Experiences and Expressions of Spirituality at the End of Life in the Intensive Care Unit

Spiritual Care Expectations Among Cancer and Noncancer Patients With Life-Threatening Illnesses

BACKGROUND

Spirituality is a core element in holistic nursing care. Therefore, it is necessary to understand the spiritual care expectations of cancer and noncancer patients with life-threatening illnesses.

OBJECTIVE

The aim of this study was to identify the spiritual care expectations of vulnerable patients with life-threatening illnesses.

INTERVENTIONS/METHODS

This study uses both quantitative and qualitative approaches, and data were collected from 232 patients. For quantitative data, we used the Nurse Spiritual Therapeutics Scale (NSTS), which comprises 20 items. Qualitative data were collected using an open-ended question. Quantitative data were analyzed using descriptive statistics, independent t tests, 1-way analysis of variance, and item and factor analysis. Qualitative data were analyzed using content analysis.

RESULTS

The mean score of spiritual care expectations ranged from 2.27 to 3.07. There was a significant difference in NSTS mean score between cancer and noncancer patients. In exploratory factor analysis, NSTS was extracted into 3 factors and items belonging to the 3 factors showed similarity between cancer and noncancer patients. Qualitative data using content analysis revealed the following 3 themes: "treat with respect," "religious support," and "comfort with presence." The 3 factors corresponded with 3 themes: factor I versus "treat with respect," factor II versus "religious ritual," and factor III versus "comfort with presence."

CONCLUSIONS

Spiritual care expectations of cancer and non-cancer patients with life-threatening illnesses were identified and the findings provide valuable data regarding the expectations of patients' spiritual care.

IMPLICATIONS FOR PRACTICE

Our findings emphasize integrating patient-reported outcomes with spiritual care to stimulate patient-centered care, thus promoting holistic palliative or end-of-life care.

Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit

End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs.

How to cite this article

Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.

Spirituality in Critical Care: An Observational Study of the Perceptions of Professionals, Patients and Families, in Spain and Latin America

This research aims to describe the perspectives of health care professionals, patients, and family members regarding spiritual care options in intensive care units (ICUs). Participants were recruited consecutively from January to August 2019, during which time data collection was conducted. A total of 1211 Spanish-language questionnaires were collected from 41 ICUs in Spain and Latin America. Approximately 655 participants worked as ICU professionals (74.5% of these participants were women, and 47.5% were nurses). Additionally, 340 questionnaires were sent to patients' families, and patients completed 216 questionnaires; 59.7% of these participants were men, and their mean age was 59.4 years. Most (69.7%) of the critical care professionals considered this type of care to be a part of their profession, 50.1% did not feel competent to provide this type of care, and 83.4% felt that training in this area was necessary. Most families (71.7%) and patients (60.2%) felt that spiritual suffering occurred during their stay in the ICU. The results of this study suggest a perceived deficit in spiritual care in ICUs.

Spiritual needs during COVID 19 pandemic in the perceptions of Spanish emergency critical care health professionals

OBJECTIVES

To investigate the perceptions and attitudes of health professionals working in emergency services and critical care units in Spain about spiritual care provided during the COVID-19 pandemic.

METHODS

A qualitative investigation was carried out using in-depth interviews.

SETTING

Emergency and emergency and ICU health professionals from different regions of Spain.

FINDINGS

The sample consisted of 47 nursing and one nursing assistant. The qualitative analysis yielded four main themes that reflect the following categories: "the experience with spirituality in clinical practice"; "resources and barriers to provide spiritual care"; "the COVID pandemic and spiritual care" and "training in spiritual care". In addition, two subdeliveries were also obtained: "ethical dilemma" and "rituals of death".

CONCLUSIONS

The majority of emergency and critical care nurses believe spiritual care is important to their clinical practice, but there are still several barriers to address patients' spiritual needs. During the COVID-19 pandemic in Spain, professionals felt that spiritual beliefs have emerged as important needs of patients and the restrictions imposed by the pandemic made health professionals more exposed to ethical dilemmas and end-of-life religious issues. The general impression of health professionals is that more training and resources are needed on this topic.

