Discussing Religious and Spiritual Issues at the End of Life

A Practical Guide for Physicians

JAMA. 2002;287:749-754

Author Information <http://jama.ama-assn.org/issues/v287n6/rfull/#aainfo>
Bernard Lo, MD; Delaney Ruston, MD; Laura W. Kates; Robert M. Arnold, MD;
Cynthia B. Cohen, PhD, JD; Kathy Faber-Langendoen, MD; Steven Z. Pantilat,
MD; Christina M. Puchalski, MD; Timothy R. Quill, MD; Michael W. Rabow, MD;
Simeon Schreiber; Daniel P. Sulmasy, OSM, MD, PhD; James A. Tulsky, MD; for
the Working Group on Religious and Spiritual Issues at the End of Life
As patients near the end of life, their spiritual and religious concerns may
be awakened or intensified. Many physicians, however, feel unskilled and
uncomfortable discussing these concerns. This article suggests how
physicians might respond when patients or families raise such concerns.
First, some patients may explicitly base decisions about life-sustaining
interventions on their spiritual or religious beliefs. Physicians need to
explore those beliefs to help patients think through their preferences
regarding specific interventions. Second, other patients may not bring up
spiritual or religious concerns but are troubled by them. Physicians should
identify such concerns and listen to them empathetically, without trying to
alleviate the patient's spiritual suffering or offering premature
reassurance. Third, some patients or families may have religious reasons for
insisting on life-sustaining interventions that physicians advise against.
The physician should listen and try to understand the patient's viewpoint.
Listening respectfully does not require the physician to agree with the
patient or misrepresent his or her own views. Patients and families who feel
that the physician understands them and cares about them may be more willing
to consider the physician's views on prognosis and treatment. By responding
to patients' spiritual and religious concerns and needs, physicians may help
them find comfort and closure near the end of life.
JAMA. 2002;287:749-754
JSC10142
As patients nearing the end of life grapple with their mortality, their
spiritual and religious concerns may be awakened or intensified. 1-5
<http://jama.ama-assn.org/issues/v287n6/rfull/#r1>  Such concerns may be the
basis of patients' medical decisions, including decisions about
life-sustaining interventions. Some patients may explicitly raise spiritual
or religious issues with physicians, 6-9
<http://jama.ama-assn.org/issues/v287n6/rfull/#r6>  whereas others may not
discuss them but may be troubled by them or make medical choices based on
them that physicians consider unreasonable. In these situations, physicians
need to address patients' spiritual or religious concerns to provide better
care. In addition, knowing these concerns helps physicians to understand
patients' needs and to provide them with respectful, comprehensive
end-of-life care. 1 <http://jama.ama-assn.org/issues/v287n6/rfull/#r1> ,
10-15 <http://jama.ama-assn.org/issues/v287n6/rfull/#r10>
Many physicians, however, feel unskilled and uncomfortable discussing
patients' spiritual and religious concerns 16-18
<http://jama.ama-assn.org/issues/v287n6/rfull/#r16>  and therefore may avoid
such conversations. 6 <http://jama.ama-assn.org/issues/v287n6/rfull/#r6>
This article suggests how physicians might respond when patients or families
raise such concerns near the end of life. Although chaplains and clergy
typically help address these issues, in some cases they may not be available
or the patient may not want to talk to them. We analyze 3 cases in which
responding to patients' spiritual and religious concerns helps physicians
reach decisions about life-sustaining interventions and alleviate patient
distress.



