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Daniel P. Sulmasy, OFM, MD, PhD, discusses spiritual issues in the care of dying patients.
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Daniel P. Sulmasy, OFM, MD, PhD, discusses spiritual issues in the care of dying patients.
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[ Music ] >> This is Christopher Muth, Editor at JAMA. And I'm interviewing Dr. Daniel Sulmasy, who wrote a chapter entitled Spiritual Issues in the Care of Dying Patients in JAMAevidence Care at the Close of Life. Thanks for joining us today, Dr. Sulmasy. Can you please tell us a little bit about yourself? >> Sure. I'm a general internist and philosopher.
I'm currently a Professor of Medicine at Georgetown, and simultaneously a Professor in the Philosophy Department, and Acting Director of the Kennedy Institute of Ethics. >> Today we're going to be talking about spiritual issues in the care of dying patients. And this is obviously a very complex topic. There's been a lot a focus that I've heard, about quality of life at the end of life near death. But I don't really hear a lot being talked about, at least in the clinical world that I'm in, about spirituality or religious beliefs towards the end of life.
Even though I think that they are probably closely tied to quality of life in a lot of ways. I'm wondering if you can start just by telling us what is meant by the word spirituality, and what's meant by religion or religiosity? >> Sure. Spirituality is really in many ways the broader term of the two. In my view, a person's spirituality is set of beliefs and practices and habits they have in relationship to questions of transcendence in their lives.
And those questions are broad. And they affect people of all faiths, and those of no faith as well. Questions about meaning, questions about value, questions about relationship that are, I think, universal to the human condition. And that's different from religion in the sense that a religion refers to a community of people who have a particular set of answers to questions about transcendence in their lives that are usually captured in texts like the Bible or the Quran, that they have certain rituals that they share in common, certain practices and beliefs that they all hold in common regarding those same transcendent questions.
Religion, obviously, gives most people in the world their answers to those questions about ultimate meaning, ultimate value, and the ultimate answers to questions about relationship. That much being said, spirituality is also in some ways more particular than religion. Because even within a particular religion, each individual is going to have slightly different ways of living out that religious answer to those transcendent questions.
And so spirituality is ultimately very particular and very personal, even though there's a way in which it's also universal. >> Oh, that's very interesting. I always hear the first part about spirituality being the more general idea that's not necessarily related to a specific religion. But I hadn't heard that second part about how it's particular within religion, too. >> Yeah, so different people within a religion have very different ways of living it out.
You can't presume because someone is a Buddhist, or a Roman Catholic, or a Jew that you know ahead of time the particular ways in which that religion relates to their own individual life. >> Great. And so you mentioned a couple of times already these different categories or overarching kind of themes of meaning, value, and relationship, and how that's, sort of, tied in with spirituality and religious questions.
I'm wondering can you talk a little bit more in specific terms about when someone is sick or near the end of their life. Can you give examples of the types of issues that within each of those categories that people near the end of life might be thinking about? >> Sure. Well, I do want to make the point that spirituality is, and medicine is not just when people are dying. Although there's a way in which being close to death really makes the questions more acute.
But serious illness of any kind does raise questions for people about meaning. The questions like What does this mean? How can this be happening to me? Why is this happening to my child? If it's a parent. Those kinds of questions are there, and they're obvious questions, I think, for anyone who is seriously ill. And we as physicians sometimes neglect to even imagine what patients are going through.
But they're all thinking about these kinds of questions. Questions about value, I think, are also critical. Illness is a way in which it really attacks a person's own sense of their own value. People become disfigured. They lose their productivity. They're no longer able to work. And this makes people begin to question what their own value is to others. What is the source of their value? And do other people see value in them?
Can they find themselves as being good and valued and loved and cherished even as they're dying? And then questions about relationship, I think again are obvious, meaning I presume that most of the audience for this is going to be clinicians, I think we know in uncanny ways from own experience how it is that brokenness in body often reminds patients of the brokenness in their own relationships. And as they are seeking healing, and maybe can't get it in a physical way, I think they want to heal the brokenness in their relationships with other people, opportunities that come at the end of life for actual growth as persons.
And reconciling, perhaps, with someone they have been estranged from for many years, and wanting to do that particularly at the end of life before they pass away. >> So these clearly are very important issues. Do we have any data, or any idea of how often these issues related to spirituality are actually discussed at the end of life? And then, do we have any sense of who's doing the discussing?