IMPLICATIONS FOR CLINICAL PRACTICE

Health professionals in emergency intensive care must provide nursing care that meets the spiritual needs of their patients to improve care in crisis situations such as the one suffered by the COVID-19 pandemic. For this, emergency services professionals must work and participate in the development of measures to overcome certain barriers present in emergency services, such as lack of time, lack of training and misconceptions that make it difficult to approach emergency services these needs.

Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians' beliefs

INTRODUCTION

Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs.

METHODS

Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians.

RESULTS

Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts.

CONCLUSION

Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.

The 3 Wishes Program Improves Families' Experience of Emotional and Spiritual Support at the End of Life

BACKGROUND

The end-of-life (EOL) experience in the intensive care unit (ICU) is emotionally challenging, and there are opportunities for improvement. The 3 Wishes Program (3WP) promotes the dignity of dying patients and their families by eliciting and implementing wishes at the EOL.

AIM

To assess whether the 3WP is associated with improved ratings of EOL care.

PROGRAM DESCRIPTION

In the 3WP, clinicians elicit and fulfill simple wishes for dying patients and their families.

SETTING

2-hospital academic healthcare system.

PARTICIPANTS

Dying patients in the ICU and their families.

PROGRAM EVALUATION

A modified Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was completed by families of ICU decedents approximately 3 months after death. We compared patients whose care involved the 3WP to those who did not using three BFS-derived measures: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care).

RESULTS

Of 314 completed surveys, 117 were for patients whose care included the 3WP. Bereaved families of 3WP patients rated the Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p = 0.003, adjusted p = 0.001) than those who did not receive the 3WP. The Respectful Care and Communication factor and BFS-PM were no different between groups.

DISCUSSION

The 3WP is a low-cost intervention that may be a feasible strategy for improving the EOL experience.

Meaning in Life, Death Anxiety, and Spirituality in the Lesbian, Gay, and Bisexual Community: A Scoping Review

The changes in people's way of life through the years raise questions on how they address existential needs and concerns, particularly those related to life and death and spiritual connections. Through a scoping review, we surveyed studies on meaning in life, death anxiety, and spirituality within the lesbian, gay, and bisexual (LGB) community. We determined the extent to which these variables have been studied among LGB participants. A total of 28 eligible articles were reviewed. Six studies were found about meaning in life, five studies about death anxiety, and 16 studies about spirituality. Results suggest that meaning in life was derived from experiences related to parenthood, couplehood, and work satisfaction. Studies on death anxiety among LGB participants, which date back to the 1980 and 1990s, indicated the need to conduct present studies in this area. The review showed that LGB members distinguished between spirituality and religion, giving them more positive recognition of the former than the latter. The forms of spiritual expression were anchored to religious practices, for some, and other expressions of belief and faith outside the confines of formally established religions. Spiritual expressions generally accorded the LGB members direction and satisfaction in life. Not all segments of the LGB community were represented in the studies. The available studies, dominantly quantitative, centered only on the LGB experience. Target age groups varied across the studies. The review indicates that future studies can work on exploring these existential factors considering the emerging contexts and paradigms. Future research can focus on determining what factors contribute to meaning in life, given the changes in time.

Holy Simplicity: The Physician's Role in End-of-Life Conversations

Early initiation of end-of-life (EOL) conversations has been shown to improve patient agency in dying, increase early access to hospice care, and facilitate a dignified death. Despite the benefits of early initiation, EOL conversations do not occur as readily as physicians or patients wish. While medicine is commonly considered both a science and an art, increasing medicalization may narrow a clinician's focus towards procedures or specialized clinical frameworks rather than a patient's end-of-life wishes. Since physicians are ambassadors of clinical knowledge and are trusted patient advocates, it is important they facilitate EOL conversations early in the dying process. Patients desire their physicians to convene these conversations. However, physicians are often hesitant to do so. Notable theologians, philosophers, and physicians offer a broad framework outlining the importance of physician-led EOL conversations.