CLARIFYING RELIGIOUS STATEMENTS BY PATIENTS



When making clinical decisions about life-sustaining interventions, some
patients refer to their religious or spiritual beliefs. In the following
case, the physician regards these religious references as a distraction from
her primary task of making a decision about cardiopulmonary resuscitation
(CPR), thereby missing an important clue about what is important to the
patient. 19 <http://jama.ama-assn.org/issues/v287n6/rfull/#r19> , 20
<http://jama.ama-assn.org/issues/v287n6/rfull/#r20>
Case 1

Case 1 concerns religious beliefs in a discussion of do not resuscitate
(DNR) orders. Mr R is a 77-year-old, white, retired mechanic who has class
II congestive heart failure and coronary artery disease that cannot be
revascularized. After an emergency department visit for an exacerbation of
congestive heart failure, his physician raises the issue of a DNR order.
After checking the patient's understanding about his illness, the physician
describes CPR. 19 <http://jama.ama-assn.org/issues/v287n6/rfull/#r19>  The
following conversation then occurs.
PHYSICIAN: In your situation, CPR is very unlikely to succeed. What do you
think about what I have said?
MR R: Well, I want you to do what you can. I trust that God will decide when
it's my time.
PHYSICIAN: Absolutely. Let me ask you, if you were to have a heart attack,
your heart stopped, and you died, would you want us to try CPR?
This exchange is typical of DNR discussions. 19
<http://jama.ama-assn.org/issues/v287n6/rfull/#r19>  This physician pursues
her agenda of settling the issue of CPR, which seldom is a priority for the
patient. 21 <http://jama.ama-assn.org/issues/v287n6/rfull/#r21>  Pressing
the patient to make a decision about CPR is unlikely to succeed, causing
both the physician and patient to feel frustrated. 19
<http://jama.ama-assn.org/issues/v287n6/rfull/#r19>  Mr R may feel that the
physician is pushing him to make a decision that he has not had time to
think through. Instead of pushing for an immediate decision about CPR, the
physician might try to understand how the patient is thinking especially in
light of his comment about God. 10
<http://jama.ama-assn.org/issues/v287n6/rfull/#r10> , 22
<http://jama.ama-assn.org/issues/v287n6/rfull/#r22> , 23
<http://jama.ama-assn.org/issues/v287n6/rfull/#r23>  Many patients want to
discuss spiritual and religious issues with physicians. 6-9
<http://jama.ama-assn.org/issues/v287n6/rfull/#r6>
PHYSICIAN: What do you mean when you say that you trust God?
MR R: Well, I place myself in God's hands.
PHYSICIAN: Tell me more about what it means to place yourself in God's
hands.
MR R: God has a plan about how long I should live.
The physician may feel frustrated that she is no closer to her goal of
clarifying Mr R's DNR preferences, even though she has tried to elicit his
concerns and values ( Box 1
<http://jama.ama-assn.org/issues/v287n6/rfull/#box1> ). 24
<http://jama.ama-assn.org/issues/v287n6/rfull/#r24> , 25
<http://jama.ama-assn.org/issues/v287n6/rfull/#r25>  Physicians vary
regarding the techniques they find useful when probing for patients' values.
For example, some physicians or patients consider a phrase such as "Tell me
more about . . ." too psychologically oriented or forced. Another way to
advance the discussion while following the patient's pace is to ask directly
how his views of God are related to his decision about CPR.
PHYSICIAN: You mention trust in God. Does your trust in God lead you to
think about CPR in a particular way?
MR R: If God calls me, I am ready. But when is he [God] really calling? I
just don't know.
At this point, physicians might proceed in several ways. Some physicians
might make an empathic comment such as, "I imagine I would feel pretty
puzzled too about not knowing" or "That sounds like a painful situation."
Such comments would be particularly useful if the physician believes that
the patient's emotions are causing distress or impeding a decision. Other
physicians might invite Mr R to say more about how his ideas about God
relate to his preferences about CPR: "Do you have any ideas about that?"
Still others might be more directive, summarizing the discussion and making
the issue of CPR more explicit: "Let me be sure I've understood. It sounds
like if you thought God was calling you, you wouldn't want us to try to
revive you. But you're not sure when God is calling you. Is that right?" If
the patient agrees, the physician might then say, "If I told you how likely
it is that CPR would succeed in various situations, would that help you
decide whether God was calling you?" or alternatively, "When you've known
other people who have died, what do you think helped them to know when God
was calling"? Through such discussions, the physician can help Mr R think
through his preferences about CPR, based on what is important to him and the
medical situation.



