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Southern Medical Journal:
doi: 10.1097/01.smj.0000242846.64982.80
Special Section: Spirituality/Medicine Interface Project

Spirituality and Care at the End of Life

Meador, Keith G. MD, ThM, MPH

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From Duke Divinity School, Duke University Medical Center, Durham, NC.

Reprint requests to Keith G. Meador, MD, Professor of the Practice of Pastoral Theology and Medicine, Duke Divinity School, Durham, NC 27707; Email: Keith.Meador@duke.edu

Comprehensive theological or pastoral education for all healthcare providers is not feasible, nor is it necessary.

The role of spirituality in healthcare is an active and ongoing conversation with varied perspectives represented within the medical community. Whatever perspective one might bring to the conversation regarding spirituality and medicine in general, the particular relevance of spirituality for many patients at the end of life compels us to a focused consideration of this issue. Many persons who might otherwise have ambivalence regarding the place of spirituality in their lives have a heightened sense of concern regarding spiritual concerns when faced with a life–limiting illness. Idler and colleagues note the importance of religion in the lives of frail elderly in a community sample of elders.1 While allowing for a decline in religious service attendance secondary to poorer health, the importance of religion and the significance of religious coping persisted into the later months of life. The importance of spirituality and religion for elderly frail and dying persons in the community challenges healthcare providers to include sensitivity to the spiritual lives of their seriously ill patients in the clinical care context.

How to best address this issue in the clinical setting is not always clear, but Steinhauser and colleagues have established that a one-item probe regarding being “at peace” can serve to effectively open the conversation regarding spirituality and allows adequate space for the patient to explore these issues if they are so inclined.2 The challenge this interjects for the clinician to be prepared to listen attentively and respond thoughtfully is reflected within Ramondetta's report of the need for candor and sensitivity regarding spirituality on the part of clinicians caring for dying persons.3 While a variety of tools and methods have been proposed for engaging the issue of spirituality in the clinical setting, end-of-life medical decision-making offers a natural context for this conversation. Ehman and colleagues surveyed adult ambulatory pulmonary patients as to whether upon becoming “gravely ill” they would want to have their doctor ask about spiritual or religious beliefs that might influence their medical decision-making.4 Two-thirds of respondents in their sample stated they would value a physician asking about their religious beliefs and noted that a physician's inquiry regarding their spiritual beliefs in regard to medical decision-making would increase their trust in the physician. They note that questions regarding spiritual and religious concerns in end-of-life care should be framed within a “posture of openness” toward the patient, along with an emphasis on the importance of the medical relevance of the inquiry.

If spirituality and religion are important to patients near the end of life and many patients would value their physician having a capacity to engage them in at least a limited conversation regarding these issues, one must consider how best to enhance the quality of end-of-life care within these considerations. Comprehensive theological or pastoral education for all healthcare providers is not feasible, nor is it necessary to address this need. Many healthcare institutions and systems providing end-of-life care have chaplains with clinical pastoral training on staff that can provide comprehensive spiritual care when appropriate. It is the responsibility of physicians to learn how to access such spiritual care for their patients and how to work with chaplains and other clergy as colleagues along with developing their own abilities and sensitivities around spiritual issues in end-of-life care. Educational interventions assisting physicians in this development, especially when these spiritual and religious issues are relevant to imminent medical decision-making for the patient with a life-limiting illness, can greatly enhance the quality of care given and the possibility of a “good death” for the patient and the family.5

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1. Idler EL, Kasl SV, Hays JC. Patterns of religious practice and belief in the last year of life. J Gerontol B Psychol Sci Soc Sci 2001;56:S326–S334.

2. Steinhauser KE, Voils CI, Clipp EC, et al. “Are you at peace?”: one item to probe spiritual concerns at the end of life. Arch Intern Med 2006;166:101–105.

3. Ramondetta LM, Sills D. Spirituality and religion in the “art of dying”. J Clin Oncology 2003;21:4460–4462.

4. Ehman JW, Ott BB, Short TH, et al. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999;159:1803–1806.

5. Hanson LC, Tulsky JA, Danis M. Can clinical interventions change care at the end of life? Ann Intern Med 1997;126:381–388.

The great secret of power is never to will to do more than you can accomplish. - —Henrik Ibsen

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