Clinician End-of-Life Experiences With Pediatric Muslim Patients at a US Quaternary Care Center

CONTEXT

A small, growing body of data exist discussing the experiences of Muslim patients with the palliative care system, both in the United States and abroad, as well as providers' experiences with Muslim patients. However, no studies evaluate clinician experiences with Muslim patients in the United States, and none address the unique dynamics of pediatric clinician experiences with Muslim patients and their families in the EOL setting.

OBJECTIVES

The purpose of this study is to perform a thematic analysis of clinician experiences with pediatric Muslim patients and families at the end of life.

METHODS

This was a qualitative study of pediatric clinicians at Duke University Medical Center in the Pediatric Intensive Care Unit, Pediatric Cardiac Intensive Care Unit, and Pediatric Bone Marrow Unit from August 2018 to February 2019. We conducted semistructured interviews with nurses, attending physicians, and social workers to assess participants' experiences caring for Muslim patients and families. We analyzed interview transcripts using descriptive content analysis with NVivo10.

RESULTS

We interviewed 16 clinicians at Duke University Medical Center Pediatric Intensive Care Unit, Pediatric Cardiac Intensive Care Unit, and Pediatric Bone Marrow Unit. Five physicians, five social workers, and six nurses were interviewed. The majority of providers were female, Caucasian, and Christian in an institution where Muslim patients are a significant minority. Several themes emerged highlighting language barriers, difficulty engaging with Muslim families, variations in approach to care and communication, discomfort with gender roles, moral distress with unrelatable decision-making, and external pressures on patient decision-making.

CONCLUSION

A thematic analysis of pediatric clinicians at a quaternary care center in the Southern United States yielded several prominent themes. Many clinicians recognize they likely provide disparate care to minority patients for a variety of reasons encompassing the above barriers. As we work to care for an increasingly diverse patient population, more research into barriers to care and effective educational methods is needed.

Spiritual Care: A Description of Family Members’ Preferences of Spiritual Care Nursing Practices in Intensive Care Units in a Private Hospital in Kwa-Zulu Natal, South Africa

Background: Spiritual care is a part of the holistic care that enables family members in intensive care units to find meaning in their life events and simultaneously bolsters their resilience and coping tools. Objective: To determine family members’ preferences of spiritual care practices that they require from nurses working in intensive care units. Methods: A quantitative, descriptive, cross-sectional study was conducted in the intensive care units of a private hospital in the province of KwaZulu-Natal. Data, using the Nurse Spiritual Therapeutic Scale, were collected from a purposive sample of family members (n = 47). Data were analyzed using descriptive statistics. Results: The mean overall Nurse Spiritual Therapeutic Scale was 58.4 (20–80). The most preferred and least preferred spiritual care practices by family members were “to be helped to have quiet time and space”, (M = 3.32, SD = 0.59) and “to arrange for a chaplain to visit them” (M = 2.70, SD= 0.91), respectively. Conclusion: The mean overall NSTS score indicated that there was a strong preference among family members for nurses to provide them with spiritual care in the intensive care units. However, due to the diversity of family members’ preferences it remains important that family members guide intensive care nurses in their spiritual care.

The Physician and End-of-Life Spiritual Care: The PALliatiVE Approach

Spiritual care is universally acknowledged as a cornerstone of palliative care, yet most healthcare professionals find it difficult to address. The present work aims to provide a simple educational tool that may help physicians address spirituality in their clinical practice. We found articles written in both Portuguese and English through PubMed, using the combination of MeSH terms: "Spirituality" and "Palliative Care." The research was complemented by relevant monographs previously known to the authors, consultation of selected references of the main bibliography, and interviews to an experienced spiritual care provider. In order to help physicians to incorporate spiritual care in their clinical practice, a flexible yet standardized approach is long overdue. This is the aim of the PALliatiVE approach, which compiles the literature in a set of 5 attitudes that may aid the clinician in the delivery of spiritual care: Prepare (P), Ask (A), Listen (L), Validate (V), and consult an Expert (E). This approach is based on a synthesis of a broad literature review, which motivated the five-layered approach. There is a significant literature coverage supporting each attitude of this five-layered approach, including at least one randomized control trial or systematic review per attitude. Though still requiring external validation, the PALliatiVE approach can be a guide to the physician on how to provide spiritual care, a practice rooted in compassion and in simply being-with the one who suffers.