RESPONDING TO STATEMENTS THAT MAY INDICATE SPIRITUAL AND RELIGIOUS CONCERNS



In other situations, the spiritual or religious nature of a patient's
concerns may be less obvious than in case 1. Yet physicians need to become
aware of these concerns to respond to them appropriately.
Case 2

Case 2 concerns questions about why an illness has happened. Mrs L is a
64-year-old woman undergoing combination chemotherapy for metastatic small
cell carcinoma of the lung. She visits her physician 2 days after an
emergency department visit for dehydration caused by nausea and vomiting
associated with the chemotherapy.
PHYSICIAN: How have you been doing?
MRS L: I don't know. I keep wondering why all of this is happening to me.
PHYSICIAN: Well, as we talked about, chemo tends to make people feel down.
Tell me, how much have you been able to eat and drink since you got home?
In this conversation, the physician presses forward with biomedical
questions, assuming that Mrs L is asking why she became dehydrated. Although
it is important to evaluate her hydration, the physician misses an
opportunity to explore her concerns first. 20
<http://jama.ama-assn.org/issues/v287n6/rfull/#r20> , 26
<http://jama.ama-assn.org/issues/v287n6/rfull/#r26>  Mrs L's question, "Why
is this happening to me?" might have several meanings. She may be asking for
scientific information. For example, why did severe vomiting occur after
premedication with antiemetics? Or, why did the cancer occur after she
stopped smoking? However, Mrs L may also be asking about psychosocial,
existential, or spiritual issues. She may be trying to find meaning in
tragic events, asking why bad things happen to good people. 13
<http://jama.ama-assn.org/issues/v287n6/rfull/#r13> , 15
<http://jama.ama-assn.org/issues/v287n6/rfull/#r15> , 27
<http://jama.ama-assn.org/issues/v287n6/rfull/#r27>  The physician can
distinguish these possibilities through an open-ended question.
PHYSICIAN: Do you have any thoughts about that?
MRS L: Well, I wonder why God would do this to me.
PHYSICIAN: Tell me more about that.
MRS L: I've been active in my church. I've tried to be a good wife and
mother. I just don't understand it.
The physician may feel that this discussion has reached a dead end, despite
his efforts to elicit the patient's perspective. However, continued attempts
may help the physician understand Mrs L's concerns, which are apparently
spiritual in nature, and thereby provide her some comfort.
PHYSICIAN: It sounds like you can't understand why this would happen given
all that you've done to lead a good life.
MRS L: Yes, I sometimes feel that God is punishing me, even though I've
tried to be a good person. Why else would God let this happen?
PHYSICIAN: It sounds like you're thinking about the past, trying to figure
out what you might have done.
MRS L: Yes, that's it [tearful].
This dialogue is not a digression but an integral part of clinical care
because it builds empathy and helps relieve distress. Empathic comments can
be therapeutic, showing that the physician has understood the patient and
cares about her. 28-31 <http://jama.ama-assn.org/issues/v287n6/rfull/#r28>
Patients who believe that the physician has really understood them may no
longer feel alone with their distress. 29
<http://jama.ama-assn.org/issues/v287n6/rfull/#r29> , 32
<http://jama.ama-assn.org/issues/v287n6/rfull/#r32>
The physician in case 2 avoids several pitfalls in responding to Mrs L's
spiritual and religious concerns ( Box 2
<http://jama.ama-assn.org/issues/v287n6/rfull/#box2> ). First, he does not