Is it-- do physicians talk about this frequently? Or is this something that is maybe left more for the chaplain to talk with the patient about, for example? >> Patients do have large numbers of unmet spiritual needs. I've been doing surveys of patients along with my colleague Alan Astrow of outpatients in cancer centers in New York City in very diverse populations where people are Chinese Buddhists and Russian orthodox Jews and Dominican Catholics.
And almost everybody has at least one unmet spiritual need. Most patients want physicians, actually, to address those questions. Less than one percent will report that any physician has ever asked them about any of these kinds of spiritual questions. And maybe three or four percent will say that someone else on the staff has done so. We also know that addressing spiritual needs of patients is really highly correlated with patient satisfaction with care.
And that the single most important driver of quality-of-life for dying patients if you administer something called the McGill Quality of Life Questionnaire is the patient's own spiritual well-being. So they'll say things like, you know, how is your pain? So, well, it's okay. How's your nausea? Well, not so great, but I'm coping. How's your ability to bathe yourself? Well, I need help.
How is your spiritual life? Outstanding. How is your overall sense of quality-of-life? Outstanding. Truly almost all being actually driven by their spiritual sense. And we talk about quality of life, but if we neglect to talk about the spiritual needs of patients we're really missing the biggest part of the picture. >> Okay. And when you say unmet spiritual needs, can you give specific examples? >> Yes. So there are some different domains that you can divide, and we do in something that we call the SNAP, the Spiritual Needs Assessment for Patients.
So one domain is, kind of, psychospiritual. So we talk about questions like fear and anxiety, which are really probably best addressed by social workers, psychologists, and others. And then there are spiritual needs in a, sort of, more proper sense, help with finding meaning in illness, help with reconciling with people from whom they are estranged. Questions about where they might find hope in the setting of their illness.
And those are more spiritual needs that can be addressed by many kinds of people on the staff, beginning with physicians and nurses, but ultimately probably taken up by chaplains or the patient's own clergy. And then there's another third domain of explicitly religious needs, which relate to the patient's own religious practices. So that a dying Buddhist patient, for instance, may really want to have people come and chant while they're dying. Or a Catholic may want somebody to come to celebrate the Sacrament of the Sick with them and give them communion before they die.
And so those are particularly done by clergy. They overlap to some extent, these three domains, and they interact with each other. But they are slightly different, and really very specific needs that patients have that we can help them with, even when chemotherapy won't do anything for them anymore, we can still help patients as life is coming to a close by paying more attention to their spiritual needs. >> Okay. And your article also mentions something called a spiritual history?
Can you tell us what that is? And what the basic components are? >> Yes. I think that there are some patients who, for instance, might be a bit frightened to have the doctor starting to talk about their spiritual needs, and maybe ask, oh, is it that bad, doc, that you're asking about those questions? But I think that there are ways in which we can do this. And I actually begin to do some of this as a general internist with all of my patients as part of their initial history and physical.
And I make it a part of preventive care and, sort of, talking about their more social history. There are some specific ways one can ask the questions. One of these is called the FICA, which was developed by myself and some colleagues on an April 15 many years ago. Maybe that's why we came up with FICA as our acronym. But the F stands for faith and beliefs, the I for importance, the C for community, and the A for address.
So the faith and beliefs part you can ask do you have any faith or set of beliefs that are important to you as a person. The I is for importance. What role and how important are they in your life? The C is a community. Are there people with whom you pray or worship or who help you in your own religious or spiritual life? And the A is for how you want me to address these as your physician in your care as patient.
I think that like [inaudible] questions or other sorts of acronyms using that kind of a formula is helpful particularly for novices, medical students, residents, or maybe even clinicians who are just trying to in practice get to answer these kinds of questions. I typically ask a more open-ended question, which is what role does spirituality and religion play in your life. Now if it's stranger medicine, as we often sadly practice in a hospitals these days when we really have not met the patient until their very end of life and we're caring for them in the hospital, then I think the approach may be even simpler.
I sit down next to the patient so that I'm at eye level with them. And I just ask something like how are you doing with this. How are you coping? How can I be of help to you? And let them begin to tell me about what's going on in their life in a way that's deeper, perhaps, than simply asking if they're having any pain and then walking out of the room. Giving them a chance to talk a bit more. I also think we can pay attention as clinicians to the clues the patients give us.