Cuidado espiritual prestado pela equipe de enfermagem à pessoa em paliação na terapia intensiva

RESUMO Objetivo: Apreender como ocorre o cuidado espiritual prestado pela equipe de enfermagem à pessoa em paliação na Unidade de Terapia Intensiva. Método: Estudo de abordagem qualitativa, realizado em uma Unidade de Terapia Intensiva em Salvador, Bahia. A coleta de dados ocorreu por entrevistas semiestruturadas entre janeiro e maio de 2019. Participaram do estudo 14 enfermeiras e 21 técnicas de enfermagem. Os dados foram submetidos à Análise de Conteúdo de Bardin e analisados à luz da Teoria Final de Vida Pacífico. Resultados: Emergiram duas categorias: 1. Cuidado espiritual prestado através de palavras de otimismo, estímulo a fé e oração; 2. Cuidado prestado através da atenção às necessidades espirituais e da garantia de conforto. Considerações finais: Embora de forma empírica e não consciente do cuidado espiritual prestado, a equipe de enfermagem oferta apoio com palavras de otimismo, fé, momentos de orações e contribui para o conforto espiritual da pessoa em paliação.

Chaplain Care in the Intensive Care Unit at the End of Life: A Qualitative Analysis

Background: The provision of spiritual care is a key component of high-quality patient-centered care, particularly in the intensive care unit (ICU). However, the integration of spiritual care into the care of patients in the ICU is variable, especially at the end of life, which may be due in part to poor or incomplete provider knowledge of the work of chaplains.

Objective: To characterize the care and services provided by chaplains to patients in an ICU at the end of life and/or their families.

Design: A retrospective chart review was performed to identify all patients admitted over a three-month period to an ICU who had visits with a chaplain and an ICU course that ended in death, discharge to a palliative care facility or discharge to hospice.

Subjects/setting: Twenty-five chaplains at a U.S. medical center.

Measurements: Qualitative analysis was performed using directed content analysis on the notes written by the chaplains.

Results: Qualitative analyses of the chaplain notes revealed four broad themes regarding the activities of chaplains in the ICU with respect to patients and families. These were that chaplains provide comfort to patients and family facing the end of life, provide prayers with a variety of purposes, assist in supporting family members through complex medical decision making, and provide connections to appropriate resources.

Conclusions: Chaplains contribute to the care of patients in the ICU through a wide range of activities that demonstrate the unique intermediary and collaborative role chaplains can play within the health care team at the end of life in the ICU.

The Relationship Between Turkish Nursing Students' Perceptions of Spiritual Care and their Attitudes Towards Death

This study aimed to examine the relationship between nursing students' perception of spiritual care and their attitudes towards death. This cross-sectional study was conducted in Turkey between March and April 2021 with 601 nursing students using the Google Forms questionnaire. The "Spirituality and Spiritual Care Rating Scale (SSCRS)" and "Attitude towards Death Scale (ATDS)" were utilised to assist with data collection and analysis. While there was no relationship between the students' total SSCRS and total ATDS scores, there was a positive relationship between the total SSCRS and the Neutral Acceptance-Approach Acceptance Subscale (r = 0.129, p = 0.002), and a negative relationship between SSCRS and the Fear of Death and Avoidance of Death Subscale (r =  - 0.097, p = 0.017). Providing support in terms of spiritual care and viewing spiritual care as related to nursing were related to the total SSCRS score. Alcohol use, viewing spiritual care as related to nursing, self-perceptions of spirituality, and fear of death were associated with the total ATDS score (p < 0.05). It is recommended that spiritual care and death perceptions be addressed more comprehensively in the educational curriculum of nursing students.