try to solve her problems. 10
<http://jama.ama-assn.org/issues/v287n6/rfull/#r10>  Trying to relieve
suffering is a compassionate human response and the goal of palliative care.
Fixing problems is the focus of biomedical training. However, spiritual
suffering cannot be "fixed" in the same way that pain may be alleviated with
analgesics. The physician cannot answer the ultimate question of why good
people have fatal diseases. Yet paradoxically, patients may feel comforted
when another person is simply present or "walks with" them. 33
<http://jama.ama-assn.org/issues/v287n6/rfull/#r33>
Second, the physician does not step beyond his expertise and role. 15
<http://jama.ama-assn.org/issues/v287n6/rfull/#r15> , 17
<http://jama.ama-assn.org/issues/v287n6/rfull/#r17> , 18
<http://jama.ama-assn.org/issues/v287n6/rfull/#r18> , 34-37
<http://jama.ama-assn.org/issues/v287n6/rfull/#r34>  Physicians should
respect patients' religious and spiritual views and avoid expounding or
imposing their own beliefs. 11
<http://jama.ama-assn.org/issues/v287n6/rfull/#r11> , 18
<http://jama.ama-assn.org/issues/v287n6/rfull/#r18> , 35
<http://jama.ama-assn.org/issues/v287n6/rfull/#r35> , 38
<http://jama.ama-assn.org/issues/v287n6/rfull/#r38>  Unlike chaplains and
clergy, few physicians have the training or expertise to engage in
theological discussions about the nature of God, sin, and punishment. 15
<http://jama.ama-assn.org/issues/v287n6/rfull/#r15> , 18
<http://jama.ama-assn.org/issues/v287n6/rfull/#r18>  Moreover, the roles of
physician and spiritual counselor usually are best kept separated, 11
<http://jama.ama-assn.org/issues/v287n6/rfull/#r11> , 15
<http://jama.ama-assn.org/issues/v287n6/rfull/#r15> , 17
<http://jama.ama-assn.org/issues/v287n6/rfull/#r17> , 18
<http://jama.ama-assn.org/issues/v287n6/rfull/#r18> , 34
<http://jama.ama-assn.org/issues/v287n6/rfull/#r34> , 35
<http://jama.ama-assn.org/issues/v287n6/rfull/#r35> , 39
<http://jama.ama-assn.org/issues/v287n6/rfull/#r39>  except perhaps when a
physician has also had pastoral care or seminary training.
Third, the physician does not offer premature reassurance. When a patient
questions the worth of her life, compassion may impel the physician to say
that cancer is not a punishment from God. However, immediate reassurance may
seem superficial and fail to achieve its goal. It might also deter patients
from disclosing other important issues and emotions. 24
<http://jama.ama-assn.org/issues/v287n6/rfull/#r24> , 26
<http://jama.ama-assn.org/issues/v287n6/rfull/#r26>  As a result, patients
may be burdened by unexpressed concerns and feel that the physician has not
understood them. 24 <http://jama.ama-assn.org/issues/v287n6/rfull/#r24> , 26
<http://jama.ama-assn.org/issues/v287n6/rfull/#r26>
Physicians may find it difficult to refrain from attempting to alleviate the
patient's spiritual suffering or from offering immediate reassurance. To
overcome their skepticism, physicians might recall the last time they came
home from work and said, "I had a terrible day." Was it helpful if your
spouse offered advice about dictating notes after each patient or
reassurance that the next day would be better? Or was it more helpful if
others listened to your story, asked questions, and acknowledged, "It does
sound like a terrible day?" Such reflections may help persuade physicians
that they may not have answers to the patient's spiritual or religious
questions, but they still can provide a supportive setting that helps
patients to find their own solutions.



