Junaid Nabi: Can addressing the spiritual needs of patients help us deliver high quality end of life care?

Should doctors only engage in conversations about life, death, and dying when it pertains to clinical matters? Or is spiritual care part of a physician’s duties?

junaid_nabi“In the last moments of her life, my mother was not worried about whether her chemotherapy was working or not, but whether her life had meaning.”

A moment of silence followed the young man’s admission of how his mother felt in the last few days of her life. He was invited as a guest speaker to a seminar on spirituality and healing in medicine—a Harvard Medical School course designed to engage young healthcare providers in their role in the last transition of life: from sickness to death.

Should doctors only engage in conversations about life, death, and dying when it pertains to clinical matters? Or is spiritual care part of a physician’s duties? And, if it is, can physicians utilize this understanding of their patients to enhance the quality of end of life care?

More than 80% of the world’s population is religiously affiliated; in addition, the same survey revealed that among the 16% of those that don’t identify with any religious doctrine, many still report holding some form of spiritual belief. In the US, for instance, the Pew Research Center reported that more than three quarters of the population identify themselves as religious, with 53% of adults considering religion or spirituality an important aspect of their lives.

After years spent immersing ourselves in scientific inquiry, and using evidence based medicine for each intervention in a management plan, it is easy to forget that many of our patients place a significant amount of trust in—and derive comfort from—faith, religion, or spirituality. Indeed, research in this area has revealed that patients reported dissatisfaction with the quality of care they received when their attending doctors did not enquire as to what their spiritual needs were or discuss what dying might be like.

It is important to recognize that spirituality does not necessarily mean affiliation to a particular religious doctrine; as corroborated by Pew surveys, it can also mean patients having a set of beliefs that help them find meaning and purpose in life and achieve peace at the end of it.

One of the most important tenets of high quality medical care is the provision of comfort, so when physicians fail to address their patients’ spirituality, an important opportunity is lost. Addressing this need doesn’t have to mean taking part in lengthy theological discussions: just keeping an open mind during conversations and exploring what spirituality means to your patient is a good start. For example, by asking questions such as “What can we do to support your spiritual needs?” Meeting this need doesn’t always take the form of doctor-patient dialogue either—it can be purely practical and involve making sure patients have access to certain resources. For example, by offering chaplaincy services or even just the provision of books or music to help patients during the end of their lives.

Since attending to a patient’s spiritual and psychological wellbeing is so crucial, it is worth identifying the constraints to realizing this. To begin with, medicine needs to let go of the culture that perceives “death as a failure.”

When resident physicians (and even consultants) are solely measured on the basis of in-hospital mortality rates—without consideration for how much time and effort was invested in a patient—it is easy to develop a mindset where the only goal of a supervising doctor is to worry about whether s/he can keep a patient alive, and not the quality of that life.

This concept of looking at “death as a failure” begins early on in medical education and can create a mindset in doctors that means we try to avoid situations that force us to confront mortality. But instead of actively avoiding discussion of the milestone of death, physicians should be providing comfort to our patients: sometimes by answering their questions and often by proactive listening.

It is also important to address the systematic constraints that limit physicians’ ability to play a part in providing this kind of end of life care. Medical malpractice claims are a real concern, and with little guidance or instruction from senior faculty or in the medical school curriculum, it is increasingly difficult to formally work towards the spiritual needs of patients. And in situations where physicians are not comfortable or do not feel trained enough to address such concerns, recommendations are scarce.

Even in situations where physicians are mindful of the religious affiliations of their patients, there is little consensus on the approach that should be employed: whether it should be active or passive, direct or indirect. Certain physician-pastors have recommended approaching such situations as an extension of the physician-patient dialogue on the plan of management, and to use it as an opportunity to ultimately work towards a franker conversation on prognosis and the episode of death. But more guidance on and training in the best way to approach this aspect of care would be welcome.

In his final book, Dr Paul Kalanithi reflects on his transition from a healthy neurosurgeon to a patient dying from cancer. He describes how important—and comforting—it was for him to have physicians who helped him to confront his mortality in the final days of his life.

In a way, it is appropriate parting advice from a fellow physician on how medicine, with all its modern complexities and ever evolving technologies, is still a form of art. And the best practice of this art is through the proper study of our patients’ concerns and by making sure that they receive dignified treatment—in sickness and in death.

Junaid Nabi is a physician, non-profit executive, and medical journalist. He is a post-doctoral researcher in surgical health services at Brigham and Women’s Hospital and Harvard Medical School. Twitter @JunaidNabiMD

Competing interests: None to declare.

Related article: Palliative care from diagnosis to death

  • nmtucson

    Could we perhaps moderate this idea to “philosophical needs”? The growing number of people who do not identify with any spiritual beliefs also have concerns about death and the meaning of life, but few will have interest in talking with a spiritual guide. In fact, using “philosophical” rather than “spiritual” might help medical professionals consider using neutral terms when asking if the patient wants to talk about their impending death, allowing the patient to direct the conversation based on their particular set of beliefs. Patients with non-spiritual beliefs might consider questions about their “spiritual” concerns disturbing or even offensive (dying people have heavy cognitive loads and may little energy to spare on the feelings of others). Rather than abandon these people to deal with their “non-spiritual” concerns on their own, it makes more sense to me to help medical professionals learn to set their own preferences and preconceptions aside and simply offer to listen to and address all concerns of the patient, wherever they focus. This approach is more inclusive and thus will help far more patients.

  • Lucy Selman

    I agree whole-heartedly with the sentiment of this piece, but most patients won’t understand the question “What can we do to support your spiritual needs?” Better to ask something like “What has helped you get through difficult times in the past?” And explore from there if the person would like any support, and what language they use to talk about purpose, meaning and suffering.

  • Ian Hamilton

    The challenges for spiritual care

    I agree with Dr Nabi that one of the tenets of high quality medical care is the provision of comfort and that when physicians fail to acknowledge their patients’ spirituality an important opportunity is lost. She also highlights the importance of recognising that spirituality does not necessarily mean affiliation to a religious doctrine and provides helpful advice on how doctors should explore spirituality.
    Spiritual care at the end of life is now widely accepted however, the evidence from systematic reviews on the effectiveness of spiritual interventions is less convincing (1,2). There are two challenges; firstly, how can we develop instruments which will more accurately assess the effectiveness of spiritual interventions (3) and secondly, how can we persuade doctors and other healthcare professionals of the importance of good spiritual care (4).

    References
    1. Candy B, Jones L, Varagunam M, et al. Spiritual and religious interventions for well-being of adults in the terminal phase of cancer. Cochrane Database of Systematic Reviews. 2012; DOI: 10.1002/14651858.CD007544.pub 2.
    2. Anderson N, Heywood-Everett S, Siddiqi N, et al. Religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomised controlled clinical trials. Psychological Medicine. 2015; 45, 14, 2937-2949.
    3. Vermandere M, De Lepeleire J, Smeets L, et al. Spirituality in general practice: a qualitative evidence synthesis. Brit J Gen Pract. 2011; DOI: 10. 399/bjgp11X606663.
    4. Hamilton I.J, Morrison J, Macdonald S. Should GPs provide spiritual care? Brit. J Gen. Pract. 2017. Accepted for publication, 30th May 2017.