Keeping Spirituality on the Table

Betty R. Ferrell, PhD, RN


November 24, 2015

Health Care Professionals' Responses to Religious or Spiritual Statements by Surrogate Decision Makers During Goals-of-Care Discussions

Ernecoff NC, Curlin FA, Buddadhumaruk P, White DB
JAMA Intern Med. 2015;175:1662-1669

The Element of Spirituality

In the movement to align serious illness care with patients' personal goals, the need to have focused "goals-of-care conversations" with family members and surrogate decision-makers is increasingly recognized. Although spirituality is also a topic of increasing interest, previous research has not evaluated the role of spirituality in goals-of-care meetings.

This study prospectively evaluated 249 goals-of-care conversations involving 651 surrogate decision-makers and 441 healthcare professionals in 13 intensive care units (ICUs). The investigators audiorecorded conversations between surrogate decision-makers and healthcare professionals and applied a rigorous qualitative analysis to identify spiritual or religious themes in the transcribed conversations.

The analysis revealed that most (77%) of the surrogates endorsed religion or spirituality as important elements of goals-of-care discussions, yet spiritual concerns were raised in only 16% of these conferences. Surrogates were the first to raise religious or spiritual considerations in 65% of the conversations. When surrogates did raise spiritual concerns, some healthcare providers changed the topic to medical issues (n = 15), offered to involve spiritual care providers (n = 14), expressed empathy (n = 13), acknowledged surrogates' statements (n = 11), or explained their own beliefs (n = 3). In few conversations (8 of 249) did healthcare providers actively pursue spirituality concerns or attempt to understand the patient's beliefs.


Several recent studies have described the significance of spirituality in serious illness.[1,2,3,4] Most of these have been descriptive surveys of patients, family members, or clinicians. Very few studies include observations of spiritual care in practice.

This study is significant for several reasons. First, the investigators focused on a very specific clinical encounter—family conferences related to goals of care—in 13 different ICUs. This clinical setting is one in which important care decisions are made.

Second, the analysis identified a striking gap between the family members' endorsement of spirituality as important in their lives and actual inclusion of spirituality issues during goals of care conferences.

A third important and equally concerning finding was that surrogates were far more likely than clinicians to raise spiritual topics, and when surrogates did so, healthcare providers often redirected the conversation away from these issues. The finding that healthcare professionals actively pursued spirituality concerns or attempted to understand the patients' beliefs during a dismal 3% of goals-of-care conversations demonstrates another marked gap between patient and family needs and the provision of spiritual care.

These results are in sharp contrast to the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, which identify spiritual care as one of the essential domains.[5] This quality gap in spiritual care is remarkable and should serve as a call for substantial change in ICUs and other settings where seriously ill patients receive care. Some of the most obvious implications are the need for an increased presence of chaplains in ICUs and in attendance at family conferences, and the very critical need for training of other healthcare providers to increase their skills in discussing spirituality.

In no other domain of palliative care would a 3% rate of quality care be acceptable. Hopefully, this study can stimulate attention to spirituality in care for serious illness, which ultimately is the focus of patient-centered care.


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