End-of-life issues and spiritual histories. (Original Article).Background: Patients facing end-of-life issues have spiritual concerns that may have an impact on their medical decision-making.Methods: To determine whether physicians address spiritual concerns in this context, we reviewed the charts of 92 elderly hospitalized patients facing decisions regarding resuscitation resuscitation /re·sus·ci·ta·tion/ (-sus?i-ta´shun) restoration to life of one apparently dead. cardiopulmonary resuscitation status or feeding tube feeding tube n. A flexible tube that is inserted through the pharynx and into the esophagus and stomach and through which liquid food is passed. placement. Results: The average age of the participants was 72.4 years and 51% of them were female. Only 6.5% of the patients had spiritual histories documented in their charts; 29% had either a spiritual history or some mention of chaplain CHAPLAIN. A clergyman appointed to say prayers and perform divine service. Each house of congress usually appoints it own chaplain. or psychiatrist psychiatrist /psy·chi·a·trist/ (si-ki´ah-trist) a physician who specializes in psychiatry. psy·chi·a·trist n. A physician who specializes in psychiatry. involvement. Conclusion: Spiritual concerns of many patients facing end-of-life decisions are not being addressed. ********** Decisions regarding resuscitation status and artificial nutrition are some of the most difficult decisions that patients and family members will ever have to face. Many factors outside of objective medical data enter into these decisions. (1-3) Family members report that end-of-life decisions often rest on religious or spiritual beliefs. (4) Unless physicians address these beliefs, they risk alienating al·ien·ate tr.v. al·ien·at·ed, al·ien·at·ing, al·ien·ates 1. To cause to become unfriendly or hostile; estrange: alienate a friend; alienate potential supporters by taking extreme positions. patients and their families or risk ignoring important factors that may assist patients and families in making appropriate and informed decisions. (5) Many patients believe it is appropriate for their physician to inquire in·quire also en·quire v. in·quired, in·quir·ing, in·quires v.intr. 1. To seek information by asking a question: inquired about prices. 2. about spiritual issues, especially when patients near the end of life. (1-3) Most physicians also believe that discussing spiritual issues with their patients is appropriate. (2,6,7) Serious and life-threatening events have been reported by patients and physicians as the most appropriate time for religious inquiry. (2,7) In the clinical setting, the highest percentage of spiritual inquiries occur around the following major life events: birth (13%), death (19%), major surgery (10%), major illness (8%), and terminal illness (6%). (2) Although some physicians have supported incorporating spiritual histories into routine history taking, (8-11) recent recommendations express an even greater need for spiritual issues to be addressed at the end of life. (12) Many physicians are uncomfortable addressing patients' religious and spiritual (7,12) Many physicians report at least occasionally addressing their patients' spiritual concerns, but studies have found that the majority of patients could not recall physician inquiries about religion. (1,2) Whether physicians are initiating discussion of these issues is of paramount importance, since patients are often reluctant to make their spiritual needs known. (1,2) Despite recent interest in the medical literature in both spirituality and end-of-life issues, (5,12) the extent to which physicians address spiritual concerns at this critical time has not been well studied. Therefore, we were interested in determining how often physicians document discussing spiritual issues with patients near the end of life. To determine whether physicians address spiritual concerns in this context, we reviewed the medical charts of 92 elderly hospitalized patients facing decisions regarding resuscitation status or feeding tube placement. Methods This study used a retrospective LAW, RETROSPECTIVE. A retrospective law is one that is to take effect, in point of time, before it was passed. 2. Whenever a law of this kind impairs the obligation of contracts, it is void. 3 Dall. 391. chart review design. Charts were reviewed by a family medicine resident at both a community hospital and a university hospital. Charts from the 2000 calendar year were obtained from a list of patients aged 65 or older who had died and had a do-not-resuscitate (DNR See dynamic noise reduction and domain name resolver. ) order on their chart at the time of death and/or patients who had had a percutaneous endoscopic gastrostomy percutaneous endoscopic gastrostomy See PEG. (PEG peg 1. To fix the price of a new security issue during the issuance period through buying and selling it in the open market in order to ensure that the price in the secondary market will not fall below the offering price. ) procedure. Subject patients were identified from hospital data obtained in the medical records department with a goal of identifying 50 patient records for review at each hospital. We found and completed all of the 50 record reviews at one hospital and 42 of the 50 at the other (8 records could not be found or were not available during the period of the study). Demographic data recorded were age, sex, race, and religion. In addition, the resident searched the charts for spiritual histories, chaplain involvement, or psychiatrist involvement. A spiritual history was considered to be present if the provider mentioned spirituality, religion, church, or faith in the history and physical examination, progress notes, or consultation part of the chart or if there was any reference to the meaning, worth, quality, or value of life. Chaplains and/or psychiatrists This list includes notable psychiatrists. Individuals listed below are all physicians, and are board certified by the American Board of Psychiatry and Neurology, or are members of the American Psychiatric Association, or the Royal College of Psychiatrists in the United Kingdom, or were considered to have been involved if there was an order or note from either of these services on the chart. In the patients who had a PEG procedure, the resident also reviewed the information contained in the operative OPERATIVE. A workman; one employed to perform labor for another. 