Religious and spiritual support in the conception of nurses and families of critical patients: a cross-sectional study

OBJECTIVE

To assess the religious and spiritual support in critical care according to the conception of patients' family members and nurses.

METHOD

This is a quantitative cross-sectional study conducted with nurses and relatives of patients admitted to intensive care units. Sociodemographic data were collected and a questionnaire on religiosity and spirituality was applied to family members and the Spirituality and Spiritual Care Rating Scale to nurses. The results with p ≤ 0.05 were significant.

RESULTS

Sample consisted of intensive care nurses (n = 22) and family members (n = 61). Intensive care nurses stated that they can provide spiritual care (p = 0.03). Of the family members, 88.5% believed that religiosity and spirituality help in coping with difficult times, highlighting prayer as part of care for critically ill patients (p = 0.02).

CONCLUSION

Nurses and family members recognized religious/spiritual support as significant to the process of caring for critically ill patients, even though professional qualification is required for greater integration of this support in daily intensive care.

Experiences and needs of families with a relative admitted to an adult intensive care unit: a systematic review of qualitative studies

OBJECTIVE

The objective of the review was to synthesize research studies that reported on the experiences and needs of families with a relative in an adult intensive care unit.

INTRODUCTION

Having a relative in an intensive care unit has been reported to be a time of turmoil, stress, and disruption to the lives of family members. Primary research studies suggest such a crisis or even a planned intensive care unit admission can have not only emotional, physical, and psychological impact, but can also affect family member roles and function. A deeper understanding of the overall experience may assist intensive care unit staff to address specific family needs.

INCLUSION CRITERIA

This review included qualitative studies of any design that described and explored the experiences and needs of family members with a relative admitted to an adult intensive care unit.

METHODS

The methods for the review followed the JBI meta-aggregation approach for synthesizing qualitative data. MEDLINE (EBSCO), CINAHL (EBSCO), PsycINFO (EBSCO), Embase (Embase.com) and Web of Science Core Collection (Clarivate Analytics) databases were searched for published studies. ProQuest Dissertations and Theses database (Ovid) was searched for unpublished studies. Studies published from 2010 to November 2019 in the English language were selected for possible inclusion in the review.

RESULTS

From 7208 citations, 20 studies were agreed upon for inclusion in the review. From these studies, 112 findings were extracted and synthesized into 12 categories. Four synthesized findings were compiled by aggregating the categories. Broadly, these synthesized findings related to: psychosocial health, proximity, information needs, and the intensive care unit environment.

CONCLUSIONS

Being a relative of a patient in an intensive care unit is a complex, emotional, and individual experience that can have physical, psychological, and emotional impact. The synthesized findings from this review can be used to support family-centered care practices in adult intensive care units, particularly in regard to information provision, visiting practices, and supportive care.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42016053300.

Nursing Students' Spiritual Orientations and Their Attitudes Toward the Principles of Dying with Dignity: A Sample from Turkey

Nurses' attitudes toward spiritual care and death are influenced by their personal belief systems and world-views. The aim of this study is to reveal the attitudes of nursing students toward spiritual orientation and principles of dying with dignity. The study was conducted with the participation of 478 nursing students. As a result of the study, it was found that the average score of the students' spiritual orientation scale was high and the average score of the assessment scale of attitudes toward the principles of dying with dignity was found to be moderate.

Nurses' Attitudes Towards Death and Their Effects on Spirituality and Spiritual Care

This study aimed to determine the effect of nurses' attitudes towards death on spirituality and spiritual care. This is a descriptive and correlational study. There was a moderate correlation between the total score on the Spirituality and Spiritual Care Rating Scale and the total and subdimension scores on the Attitude Towards Death Scale. It was found that the scores on the subdimensions of objective acceptance, escaping/acceptance and fear of death explained 41.7% of nurses' perceptions of spirituality and spiritual care. For holistic nursing care, it is very important that nurses are aware of their patients' spiritual needs and are capable of providing supportive spiritual service without regard for their own attitudes towards or spiritual thoughts about death.