Just as we want to recognize pathognomonic signs or clinical cues in the physical exam, so if we as clinicians walk into the room of a patient and there are Shabbat candles or rosary beads or the Quran or a Bible on a bed stand next to the patient's bed most of the time, I'm sure, clinicians who are listening to this will say that, will recognize they walk into the room, and they will remember having sort of seeing but then ignoring it.
I think all one has to do is in a very simple way say Is that the Koran? Is that the Bible? And let the patient then respond. Because what we communicate to them when we do that is to say that I recognize something that is important to you, important enough that you've made sure that it's visible on your bed when someone comes to visit you. It must be saying something important about you. And I'm recognizing that and giving you the space to talk to me about it, and the permission to talk to me about that.
And I think that that's a simple way of helping to open these more difficult questions. >> That's a good example. What would you say to the clinician who might think that, well, that's maybe something personal to the patient, that maybe it might be invasive to ask them about that? >> Yes, I think physicians tend to have that kind of fear. But we, I think, in many ways have to get past that. There are lots of incredibly personal questions that we ask patients all the time.
We ask them very detailed questions about their sexual histories. And religion and spirituality seems to be a kind taboo. I think we have, do have evidence that I've talked about earlier that patients do want clinicians to be able to open up these questions and make it a safe space for them. And if the patient doesn't want to talk about it, then they'll tell you. They'll say that's personal, doc. And then you can say okay.
But if we ignore it, then we don't give that large number of patients who want the opportunity to talk to us about it the safe space in which to address those questions. >> That's great. And I think another barrier, potentially, for physicians or other healthcare professionals to bring these issues up is what if the patient is of a different religious or spiritual tradition that the provider might not be very familiar with? Do you have any tips? Or what can people say to, sort of, engage patients to make sure that they feel like their spiritual needs are being heard, even if people are of different backgrounds?
>> Well, I think we have actually a moral duty, if we are committed to treating patients as whole persons, to recognize their spiritual needs and try to make sure that those are addressed. And that, I believe, is actually a duty even for a physician who is an atheist. Because if it's important to the patient, and we really are committed to their care, then our own beliefs or lack thereof, should secondary. So that we try to encourage-- I would try to encourage any physician to recognize that the patient may in fact have needs that are important to them in a very personal way that you might not share, but need to be able to ask these same kinds of questions.
If I am Roman Catholic physician and I am treating a patient who's a Buddhist, it doesn't mean that I'm betraying my own beliefs by asking him about his beliefs. And then asking is there anything I can do to help you as a person who's a very devout Buddhist to prepare for your own death as best you can, and then facilitating that person to get the resources that they need.
And I think the same would be for someone who is even an atheist to be respectful of the patient's belief which differ from their own. And try to muster the resources that the patient needs as a whole person grappling with the questions that we all have about meaning, value, and relationship. >> That's very important. And then you mentioned in the chapter situations when patients near the end of life might hold out hope for a miracle, or a miraculous recovery.
And from the perspective of a physician, I think sometimes this can complicate the treatment plans if the family is either refusing a course of care that's recommended by the physician because they're holding out hope for a miracle. Or conversely, they might want an intervention when the medical team might feel as though additional interventions would be futile. Can you offer any insight into how this type of situation might be approached?
>> Yes, it's a complicated situation. Sadly, sometimes it's the only one that people think of when they think about religion and care at the end of life. And I think that's very narrow way of looking at it. And I hope our conversation has gone a long way toward helping to open up the spiritual questions beyond this one. But I think it pays, again, to not be too frightened about that question, or fearful about it, but to really try to make better effort at trying to understand what's really going on.
So sometimes what appears to be an impasse over this hope for treatment to deliver the patient when we think that there is really no realistic chance from a biomedical point of view that it's going to happen, quite often we run away from those kinds of questions. Rather than sitting down with the patient and beginning to ask a bit more about what their concerns really are. Sometimes it's actually a disparity, not only in religion but in race between the physician and the patient, and there may be a lot of distrust, that the judgment that no more treatment is going to affect the course of the patient is a way of taking treatment away from someone who's of another race, particularly if they're African-Americans, who have good reasons for being suspicious of medicine.
