to get to know the person, so it’s even more important for them to have conversations about religion and end-of-life-care, says the study’s lead author Susan DesHarnais, PhD, of Pennsylvania State University’s Hershey Department of Public Health Sciences, Milton S. Hershey Medical Center College of Medicine. As important as these conversations are, Dr. DesHarnais learned hospitalists rarely have them.
When asked why she thinks these conversations rarely occur, Dr. DesHarnais said the research did not directly address that question, but she suspects the physicians don’t have a lot of time. Also, end-of-life decision-making is difficult, and some people are not comfortable talking about it, she says.
“Another factor may be that hospitalists are used to using technology for medical intervention more than they are used to working with people when not much more can be done,” she says.
Dr. Holler, who worked as a social worker before attending medical school, agrees that many physicians are uncomfortable with end-of-life decisions.
“Many physicians are 25 to 30 years old during their training,” says Dr. Holler. “They have been in school for many years. Some are discovering their own spiritual identity at the same time they are dealing, or learning to deal, with patients and families and where they are spiritually or religiously. Many haven’t dealt with these issues in their own personal lives yet.”
While Dr. Holler says she believes most doctors are caring and compassionate, end-of-life and religious discussions use different skill sets than those that preserve and extend life. “Often times we are not taught when enough is enough and how to convey that to patients and families,” says Dr. Holler. “Many doctors are afraid that they are conveying that they are giving up or that it isn’t worth it in the long run. So, many physicians find it easier to ‘keep going.’ ”
The Medical Community’s Response
The medical community is responding to shifting cultural and religious demographics, and more doctors are paying attention to religious diversity, Clark says. But a 2003 Joint Commision study of 60 public and private hospitals across the country, “Hospitals, Language and Culture: A Snapshot of the Nation,” found that hospitals still have work to do in this area.
“We found that hospitals are collecting data on patients’ religion, but it’s just not clear how they use it to improve services,” says Amy Wilson-Stronks, project director for health disparities with the Joint Commission and principal investigator of the study.
The current Joint Commission standards require hospitals to respect patients’ spiritual needs, beliefs, and values. Spiritual care issues first appeared in the 1969 accreditation manual and were adopted into standards in 1992, Wilson-Stronks says.
Awareness and communication can benefit patients, hospitalists, and medical staff as a whole. For example, Alta Bates Summit’s intensive care unit staff in Berkely, Calif., turned to Chaplaincy Services about Muslim patients’ requests to continue their daily prayers, which include thorough washing of their hands, forearms, and other parts of their bodies (even when intravenous lines are attached). Chaplaincy Services reached out to an Islamic network group for advice and learned patients could rub a stone across their bodies to wash themselves. Chaplaincy Services now makes these stones available for staff and patients, Clark says.
Medical staff also works with Chaplaincy Services to accommodate Muslim patients’ wishes to face in the direction of Mecca during prayer, which can require maneuvering beds and other equipment, he says.
Some patients and their families may not understand how their religious tradition addresses code status, resuscitation, and when it is appropriate to withhold treatment, says Richard Rohr, MD, vice president of medical affairs at Cortland Regional Medical Center in Cortland, N.Y. While working as a hospitalist, Dr. Rohr suggested moving a terminal patient to palliative care and seeking a do not resuscitate (DNR) order. The patient’s family refused, and told Dr. Rohr they were Catholic and a DNR would violate their religious beliefs.
According to Dr. Rohr, DNR status and palliative care are described in the code of ethics adopted by the Catholic Health Association, and this type of care is generally provided at Catholic hospitals.
“I gently told them that this was within their religion, but they said no to palliative care and the DNR,” Dr. Rohr says. “The patient eventually died but it was much more difficult for them. They were subjected to active treatment that they couldn’t really benefit from.”
Families often seek the advice of spiritual advisors when making difficult decisions about code status and DNR orders. Barbara Egan, MD, a hospitalist at Memorial Sloan-Kettering Cancer Center in New York City, recalls treating an Orthodox Jewish patient who was suffering from end-stage disease. Death was imminent, and hospitalists recommended palliative care. The patient’s family members balked at the recommendation and insisted hospitalists “do everything possible” to treat their loved one. Soon after, the family’s rabbi arrived to counsel the family. After visiting the patient and speaking to medical staff about the prognosis, the rabbi urged the family not to pursue further treatment or artificial resuscitation. The patient was moved to a palliative care unit and passed away within a few days.
“The family’s rabbi told them exactly what I had: that there were no useful medical interventions for the patient,” Dr. Egan says. “But they really needed to hear it from him before they could come to an agreement on a DNR.”
Physicians’ reactions to religion at the bedside have evolved the past 25 years, says Kenneth Patrick, MD, ICU director at Chestnut Hill Hospital in Philadelphia. Physicians were more paternalistic then, and believed they knew what was best for their patients—and their families—regardless of their patient’s religious beliefs.
While serving as a fellow at Memorial Sloan-Kettering Cancer Center, Dr. Patrick worked with a terminally ill Buddhist patient in the intensive care unit. When death was imminent, the ICU director allowed Buddhist monks to light candles and pray in the room during the hours leading up to the patient’s death. At the time, this was not something that was normally done in a hospital, Dr. Patrick says. While the ritual may have kept medical staff from checking vital signs as often as they would have normally, he says this did not affect the patient’s treatment.
“I believe it is incumbent on the hospitalist to adjust his or her beliefs to be more accepting of our patients’ values,” Dr. Patrick says. “I can agree to any request I find to be reasonable and in the patient’s best interest, even if it is different than what I believe.” TH
Gina Gotsill is a journalist based in California.
- DesHarnais S, Carter RE, Hennessy W, Kurent JE, Carter C. Lack of concordance between physicians and patient: Reports on end-of-life care discussions. J Pall Med. 2007 June;10(3):728-740.