Chaplaincy Care in the MICU: Examining the Association Between Spiritual Care and End-of-Life Outcomes

BACKGROUND

Seriously ill patients admitted to the Intensive Care Unit (ICU) experience severe spiritual and existential distress. Patients' surrogate decision makers face the burden of making complex decisions about their loved ones' care. Experienced chaplains may play a role in assisting with decision-making, possibly by aligning patients' values and wishes with treatment plans and avoiding non-beneficial aggressive measures.

OBJECTIVES

To identify associations between chaplaincy care and length of stay (LOS) in the medical ICU (MICU).

METHODS

This was a retrospective observational study of usual spiritual care in the adult MICUs of 4 medical centers in the United States over a 3-month period. Inclusion criteria were death in the MICU or discharge to palliative care or hospice. Measures included medical, treatment, and spiritual care information. Through bivariate and multivariable analyses associations between spiritual care and LOS were examined.

RESULTS

In multivariable analysis of the 254 patients, receiving spiritual care was associated with an increased likelihood of being in a higher LOS tertile (adjusted odds ratio = 2.94, p < .001). In post hoc bivariate analysis, cases receiving spiritual care within the first 48 hours of MICU admission revealed a trend toward lower LOS (p = .181).

CONCLUSION

Spiritual care in the MICU was associated with longer LOS. Early intervention by chaplains who are well-integrated in the ICU may assist patients and their loved ones in coming to terms with grave illness and making difficult treatment decisions. Further well-designed studies of spiritual care interventions that may affect outcomes are needed.

Barriers to Addressing the Spiritual and Religious Needs of Patients and Families in the Intensive Care Unit: A Qualitative Study of Critical Care Physicians

OBJECTIVES

Though critical care physicians feel responsible to address spiritual and religious needs with patients and families, and feel comfortable in doing so, they rarely address these needs in practice. We seek to explore this discrepancy through a qualitative interview process among physicians in the intensive care unit (ICU).

METHODS

A qualitative research design was constructed using semi-structured interviews among 11 volunteer critical care physicians at a single institution in the Midwest. The physicians discussed barriers to addressing spiritual and religious needs in the ICU. A code book of themes was created and developed through a regular and iterative process involving 4 investigators. Data saturation was reached as no new themes emerged.

RESULTS

Physicians reported feeling uncomfortable in addressing the spiritual needs of patients with different religious views. Physicians reported time limitations, and prioritized biomedical needs over spiritual needs. Many physicians delegate these conversations to more experienced spiritual care providers. Physicians cited uncertainty into how to access spiritual care services when they were desired. Additionally, physicians reported a lack of reminders to meet these needs, mentioning frequently the ICU bundle as one example.

CONCLUSIONS

Barriers were identified among critical care physicians as to why spiritual and religious needs are rarely addressed. This may help inform institutions on how to better meet these needs in practice.

Keepsakes at the End of Life

CONTEXT

Keepsakes are a relatively unexplored form of bereavement support that is frequently provided as part of the 3 Wishes Project (3WP). The 3WP is a palliative care intervention in which individualized wishes are implemented in the adult intensive care unit for dying patients and their families.

OBJECTIVES

We aimed to characterize and enumerate the keepsakes that were created as part of the 3WP and to understand their value from the perspective of bereaved family members.

METHODS

We performed a secondary analysis of family interviews during a multicenter study on the 3WP and characterized all wishes that involved keepsakes. Sixty interviews with family members regarding the 3WP were reanalyzed using qualitative analysis to identify substantive themes related to keepsakes.

RESULTS

Of 730 patients, 345 (47%) received keepsakes as part of their participation in 3WP. Most keepsakes were either tangible items that served as reminders of the patient's presence (thumbprints and locks of hair) or technology-assisted items (photographs and word clouds). The median cost per keepsake wish was $8.50 (interquartile range $2.00-$25.00). Qualitative analysis revealed two major themes: keepsakes are tangible items that are highly valued by family members; and the creation of the keepsake with clinical staff is valued and viewed as a gesture of compassion.