RESPONDING TO A PATIENT'S QUESTIONS ABOUT THE PHYSICIAN'S RELIGION



During discussions of the patient's spiritual and religious concerns, he/she
may ask about the physician's religion or whether the physician believes in
God or is born-again. 18 <http://jama.ama-assn.org/issues/v287n6/rfull/#r18>
Patients may have various reasons for such inquiries. They may wonder
whether it is safe to talk about spiritual and religious issues with the
physician. They may prefer a physician who is sensitive to spiritual issues,
is religious, or shares the same faith. 18
<http://jama.ama-assn.org/issues/v287n6/rfull/#r18> , 40
<http://jama.ama-assn.org/issues/v287n6/rfull/#r40>  In social
relationships, a disclosure by one person often leads to a reciprocal
disclosure by the other. More problematically, some patients may be curious
to know personal information about their physician or may want to engage the
physician in religious discussions.
Physicians might respond in several ways to such questions. Many physicians
may feel that their religion is a private matter and choose not to disclose
it to their patients. 18 <http://jama.ama-assn.org/issues/v287n6/rfull/#r18>
If they are of a different faith, they may be concerned about a rift with
the patient. 18 <http://jama.ama-assn.org/issues/v287n6/rfull/#r18>
Physicians have no obligation to answer questions about their religion.
However, physicians need to consider how to decline without discouraging
patients from voicing their spiritual or religious concerns. A physician
might say, "I'd like to keep the focus on you rather than me."
Other physicians might simply disclose their denomination. However, in
addition to answering the patient's factual inquiry, such physicians should
also explore why the question is important to the patient. 24
<http://jama.ama-assn.org/issues/v287n6/rfull/#r24>
PHYSICIAN: I am Jewish, but I am curious about why you asked.
MRS L: I guess I was wondering if you could understand my questioning of
God.
PHYSICIAN: I'll certainly try my best. Many patients question why bad things
happen to good people. It is important for me to know that you are
struggling with this and that religion is important in your life.
Physicians who disclose their denomination need to set appropriate limits.
The question "What religion are you?" is not an invitation for physicians to
explicate their spiritual and religious beliefs. If patients ask about
details, it is appropriate to focus the conversation back on the patient.



RESPONDING TO RELIGIOUS REASONS FOR REJECTING THE PHYSICIAN'S MEDICAL
RECOMMENDATIONS



Patients and their families may insist on interventions that physicians
consider futile. 41 <http://jama.ama-assn.org/issues/v287n6/rfull/#r41> , 42
<http://jama.ama-assn.org/issues/v287n6/rfull/#r42>  Such insistence may
result from disagreements over prognosis, rejection of physician authority,
distrust of the medical system, or a religious belief in miracles.
Case 3