2. This word is used in the bankrupt law of 19th August, 1841, s. 5, which directs that any person who shall have performed any labor as an operative in the service of any bankrupt shall be note. Results A total of 92 patient charts met the criteria and were reviewed as part of the study. The average age of patients was 76.2 years, and 51% were female. Twenty-eight percent of patients were black, 66% white, and 5% other or unknown. Religious denominations For other senses of this word, see denomination. A religious denomination (also simply denomination) is a subgroup within a religion that operates under a common name, tradition, and identity. , obtained from hospital admission forms, were 47% Protestant; 8% Catholic; and 11% other religions; 34% of the forms showed no religious preference. Documented spiritual histories by a physician were found in 6.5% of charts reviewed. An additional 23% of records contained an order or note for consultation by the psychiatry psychiatry (səkī`ətrē, sī–), branch of medicine that concerns the diagnosis and treatment of mental, emotional, and behavioral disorders, including major depression, schizophrenia, and anxiety. or chaplain service. The table shows the documentation of spiritual histories according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. DNR or PEG status. Discussion This study found that few patients nearing the end of life had any documentation in the medical record that spiritual issues were addressed. Only 6.5% of patients had spiritual history recorded by a physician, and only 29% of records showed spiritual issues addressed, which included any involvement by a psychiatrist or chaplain. The fact that spiritual history was found more frequently in patients facing DNR than in those facing feeding tube decisions (38% versus 23%) offers further validity to our findings, since resuscitation decisions are more serious and more indicative of end-of-life issues. We consider the criteria that we used for including a documented spiritual history by the chaplain or psychiatrist to be a broad and inclusive definition, since we did not require that the psychiatrist specifically mention spiritual or religious issues. Despite this broad definition, less than one third of patients had spiritual issues addressed at a time when recent recommendations suggest it is extremely important to do so. (12) Attempting to facilitate the end-of-life decision-making process without knowledge of a patient's personal and spiritual beliefs may not serve the best interests of the patient. This study shows that physicians infrequently in·fre·quent adj. 1. Not occurring regularly; occasional or rare: an infrequent guest. 2. document addressing these issues. Why is this true, when physicians seem to agree on the importance of doing so? (8,11,12) One explanation is that these discussions actually are occurring but are just not being documented in the medical record. However, in the current study, any reference to the meaning, worth, quality, or value of life in the medical record was considered positive for spiritual history, despite the lack of specificity of such references. Physicians may believe it is not important to document discussions of spiritual issues in the medical record, or they may be uncomfortable doing so in any detail. However, addressing goals and values in the context of palliative care palliative care (paˑ·lē·ā·tiv kerˑ), n an approach to health care that is concerned primarily with attending to physical and emotional comfort rather , which includes spirituality and religious issues, is clearly an obligation of the physician. (13) If physicians have an obligation to counsel patients regarding such issues, then they have a parallel obligation to document their efforts in the medical record, to inform other members of the health care team. Rarely do physicians care for patients in isolation. It is essential to communicate the patient's beliefs, concerns, values, and preferences to other people taking part in the patient's care near the end of life. Perhaps these discussions were not in the medical record because of timing issues. Spiritual issues may have been discussed at another time and not documented in the medical record. This explanation is unlikely, since discussions of resuscitation status may be the first time that patients and families contemplate death and the limitations of medical measures. (12,13) Furthermore, making the medical team aware of the patient's cultural, spiritual, and religious background is critical to advising and caring for patients receiving palliative care. (14) Another possible explanation for the low rate of documented spiritual histories is that physicians may have believed they lack the expertise to properly address patients' spiritual concerns. Ellis et at (17) surveyed physicians in Missouri and found that physicians were uncomfortable addressing spiritual issues in the clinical context, although they thought that it was important to do so in patients nearing the end of life. Another explanation may be time constraints In law, time constraints are placed on certain actions and filings in the interest of speedy justice, and additionally to prevent the evasion of the ends of justice by waiting until a matter is moot. in the clinical setting of the busy acute care hospital. Discussions of spiritual issues may take considerable time, and physicians may be pressed to deal with more acute medical issues. Physicians may need more education to acquire the skills to be able to assess relevant spiritual issues in patients facing important medical decisions. One option available to physicians with limited time, personal resources, or training is use of consultants. Physicians can ask psychiatrists or chaplains to address spiritual issues if they perceive that they lac lac, resinous exudation from the bodies of females of a species of scale insect (Tachardia lacca), from which shellac is prepared. India is the chief source of shellac, although some is obtained from other areas in Southeast Asia. k time or expertise. In the current study, we considered consultation with a psychiatrist or chaplain as positive for addressing spiritual issues. Despite including these cases as "documented" in the current study, less than one third of patients had spiritual issues addressed by the medical team. This study has several limitations. The study was conducted at only two hospitals, although one was a community hospital and one was a university medical center. The hospitals were in the same city in the Southeast, and results may not be the same in other areas of the country. The charts selected for review were not randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. but constituted a convenience sample from the available charts during the selected period. Finally, documenting a spiritual history may be considered "personal" (rather than medical) information that does not need to be recorded in the medical record. Thus, the medical record review may not reflect the actual number of patients who had spiritual issues addressed by the medical team. Conclusion We found that physicians do not routinely document spiritual histories in hospitalized patients facing end-of-life decisions. Further research should focus on whether specific factors or patient characteristics play a role in predicting who will have spiritual issues addressed and how to facilitate and improve physicians' ability to assist patients with spiritual concerns at the end of life.
