Spirituality Often Left Out of Goals-of-Care Discussions in ICU

Beth Skwarecki

September 03, 2015

Even when family members consider themselves religious, goals-of-care conferences only included mentions of spirituality 16.1% of the time in a multicenter, qualitative study. Healthcare professionals rarely brought up the subject and often redirected the conversation when religious beliefs came up.

"Although many patients wish to have their religious values incorporated in end-of-life decisions, our research indicates that religious and spiritual considerations are infrequently discussed during physician-family meetings. Developing strategies to ensure adequate exploration and integration of religious and spiritual consideration may be important for improving patient-centered care in [intensive care units (ICUs)]," the investigators write in an article published online August 31 in JAMA Internal Medicine.

Previous studies reported that patients who discussed religious and spiritual concerns with their providers are more satisfied with their care. These discussions "foster appropriate levels of hope and help guide medical decisions," the authors write.

Investigators recorded 249 goals-of-care conversations between healthcare professionals and the surrogate decision-makers of adults who were on a ventilator and had acute lung injury and a likelihood of severe long-term functional impairment. They categorized and counted references to spirituality or religion, which only occurred in 40 of the conferences, or 16.1%.

Family members were the first to bring up the subject in 26 of the meetings, and healthcare professionals were the first in 14. Most family members (77.6%) had indicated on a survey that religion or spirituality was "fairly" or "very" important in their life; 74.0% identified as Christian compared with only 44.1% of the healthcare professionals.

The most common theme in the family members' religious statements, made in 15 of the 40 conferences, was the belief that God is ultimately responsible for physical and spiritual health, including references to miracles. Another common theme, in 10 of the 40 meetings, was referring to prayer or other rituals such as last rites.

Healthcare providers most often responded to religious statements by speaking about the medical plan for care (15 of 40 meetings) or with empathic statements that did not refer to religion. Only rarely (3 of 40 meetings) did the physician ask about the patient's or family member's beliefs or speak about their own beliefs. This may be, the authors write, because healthcare professionals place less value on religious beliefs than on decision-making by medical facts only. They may also feel unprepared for religious discussions because of a lack of training.

These findings "indicate the crucial need for greater integration of chaplaincy into ICU care and for spiritual care education for health care professionals," Tracy Balboni, MD, from the Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, and the Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, and colleagues write in an accompanying editorial.

The study leaves some questions unanswered, Dr Balboni and colleagues write: When family members did not bring up religion, was that because they felt uncomfortable doing so? Or because they did not think it was relevant to a medical discussion? They also consider that nonreligious mentions of spirituality, such as values relating to an atheist patient's beliefs, may not have been accounted for.

This study was supported by the National Institutes of Health. The authors and commentators have disclosed no relevant financial relationships.

JAMA Intern Med. Published online August 31, 2015. Article abstract, Commentary extract


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