Case 3 deals with belief that a miracle will occur. Mrs M is a 72-year-old
black woman with chronic obstructive pulmonary disease who has been
receiving mechanical ventilation for 2 months because of acute respiratory
distress syndrome and multiorgan failure. Believing that Mrs M now has only
a 1% chance of being successfully extubated, her physicians begin to discuss
limiting life-sustaining interventions. Mrs M is unable to participate in
these discussions. She had previously indicated that her husband should act
as her surrogate but did not provide specific directives for her care. Mr M
and their 2 children insist that mechanical ventilation be continued.
PHYSICIAN: Let me explain again how sick she is and that she has not
improved, despite all our efforts.
MR M: We know that she is very sick.
PHYSICIAN: Yes, she is very sick. Her lungs are not healing. She is barely
holding on.
MR M: God has stronger healing powers. He will answer our prayers and work a
miracle.
PHYSICIAN: You know, miracles are rare. Most of the time they don't occur.
This exchange illustrates how physicians may seem to dismiss religious-based
insistence on interventions they consider ill-advised. In these
conversations, each party may feel frustrated and believe the other party is
not listening. The physician in this case uses common but usually
ineffective tactics to try to dissuade the family. First, she tries to
provide more facts or arguments. 43
<http://jama.ama-assn.org/issues/v287n6/rfull/#r43>  However, such
insistence usually springs from different values, not factual
misunderstandings or disagreements. Second, the physician argues that
miracles by definition are unlikely. However, faith in miracles does not
depend on their probability. Other physicians might try to reframe the
concept of "miracle." For example, they might suggest that the miracle will
not be Mrs M's recovery but rather the gathering of relatives to be with her
a final time. Although the family might reach this reformulation on their
own, they are unlikely to be persuaded by someone who does not believe in
miracles. Furthermore, using the family's religious terms to get them to
agree with the physician's plan can be manipulative. As tension mounts,
physicians and families may become polarized, and disagreements may escalate
into conflicts. Rather than reiterate her own position or press the issue of
limiting interventions, the physician might do better to listen to the
family and try to understand their views. 44
<http://jama.ama-assn.org/issues/v287n6/rfull/#r44>
PHYSICIAN: What would a miracle look like to you?
MR M: We know that he [God] will answer our prayers. The bible says that
prayer can move mountains.
PHYSICIAN: I see that your faith is very important to you.
MR M: It is. Our faith is strong that God will work a miracle and she will
come home with us.
PHYSICIAN: I also hope she can go home.
MR M: We just want you to do your best, so that God's will can be done.
The physician has defused the disagreement by listening to Mr M's views on
miracles, acknowledging the importance of religion for him, and aligning
with his hopes that Mrs M might recover. In turn, Mr M seems more accepting
of the limits of medicine in this situation. "I wish" or "I hope" statements
by physicians can be particularly useful in such situations. 45
<http://jama.ama-assn.org/issues/v287n6/rfull/#r45>  Stating a wish allows
the physician to share the family's hope without reinforcing unrealistic
expectations. 45 <http://jama.ama-assn.org/issues/v287n6/rfull/#r45>
However, framing the statement in this way also implies that it is unlikely
that these hopes will be realized.
After finding common ground with Mr M, the physician can explore whether his
religious views have other implications for Mrs M's medical care.
PHYSICIAN: As you think about Mrs M's illness, what else do you hope for?
MR M: We hope, we know, that God will not let her suffer.
PHYSICIAN: Do you feel that she is suffering now?
MR M: She has all those needles and tubes, and she doesn't recognize us most
of the time.
After listening to Mr M's belief in miracles, acknowledging the importance
of religion to him, and aligning with his hopes, the physician may
appropriately turn the discussion toward other hopes for that patient.
However, asking about Mr M's other hopes as soon as he mentioned miracles
might seem dismissive or disrespectful of his religious beliefs.
In addressing Mr M's religious concerns, the physician achieves several
important goals ( Box 3
<http://jama.ama-assn.org/issues/v287n6/rfull/#box3> ). First, clarifying Mr
M's belief in miracles helps the physician appreciate why the family wants
to continue "futile" interventions and how faith is a source of support and
hope to this family. Second, the physician connects with the family.
Listening respectfully does not require the physician to agree with the
family or misrepresent her own views. Once the family feels that the
physician understands them and cares about the patient, they may be more
willing to hear her views on prognosis and care. 44
<http://jama.ama-assn.org/issues/v287n6/rfull/#r44>  Third, the physician
works toward shared goals. After the physician acknowledges the importance
of religion to Mr M, it is safer for Mr M to express his ambivalence about
his wife's condition. Subsequently, the physician and Mr M might be able to
agree on relief of suffering as a goal of care. In turn, this goal might
help the physician and family agree on specific clinical decisions about
ventilation, vasopressors, dialysis, and CPR. After such discussions, some
families or patients may make choices that differ from the physician's
recommendation. However, these discussions will at least reduce the conflict
and ill will over such decisions.
When a patient cannot speak for herself, her physicians need to ascertain
whether her own beliefs are consistent with those expressed by her family.
In this case, the physician later learned that Mrs M had led prayer
breakfasts and bible study groups and had expressed views similar to her
husband's. The physician therefore felt reassured that Mr M was accurately
conveying her beliefs.
Knowledge of their religious concerns and beliefs may help physicians
mobilize support for patients and families. Many will welcome visits,
prayers, scriptural readings, and religious rituals from chaplains or clergy
of their own choosing. Equally important, however, other patients and
families may not want ministrations from chaplains and clergy; their views
should also be respected.
In conclusion, physicians responding to spiritual and religious concerns
that patients raise near the end of life can keep in mind several
guidelines. First, they should respect the patient's views and follow the
patient's lead in exploring how these issues affect their decisions about
medical care, cause distress, or provide comfort. Second, physicians need to
appreciate the limits of their expertise, role, and training. It is
appropriate for the physician to listen, ask clarifying questions, and
explore the patient's feelings, as with any topic of importance to the
patient. However, physicians should not try to convert patients and
generally should not engage in theological discussions or invite patients to
participate in religious rituals. Third, physicians should maintain their
integrity and not say or do anything that violates their own spiritual or
religious views. These guidelines may provide physicians with tools to help
patients find comfort and closure near the end of life.



