Religion, physicians and surrogate decision-makers in the intensive care unit

Understanding how frequently discussions of spiritual concerns take place -- and what characterizes them -- is a first step toward clarity regarding best practices of responding to spiritual concerns in advanced illness.

Douglas B. White, M.D., M.A.S., of the University of Pittsburgh School of Medicine, and colleagues analyzed audio-recorded conversations between surrogate decision-makers and health care professionals. The study included 249 audio-recorded in physician-family meetings between surrogate decision-makers and health care professionals in 13 intensive care units at six medical centers around the country between October 2009 and October 2012.

The authors report that discussion of religious or spiritual consideration happened in 40 of the 249 family conferences (16.1 percent) and surrogates were the first to raise the religious or spiritual considerations in most cases (26 of 40).

When surrogates brought up religious or spiritual consideration, their statements fell into five main categories: reference to their beliefs, including miracles; religious practices; religious community; the notion that the physician is God's instrument to promote healing; and the interpretation that the end of life is a new beginning for their loved one.

In response to surrogates' religious or spiritual statements, health care professionals redirected the conversation to medical considerations; offered to involve hospital spiritual care providers or the patient's own religious or spiritual community; expressed empathy; acknowledged surrogates' statements; or very rarely explained their own religious beliefs. In very few family conferences did health care professionals attempt to further understand surrogates' beliefs, for example, by asking questions about the patient's religion.

Study results include snippets of conversations from the family-physician meetings. For example, after one surrogate said, "I know my God's a big God. And I know he can even guide your guys' hands to do the right thing," a physician responded, "We'll do the best with what we've got." In other situations, physicians responded with empathetic statements. After one surrogate said, "Prayer's not gonna work," a physician responded, "Hang in there. I know it's hard. I know."

"Although many patients wish to have their religious values incorporated in end-of-life decisions, our research indicates that religious and spiritual consideration 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 ICUs," the authors conclude.

Commentary: Religion, Spirituality and the Intensive Care Unit

In a related commentary, Tracy A. Balboni, M.D., M.P.H., of the Dana-Farber Cancer Institute, Boston, and coauthors write: "The article by Ernecoff and colleagues discusses with clarity and nuance the silence regarding spirituality in the setting of critical care. ... Our patients and families who face serious illness typically find themselves in spiritual isolation in the medical setting; their medical caregivers do not hear the spiritual reverberations of illness on their well-being and medical decisions. As with the lonely, falling tree, the reverberations are undeniably there. The question remains whether we who care for dying persons and their families will learn how to be present and listen."