Or it may be that people, actually the patient himself or herself, misunderstands their own religion. And so I've had situations in which in those circumstances asked patients if I can bring the chaplain in or talk to their own clergy about it. And they may be, even within their own belief structure, misinterpreting what their own religion teaches them about what they need to do. And rather than ignoring that, if we can get the chaplains involved we may be able to help patients through.
Or maybe it's actually denial, the real dynamic there, or anticipatory grief on the part of family. And so if we shy away from talking about these questions, don't unpack it a bit more, we let it stay flat as in a kind of one-dimensional argument or impasse between physicians and patients when what's really going on may be more complex, more difficult. And if we are willing to listen to the patient to understand what their real concerns are we may be able to get past what otherwise would be an impasse.
>> Okay. That's all the questions that I had prepared. Is there anything else that you'd like to mention? >> Well, one more thing. Another barrier I think that clinicians sometimes have is a fear opening up spiritual questions because they're unprepared and that this may be a Pandora's Box. And so I want to assure them that they can have an exit strategy. That if you open up these questions and find, for instance, that the reason that the patient isn't taking pain medicine is because they fear they're actually being punished by God for something that they did, and therefore they need to feel pain because this is God's punishment for them and you don't know how to answer those questions, I think that the real advantage of having had the physician ask the questions in the first place is that that person may not have brought those such concerns up to a chaplain or a nurse if we hadn't opened the questions to begin with.
But then to let physicians know they don't have to have the answers to those questions. That we do work as part of a team. There are pastoral care, spiritual care people who are in the hospital, who can help with those. And that the way to handle that is to say I'm very glad, Mrs. Jones, that you told me that. It sounds like a very complicated set of questions that I'm not really prepared as your physician to answer, but we do have chaplains here who could, I think, really help you in thinking about those questions.
Would it be okay with you if I asked Reverend Smith to come by later to talk to you a little bit more about that. And that, I think, becomes a way for a physician to, sort of, gently back out, make a referral, which is proper, but also letting physicians know they don't have to have the answers to those kinds of questions. And that they're all resources for them. And there if there is a way out if they feel they've gotten in over their heads. >> Thank you, Dr. Sulmasy, for taking the time to speak with us.
You've been listening to Chapter 29, Spiritual Issues in the Care of Dying Patients from JAMAevidence Care at the Close of Life. This is Christopher Muth, Editor at JAMA with this JAMAevidence podcast.
Segment:0 .
[ Music ] >> This is Christopher Muth, Editor at JAMA. And I'm interviewing Dr. Daniel Sulmasy, who wrote a chapter entitled Spiritual Issues in the Care of Dying Patients in JAMAevidence Care at the Close of Life. Thanks for joining us today, Dr. Sulmasy. Can you please tell us a little bit about yourself? >> Sure. I'm a general internist and philosopher.
I'm currently a Professor of Medicine at Georgetown, and simultaneously a Professor in the Philosophy Department, and Acting Director of the Kennedy Institute of Ethics. >> Today we're going to be talking about spiritual issues in the care of dying patients. And this is obviously a very complex topic. There's been a lot a focus that I've heard, about quality of life at the end of life near death. But I don't really hear a lot being talked about, at least in the clinical world that I'm in, about spirituality or religious beliefs towards the end of life.
Even though I think that they are probably closely tied to quality of life in a lot of ways. I'm wondering if you can start just by telling us what is meant by the word spirituality, and what's meant by religion or religiosity? >> Sure. Spirituality is really in many ways the broader term of the two. In my view, a person's spirituality is set of beliefs and practices and habits they have in relationship to questions of transcendence in their lives.
And those questions are broad. And they affect people of all faiths, and those of no faith as well. Questions about meaning, questions about value, questions about relationship that are, I think, universal to the human condition. And that's different from religion in the sense that a religion refers to a community of people who have a particular set of answers to questions about transcendence in their lives that are usually captured in texts like the Bible or the Quran, that they have certain rituals that they share in common, certain practices and beliefs that they all hold in common regarding those same transcendent questions.
Religion, obviously, gives most people in the world their answers to those questions about ultimate meaning, ultimate value, and the ultimate answers to questions about relationship. That much being said, spirituality is also in some ways more particular than religion. Because even within a particular religion, each individual is going to have slightly different ways of living out that religious answer to those transcendent questions.