Author/Article Information


Author Affiliations: Program in Medical Ethics, Division of General Internal
Medicine, University of California, San Francisco (Drs Lo, Ruston, Pantilat,
and Rabow and Ms Kates); Division of General Internal Medicine, Center for
Bioethics and Health Law, University of Pittsburgh School of Medicine,
Pittsburgh, Pa (Dr Arnold); Kennedy Institute of Ethics, Georgetown
University, Washington, DC (Dr Cohen); Center for Bioethics and Humanities,
State University of New York Upstate Medical University, Syracuse (Dr
Faber-Langendoen); Division of Aging Studies, Institute for Spirituality and
Health, George Washington University School of Medicine, St Louis, Mo (Dr
Puchalski); Program for Biopsychosocial Studies, Department of Medicine,
University of Rochester School of Medicine, Rochester, NY (Dr Quill);
Hackensack University Medical Center, Hackensack, NJ (Rabbi Schreiber); John
J. Conley Department of Ethics, Saint Vincent's Manhattan, The Bioethics
Institute of New York Medical College, New York, NY (Dr Sulmasy); and
Program on the Medical Encounter and Palliative Care, Department of
Medicine, Duke University, Durham, NC (Dr Tulsky).

Corresponding Author and Reprints: Bernard Lo, MD, Room C 126, 521 Parnassus
Ave, San Francisco, CA 94143 (e-mail: [log in to unmask]
<mailto:[log in to unmask]> ).
Funding/Support: The Working Group on Religious and Spiritual Issues at the
End of Life was supported by the Greenwall Foundation, New York, NY.
Acknowledgment: We thank the other members of the Working Group on Religious
and Spiritual Issues at the End of Life for their thoughtful review and
analysis of cases and dialogues: Connie Borden, RNP, LaVera Crawley, MD,
Nancy Neveloff Dubler, LLB, Seth Holmes, and Rodney Seeger, MDiv.


Box 1. Phrases to Help Elicit the Patient's Concerns
1. Use open-ended questions.
Examples:
mid bulletDoes your trust in God lead you to think about cardiopulmonary
resuscitation in a particular way?
mid bulletDo you have any thoughts about why this is happening?
2. Ask the patient to say more.
Examples:
mid bulletTell me more about that.
mid bulletCan you tell me how you think she is suffering?
3. Acknowledge and normalize the patient's concerns.
Examples:
mid bulletMany patients ask such questions.
4. Use emphathic comments.
Examples:
mid bulletI imagine I would feel pretty puzzled to not know.
mid bulletThat sounds like a painful situation.
5. Ask about patient's emotions.
Examples:
mid bulletHow do you feel about . . .?
mid bulletHow has it been for you with your wife in the intensive care unit
for so long?
Return to text <http://jama.ama-assn.org/issues/v287n6/rfull/#text1> .)




Box 2. Pitfalls in Discussions About Spiritual and Religious Issues Near the
End of Life
mid bulletTrying to solve the patient's problems or resolve unanswerable
questions.
mid bulletGoing beyond the physician's expertise and role, or imposing the
physician's religious beliefs on the patient.
mid bulletProviding premature reassurance.
Return to text <http://jama.ama-assn.org/issues/v287n6/rfull/#text2> .)




Box 3. Goals for Physicians When Discussing Spiritual and Religious Issues
With Patients and Families Near the End of Life
mid bulletClarify the patient's concerns, beliefs, and needs and follow
hints about spiritual or religious issues.
mid bulletMake a connection with the patient by listening carefully,
acknowledging the patient's concerns, exploring emotions, making empathic
statements, and using wish statements.
mid bulletIdentify common goals for care and reach agreement on clinical
decisions.
mid bulletMobilize sources of support for the patient.
Return to text <http://jama.ama-assn.org/issues/v287n6/rfull/#text3> .)






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Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.