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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 status or feeding tube 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 or psychiatrist 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 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 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.


This study used a retrospective 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) order on their chart at the time of death and/or patients who had had a percutaneous endoscopic gastrostomy (PEG) 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 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 note.


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, 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 or chaplain service. The table shows the documentation of spiritual histories according to DNR or PEG status.


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 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, 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 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 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 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.


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

 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.


(1.) King DE, Bushwick BM. Beliefs and attitudes of hospital inpatients about faith healing 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 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 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 Practitioner. New York, 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 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 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 2002;287:749-754.

(13.) Quill TE. Initiating end-of-life discussions with seriously ill patients: Addressing the "elephant in the room." 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.


* 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, and Trident Regional Medical Center, Charleston, SC.

Reprint 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

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Article Details
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Title Annotation:medical research; includes study table and related article "Key Points"
Author:Wells, Brian J.
Publication:Southern Medical Journal
Geographic Code:1USA
Date:Apr 1, 2003
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