And so spirituality is ultimately very particular and very personal, even though there's a way in which it's also universal. >> Oh, that's very interesting. I always hear the first part about spirituality being the more general idea that's not necessarily related to a specific religion. But I hadn't heard that second part about how it's particular within religion, too. >> Yeah, so different people within a religion have very different ways of living it out.
You can't presume because someone is a Buddhist, or a Roman Catholic, or a Jew that you know ahead of time the particular ways in which that religion relates to their own individual life. >> Great. And so you mentioned a couple of times already these different categories or overarching kind of themes of meaning, value, and relationship, and how that's, sort of, tied in with spirituality and religious questions.
I'm wondering can you talk a little bit more in specific terms about when someone is sick or near the end of their life. Can you give examples of the types of issues that within each of those categories that people near the end of life might be thinking about? >> Sure. Well, I do want to make the point that spirituality is, and medicine is not just when people are dying. Although there's a way in which being close to death really makes the questions more acute.
But serious illness of any kind does raise questions for people about meaning. The questions like What does this mean? How can this be happening to me? Why is this happening to my child? If it's a parent. Those kinds of questions are there, and they're obvious questions, I think, for anyone who is seriously ill. And we as physicians sometimes neglect to even imagine what patients are going through.
But they're all thinking about these kinds of questions. Questions about value, I think, are also critical. Illness is a way in which it really attacks a person's own sense of their own value. People become disfigured. They lose their productivity. They're no longer able to work. And this makes people begin to question what their own value is to others. What is the source of their value? And do other people see value in them?
Can they find themselves as being good and valued and loved and cherished even as they're dying? And then questions about relationship, I think again are obvious, meaning I presume that most of the audience for this is going to be clinicians, I think we know in uncanny ways from own experience how it is that brokenness in body often reminds patients of the brokenness in their own relationships. And as they are seeking healing, and maybe can't get it in a physical way, I think they want to heal the brokenness in their relationships with other people, opportunities that come at the end of life for actual growth as persons.
And reconciling, perhaps, with someone they have been estranged from for many years, and wanting to do that particularly at the end of life before they pass away. >> So these clearly are very important issues. Do we have any data, or any idea of how often these issues related to spirituality are actually discussed at the end of life? And then, do we have any sense of who's doing the discussing?
Is it-- do physicians talk about this frequently? Or is this something that is maybe left more for the chaplain to talk with the patient about, for example? >> Patients do have large numbers of unmet spiritual needs. I've been doing surveys of patients along with my colleague Alan Astrow of outpatients in cancer centers in New York City in very diverse populations where people are Chinese Buddhists and Russian orthodox Jews and Dominican Catholics.
And almost everybody has at least one unmet spiritual need. Most patients want physicians, actually, to address those questions. Less than one percent will report that any physician has ever asked them about any of these kinds of spiritual questions. And maybe three or four percent will say that someone else on the staff has done so. We also know that addressing spiritual needs of patients is really highly correlated with patient satisfaction with care.
And that the single most important driver of quality-of-life for dying patients if you administer something called the McGill Quality of Life Questionnaire is the patient's own spiritual well-being. So they'll say things like, you know, how is your pain? So, well, it's okay. How's your nausea? Well, not so great, but I'm coping. How's your ability to bathe yourself? Well, I need help.
How is your spiritual life? Outstanding. How is your overall sense of quality-of-life? Outstanding. Truly almost all being actually driven by their spiritual sense. And we talk about quality of life, but if we neglect to talk about the spiritual needs of patients we're really missing the biggest part of the picture. >> Okay. And when you say unmet spiritual needs, can you give specific examples? >> Yes. So there are some different domains that you can divide, and we do in something that we call the SNAP, the Spiritual Needs Assessment for Patients.
So one domain is, kind of, psychospiritual. So we talk about questions like fear and anxiety, which are really probably best addressed by social workers, psychologists, and others. And then there are spiritual needs in a, sort of, more proper sense, help with finding meaning in illness, help with reconciling with people from whom they are estranged. Questions about where they might find hope in the setting of their illness.
And those are more spiritual needs that can be addressed by many kinds of people on the staff, beginning with physicians and nurses, but ultimately probably taken up by chaplains or the patient's own clergy. And then there's another third domain of explicitly religious needs, which relate to the patient's own religious practices. So that a dying Buddhist patient, for instance, may really want to have people come and chant while they're dying. Or a Catholic may want somebody to come to celebrate the Sacrament of the Sick with them and give them communion before they die.