CONCLUSION

Keepsakes are common wishes that clinicians in the intensive care unit are able to provide and sometimes cocreate with families when patients are dying. Both the offering to create the keepsake and receipt of the final product are perceived by family members as helpful.

End-of-Life Wishes Among Non-Hispanic Black and White Middle-Aged and Older Adults

PURPOSE

Although some research has been done on end-of-life (EOL) preferences and wishes, our knowledge of racial differences in the EOL wishes of non-Hispanic White and non-Hispanic Black middle-aged and older adults is limited. Previous studies exploring such racial differences have focused mainly on EOL decision-making as reflected in advance healthcare directives concerning life-sustaining medical treatment. In need of examination are aspects of EOL care that are not decision-based and therefore not normally covered by written advance healthcare directives. This study focuses on racial differences in non-decision-based aspects of EOL care, that is, EOL care that incorporates patients' beliefs, culture, or religion.

AIM

To test the combined effects of race, socioeconomic status, health status, spirituality, perceived discrimination and medical mistrust on the EOL non-decision-based desires and wishes of a representative sample of non-Hispanic White and non-Hispanic Black older California adults.

METHODS

This cross-sectional study used data from the Survey of California Adults on Serious Illness and End-of-Life 2019. To perform data analysis, we used multiple logistic regression models.

RESULTS

Non-Hispanic Blacks reported more EOL non-decision-based desires and wishes than non-Hispanic Whites. In addition to gender, age, and education other determinants of EOL non-decision-based medical desires and wishes included perceived and objective health status, spirituality, and medical trust. Poverty level, perceived discrimination did not correlate with EOL medical wishes.

CONCLUSION

Non-Hispanic Blacks desired a closer relationship with their providers as well as a higher level of respect for their cultural beliefs and values from their providers compared with their White counterparts. Awareness, understanding, and respecting the cultural beliefs and values of older non-Hispanic Black patients, that usually are seen by non-Hispanic Black providers, is the first step for meaningful relationship between non-Hispanic Black patients and their providers that directly improve the end-of-life quality of life for this segment of our population.

An understanding of spirituality and spiritual care among people from Chinese backgrounds: A grounded theory study

AIM

To investigate the meaning of spirituality and spiritual care among people from Chinese backgrounds living in England.

DESIGN

Strauss and Corbin's grounded theory design was used.

METHOD

Twenty-five participants were recruited from Chinese community centres after which data saturation was reached in September 2016. In-depth interviews in Chinese were carried out. Transcribed digital recordings were translated into English. Data analysis followed the techniques of open coding, axial coding, and selective coding, using NVivo11. Data collection and analysis were conducted simultaneously.

RESULTS

Three themes emerged from the data which provide an understanding of spirituality and spiritual care in the study context: 'essence and nature of life', 'driving forces', 'self-support'.

CONCLUSION

This study provides an understanding of spirituality and spiritual care from a Chinese cultural perspective. From a Daoist tradition, spirituality is seen as essence and driving force in the human body. From a Confucian viewpoint, it appears that patients saw themselves or the 'self' as a supporting resource.

IMPACT

The knowledge gained from this study has potential to support nurses and healthcare practitioners to identify the spiritual needs of people from Chinese backgrounds and to remove some of the Chinese misconceptions Chinese people hold about spiritual care by explaining what these concepts could mean. It could also improve cultural awareness for student nurses around what constitutes spiritual care. Further research is recommended among the wider community of health and social care workers to explore spirituality and spiritual care among people from Chinese backgrounds living in England.

Differences in the association of spirituality, forgiveness, PTSD and stress among social workers and social work students treating trauma survivors

Providing professional assistance to trauma victims may cause significant emotional distress to those who provide the assistance. Dealing with such stress requires attention to significant personal resources. This study examined the relationship between tendency to forgive and spirituality with PTSD symptoms and stress among social workers and social work students (N = 157) who are at the front line dealing with trauma survivors. The study results demonstrated that social work students had higher levels of stress while no significant differences were found regarding spiritually, PTSD, and forgiveness. Examining the subscales revealed that social work students had higher negative PTSD alteration symptoms than trained social workers while trained social workers had higher levels of forgiveness to self. Additionally, structural equation models showed that among social workers, forgiveness to self and spirituality were associated simultaneously with lower PTSD symptoms and stress. However, among social work students, the tendency to forgive the self was associated with lower PTSD symptoms only. The findings illuminate spirituality and forgiveness as key factors that can help cope with the emotional toll of those who assist trauma survivors, while focusing on differences for trained professionals and training professionals. Theoretical and clinical implications are discussed.