Table 1
Documented spiriutal histories in patients facing end-of-the decisions
(a)
Spiritual
history of
Spiritual psychiatrist
Patient group history or chaplain
All patients (n = 92) 6 (6.5%) 27 (29.3%)
Patients who had PEG (n = 25) 0 (0%) 4 (23.1%)
Patients with DNR order (n = 40) 6 (15%) 15 (37.5%)
Patients having both (n = 27) 2 (7.4%) 8 (29.6%)
(a) PEG, percutanueous endoscopic gastrostomy; DNR, do not resuscitate.
Accepted July 2, 2002. References (1.) King DE, Bushwick BM. Beliefs and attitudes of hospital inpatients about faith healing faith healing, relief or cure of bodily ills through some religious attitude on the part of the sufferer. In the Jewish and Christian traditions prayers for cures and miracles are usual; thus the apostles developed a ritual of healing (James 5. and prayer. J Fam Pract 1994;39:349-352. (2.) Maugans TA, Wadland WC. Religion and family medicine: A survey of physicians and patients. J Fam Pract 1991;32:210-213. (3.) Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine. in·tern or in·terne n. Med 1999;159:1803-1806. (4.) Mitchell SL, Berkowitz RD, Lawson FM, Lipsitz. A cross-national survey of tube-feeding decisions in cognitively impaired older persons. J Am Geriatr Soc 2000;48:391-397. (5.) Kaldjian LC, Jekel JF, Friedland G. End-of-life decisions in HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. positive patients: The role of spiritual beliefs. AIDS 1998;12:103-107. (6.) Koenig HG, Bearon LB, Dayringer R. Physician perspectives on the role of religion in the physician-older patient relationship. J Fam Pract 1989;28:441-448. (7.) Ellis MR, Vinson DC, Ewigman B. Addressing spiritual concerns of patients: Family physicians' attitudes and practices. J Fam Pract 1999;48:105-109. (8.) King DE. Faith, Spirituality and Medicine: Towards the Making of the Healing Healing See also Medicine. Achilles’ spear had power to heal whatever wound it made. [Gk. Lit.: Iliad] Agamede Augeas’ daughter; noted for skill in using herbs for healing. [Gk. Myth. Practitioner. New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , Haworth Press, 2000. (9.) Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health: A Century of Research Reviewed. New York, Oxford University Press, 2000. (10.) Anandarajah G, Hight hight adj. Archaic Named or called. [Middle English, past participle of highten, hihten, to call, be called, from hehte, hight, past tense of hoten E. Spirituality and medical practice: Using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician 2001;63:81-89. (11.) Cohen cohen or kohen (Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male. CB, Wheeler SE, Scott DA. Walking a fine line: Physician inquiries into patients' religious and spiritual beliefs. Hastings Cent Rep 200l;31:29-39. (12.) Lo B, Ruston D, Kates LW, Arnold RM, Cohen GB, Faber-Langendoen K, et al. Discussing religious and spiritual issues at the end of life. JAMA JAMA abbr. Journal of the American Medical Association 2002;287:749-754. (13.) Quill quill: see pen. TE. Initiating end-of-life discussions with seriously ill A patient is seriously ill when his or her illness is of such severity that there is cause for immediate concern but there is no imminent danger to life. See also very seriously ill. patients: Addressing the "elephant in the room Not to be confused with White elephant. The elephant in the room (also elephant in the living room, elephant in the corner, elephant on the dinner table, elephant in the kitchen, horse in the corner, 400lb gorilla in the room, etc. ." JAMA 2000;284:2502-2507. (14.) Koenig BA, Gates WJ. Understanding cultural differences in caring for dying patients. West J Med 1995;163:244-249. RELATED ARTICLE: Key Points * Family members often report that medical decisions rest on religious or spiritual beliefs. * Most physicians believe that discussing spiritual issues with their patients is appropriate, especially when patients are facing serious medical or end-of-life decisions. * Only 6.5% of the medical records in this study contained any spiritual or religious history information; an additional 23% had some documentation of chaplain or psychiatrist involvement. From the Department of Family Medicine, Medical University of South Carolina “MUSC” redirects here. For Abel Santa María airport in Santa Clara, Cuba (ICAO code MUSC), see Abel Santa María Airport. The Medical University of South Carolina , and Trident Regional Medical Center, Charleston, SC. Reprint reprint An individually bound copy of an article in a journal or science communication requests to Dana E. King, MD, Department of Family Medicine, Medical University of South Carolina, 295 Calhoun Street, P.O. Box 250192, Charleston, SC 29406. Email: kingde@musc.cdu Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9604-039 |
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