And so those are particularly done by clergy. They overlap to some extent, these three domains, and they interact with each other. But they are slightly different, and really very specific needs that patients have that we can help them with, even when chemotherapy won't do anything for them anymore, we can still help patients as life is coming to a close by paying more attention to their spiritual needs. >> Okay. And your article also mentions something called a spiritual history?
Can you tell us what that is? And what the basic components are? >> Yes. I think that there are some patients who, for instance, might be a bit frightened to have the doctor starting to talk about their spiritual needs, and maybe ask, oh, is it that bad, doc, that you're asking about those questions? But I think that there are ways in which we can do this. And I actually begin to do some of this as a general internist with all of my patients as part of their initial history and physical.
And I make it a part of preventive care and, sort of, talking about their more social history. There are some specific ways one can ask the questions. One of these is called the FICA, which was developed by myself and some colleagues on an April 15 many years ago. Maybe that's why we came up with FICA as our acronym. But the F stands for faith and beliefs, the I for importance, the C for community, and the A for address.
So the faith and beliefs part you can ask do you have any faith or set of beliefs that are important to you as a person. The I is for importance. What role and how important are they in your life? The C is a community. Are there people with whom you pray or worship or who help you in your own religious or spiritual life? And the A is for how you want me to address these as your physician in your care as patient.
I think that like [inaudible] questions or other sorts of acronyms using that kind of a formula is helpful particularly for novices, medical students, residents, or maybe even clinicians who are just trying to in practice get to answer these kinds of questions. I typically ask a more open-ended question, which is what role does spirituality and religion play in your life. Now if it's stranger medicine, as we often sadly practice in a hospitals these days when we really have not met the patient until their very end of life and we're caring for them in the hospital, then I think the approach may be even simpler.
I sit down next to the patient so that I'm at eye level with them. And I just ask something like how are you doing with this. How are you coping? How can I be of help to you? And let them begin to tell me about what's going on in their life in a way that's deeper, perhaps, than simply asking if they're having any pain and then walking out of the room. Giving them a chance to talk a bit more. I also think we can pay attention as clinicians to the clues the patients give us.
Just as we want to recognize pathognomonic signs or clinical cues in the physical exam, so if we as clinicians walk into the room of a patient and there are Shabbat candles or rosary beads or the Quran or a Bible on a bed stand next to the patient's bed most of the time, I'm sure, clinicians who are listening to this will say that, will recognize they walk into the room, and they will remember having sort of seeing but then ignoring it.
I think all one has to do is in a very simple way say Is that the Koran? Is that the Bible? And let the patient then respond. Because what we communicate to them when we do that is to say that I recognize something that is important to you, important enough that you've made sure that it's visible on your bed when someone comes to visit you. It must be saying something important about you. And I'm recognizing that and giving you the space to talk to me about it, and the permission to talk to me about that.
And I think that that's a simple way of helping to open these more difficult questions. >> That's a good example. What would you say to the clinician who might think that, well, that's maybe something personal to the patient, that maybe it might be invasive to ask them about that? >> Yes, I think physicians tend to have that kind of fear. But we, I think, in many ways have to get past that. There are lots of incredibly personal questions that we ask patients all the time.
We ask them very detailed questions about their sexual histories. And religion and spirituality seems to be a kind taboo. I think we have, do have evidence that I've talked about earlier that patients do want clinicians to be able to open up these questions and make it a safe space for them. And if the patient doesn't want to talk about it, then they'll tell you. They'll say that's personal, doc. And then you can say okay.
But if we ignore it, then we don't give that large number of patients who want the opportunity to talk to us about it the safe space in which to address those questions. >> That's great. And I think another barrier, potentially, for physicians or other healthcare professionals to bring these issues up is what if the patient is of a different religious or spiritual tradition that the provider might not be very familiar with? Do you have any tips? Or what can people say to, sort of, engage patients to make sure that they feel like their spiritual needs are being heard, even if people are of different backgrounds?
>> Well, I think we have actually a moral duty, if we are committed to treating patients as whole persons, to recognize their spiritual needs and try to make sure that those are addressed. And that, I believe, is actually a duty even for a physician who is an atheist. Because if it's important to the patient, and we really are committed to their care, then our own beliefs or lack thereof, should secondary. So that we try to encourage-- I would try to encourage any physician to recognize that the patient may in fact have needs that are important to them in a very personal way that you might not share, but need to be able to ask these same kinds of questions.
