Spirituality and End-of-Life Care

The young doctor stood next to the bed of Bea, a 72 year old woman dying of stage four ovarian cancer with numerous metastases. A chest tube was in place, draining a pleural effusion. Her pain medications were doing the trick. Her vitals were steady. He asked Bea how she was feeling; she replied, "Never been better, doc." He scarcely heard her answer. He didn't stop to think how a patient so close to death could say, "Never been better." Already, so early in his career, patients became "cases," and caring for dying patients had become routine to the doctor. He liked patients like Bea who never complained and made his life easy…. until now, that is. As he turned to leave, she asked him, "Doctor, will you pray with me?" The doctor stopped in his tracks. He had no idea what to do. He quickly remembered the one day he had been required to spend during the third year of medical school shadowing a chaplain. Though it felt like a waste of time then, he knew that it would come in handy someday. And so, without hesitation, he coolly replied, "Just a minute, let me go get the chaplain."

What would you do if a patient asked you this? Would you feel uncomfortable? Would you consider it a waste of time? Would you bolt from the room as soon as possible and get the chaplain? Or would you realize that this was a golden opportunity to connect with your patient and maybe help them with death in a way that no dose of morphine, no matter how high, ever could?

Our technocratic education system drills into our heads from the first day of medical school that our main goal as doctors is to diagnose illness, prescribe medications, and cure disease when we can. All non-biological areas of a patient’s life are lumped into that category called "social issues." We diligently take social histories, but seldom incorporate our findings into our interactions with our patients. Do we ever really connect with our patients? Do we understand their situation, their hopes and their fears? If we do not, then we do not understand the unique "spirit" of our patient; then our patient Bea is no different than any other 72 y.o. white female with stage four ovarian cancer. Without this connection, patients become cases and diseases, and it then is no wonder that so many physicians get burned out. The incorporation of spirituality into end-of-life care can be therapeutic, for both patient and physician.

Death has changed dramatically in recent decades. Though most people who are asked how they want to die reply, "Suddenly or in my sleep and at home," the facts are quite opposite. Most patients today die in an institution and death is seen coming long beforehand. This gives patients a lot of time to contemplate questions such as, "What was the meaning of my life? Why am I suffering? Where am I going after death? What will happen to my loved ones after I die?" Medical science has no answers to these sorts of questions. As the end approaches, many people do a "life review" and need help dealing with guilt and regrets that often surface. Very often, these feelings are more painful than the disease afflicting the patient.

So what is a medical student to do? Take a year off of medical school and take up a chaplain-training program? No, of course not. We need to, first and foremost, become comfortable with death. We need to come to terms with the fact we will, one day, die. Overcoming our fear of the death is the only way we can have hope of helping patients to work through their issues surrounding death. The second thing we must do as physicians is to get in touch with our spiritual selves. This requires a lot of introspection, but the only way to connect with other people in a spiritual manner is if you are spiritual yourself. The third thing we must do is to become comfortable with talking to our patients about their spiritual beliefs. Does this sound outside the realm of medicine to you? Many physicians think so, but a recent USA Today poll, showed 65% of patients would like to discuss their spiritual beliefs with their physicians, but only 10% of those physicians actually did. 44% of hospitalized patients in a Duke University study said that spiritual beliefs were the most important thing in coping with an illness (only 9% of physicians thought so). Spirituality becomes of even greater importance when dealing with patients who are near death. It is not uncommon for patients to want some sort of spiritual/religious ritual done near death. In fact, a recent Gallup poll showed that close to one-half of people believe that they would find comfort in a spiritual activity (prayer, ritual, having someone help you become spiritually at peace, etc) at the end-of-life. It does not take too much effort to learn the basic end-of-life rituals and beliefs of the major religions and cultures represented where you practice medicine (see the chapter on cultural issues and end-of-life care). You can learn a few simple prayers to do with a patient. Or, if you do not know, rather running out of the room, ask the patient to lead the prayer. It also is good habit to begin taking "spiritual histories" as routinely as we do "family histories" on all of your patients. Dr. Christina Puchaliski has come up with a quick, four-step spiritual assessment that I urge everyone to read and apply in their day-to-day practices.

When it comes time to die, spiritual issues often become of paramount importance. A hospice nurse with 22 years of experience said, "I never cease to be amazed at how profoundly a person’s perceptions and beliefs about what is going to happen to them after they die affects the quality of the last few moments of their life." We must realize this as physicians, and realize that just because there are no more tests to order and no more medicines to give that our work is not over. The greatest thing we might be able to do is sit with the patient for a few minutes and to support their search for meaning in life. Who knows, in this process we may just find meaning in our lives and in our profession.

Good resources to start out with:

Puchalski, Christina. "Spirituality and End-of-Life Care." Faith and Medicine Connection. Summer 1998. http://www.nihr.org

Puchalski, Christina. "Taking A Spiritual History: FICA." Spirituality and Medicine Connection. Spring, 1999. http://www.nihr.org

For information on the various faiths of the world:

"Health/Medicine and the Faith Traditions" series from The Park Ridge Center for the Study of Health, Faith, and Ethics. 14 volumes. New York: Crossroad Publishing Co.

A good book to read:

Albom, Mitch. Tuesdays With Morrie.