If I am Roman Catholic physician and I am treating a patient who's a Buddhist, it doesn't mean that I'm betraying my own beliefs by asking him about his beliefs. And then asking is there anything I can do to help you as a person who's a very devout Buddhist to prepare for your own death as best you can, and then facilitating that person to get the resources that they need.
And I think the same would be for someone who is even an atheist to be respectful of the patient's belief which differ from their own. And try to muster the resources that the patient needs as a whole person grappling with the questions that we all have about meaning, value, and relationship. >> That's very important. And then you mentioned in the chapter situations when patients near the end of life might hold out hope for a miracle, or a miraculous recovery.
And from the perspective of a physician, I think sometimes this can complicate the treatment plans if the family is either refusing a course of care that's recommended by the physician because they're holding out hope for a miracle. Or conversely, they might want an intervention when the medical team might feel as though additional interventions would be futile. Can you offer any insight into how this type of situation might be approached?
>> Yes, it's a complicated situation. Sadly, sometimes it's the only one that people think of when they think about religion and care at the end of life. And I think that's very narrow way of looking at it. And I hope our conversation has gone a long way toward helping to open up the spiritual questions beyond this one. But I think it pays, again, to not be too frightened about that question, or fearful about it, but to really try to make better effort at trying to understand what's really going on.
So sometimes what appears to be an impasse over this hope for treatment to deliver the patient when we think that there is really no realistic chance from a biomedical point of view that it's going to happen, quite often we run away from those kinds of questions. Rather than sitting down with the patient and beginning to ask a bit more about what their concerns really are. Sometimes it's actually a disparity, not only in religion but in race between the physician and the patient, and there may be a lot of distrust, that the judgment that no more treatment is going to affect the course of the patient is a way of taking treatment away from someone who's of another race, particularly if they're African-Americans, who have good reasons for being suspicious of medicine.
Or it may be that people, actually the patient himself or herself, misunderstands their own religion. And so I've had situations in which in those circumstances asked patients if I can bring the chaplain in or talk to their own clergy about it. And they may be, even within their own belief structure, misinterpreting what their own religion teaches them about what they need to do. And rather than ignoring that, if we can get the chaplains involved we may be able to help patients through.
Or maybe it's actually denial, the real dynamic there, or anticipatory grief on the part of family. And so if we shy away from talking about these questions, don't unpack it a bit more, we let it stay flat as in a kind of one-dimensional argument or impasse between physicians and patients when what's really going on may be more complex, more difficult. And if we are willing to listen to the patient to understand what their real concerns are we may be able to get past what otherwise would be an impasse.
>> Okay. That's all the questions that I had prepared. Is there anything else that you'd like to mention? >> Well, one more thing. Another barrier I think that clinicians sometimes have is a fear opening up spiritual questions because they're unprepared and that this may be a Pandora's Box. And so I want to assure them that they can have an exit strategy. That if you open up these questions and find, for instance, that the reason that the patient isn't taking pain medicine is because they fear they're actually being punished by God for something that they did, and therefore they need to feel pain because this is God's punishment for them and you don't know how to answer those questions, I think that the real advantage of having had the physician ask the questions in the first place is that that person may not have brought those such concerns up to a chaplain or a nurse if we hadn't opened the questions to begin with.
But then to let physicians know they don't have to have the answers to those questions. That we do work as part of a team. There are pastoral care, spiritual care people who are in the hospital, who can help with those. And that the way to handle that is to say I'm very glad, Mrs. Jones, that you told me that. It sounds like a very complicated set of questions that I'm not really prepared as your physician to answer, but we do have chaplains here who could, I think, really help you in thinking about those questions.
Would it be okay with you if I asked Reverend Smith to come by later to talk to you a little bit more about that. And that, I think, becomes a way for a physician to, sort of, gently back out, make a referral, which is proper, but also letting physicians know they don't have to have the answers to those kinds of questions. And that they're all resources for them. And there if there is a way out if they feel they've gotten in over their heads. >> Thank you, Dr. Sulmasy, for taking the time to speak with us.
You've been listening to Chapter 29, Spiritual Issues in the Care of Dying Patients from JAMAevidence Care at the Close of Life. This is Christopher Muth, Editor at JAMA with this JAMAevidence podcast.
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