Expanding the 3 Wishes Project for compassionate end-of-life care: a qualitative evaluation of local adaptations

BACKGROUND

The 3 Wishes Project (3WP) is an end-of-life program that honors the dignity of dying patients by fostering meaningful connections among patients, families, and clinicians. Since 2013, it has become embedded in the culture of end-of-life care in over 20 ICUs across North America. The purpose of the current study is to describe the variation in implementation of 3WP across sites, in order to ascertain which factors facilitated multicenter implementation, which factors remain consistent across sites, and which may be adapted to suit local needs.

METHODS

Using the methodology of qualitative description, we collected interview and focus group data from 85 clinicians who participated in the successful initiation and sustainment of 3WP in 9 ICUs. We describe the transition between different models of 3WP implementation, from core clinical program to the incorporation of various research activities. We describe various sources of financial and in-kind resources accessed to support the program.

RESULTS

Beyond sharing a common goal of improving end-of-life care, sites varied considerably in organizational context, staff complement, and resources. Despite these differences, the program was successfully implemented at each site and eventually evolved from a clinical or research intervention to a general approach to end-of-life care. Key to this success was flexibility and the empowerment of frontline staff to tailor the program to address identified needs with available resources. This adaptability was fueled by cross-pollination of ideas within and outside of each site, resulting in the establishment of a network of like-minded individuals with a shared purpose.

CONCLUSIONS

The successful initiation and sustainment of 3WP relied on local adaptations to suit organizational needs and resources. The semi-structured nature of the program facilitated these adaptations, encouraged creative and important ways of relating within local clinical cultures, and reinforced the main tenet of the program: meaningful human connection at the end of life. Local adaptations also encouraged a team approach to care, supplementing the typical patient-clinician dyad by explicitly empowering the healthcare team to collectively recognize and respond to the needs of dying patients, families, and each other.

TRIAL REGISTRATION

NCT04147169 , retrospectively registered with clinicaltrials.gov on October 31, 2019.

Spiritual Dimension at the End of Life: A Phenomenological Study from the Caregiver's Perspective

The lives of healthy and sick people are structured according to a variety of conceptual matrices. One of these matrixes consists of philosophical, spiritual, and religious convictions, being this especially relevant in the process of the end of life. The objective of the study is to understand the meaning that individuals at the end of life and the relatives of such individuals award spiritual and/or religious beliefs through an examination of caregiver narratives. Multicentric study was developed that used a qualitative design and a phenomenological approach. The study was conducted in the autonomous community of Andalusia, specifically in the provinces of Almeria, Malaga, Seville, Granada, and Huelva. The selection method was purposive sampling. Caregivers who had lost a relative in a period between 2 months and 2 years previously and who were not in a process of pathological grieving were selected for inclusion in the study. The method involved five discussion groups and 41 in-depth interviews, with a total of 87 participants. A change of paradigms is necessary in which, among other elements, the focus of palliative care is centered on the ability to address these spiritual needs, and healthcare professionals are trained to assist in the provision of such care. Another important consideration is the inequality of spiritual supported provided by clergy from various religions. At least in the cultural context of the research, Catholic chaplains were the only institutional figures whose presence was assumed necessary by health organizations. However, the cultural and/or religious diversity in the autonomous community in which the study was conducted is increasingly broad and complex. It appears necessary to incorporate a variety of clergies in health units so that all patients may find support, whether in terms of companionship or celebration.

Chaplaincy Care in the MICU: Describing the Spiritual Care Provided to MICU Patients and Families at the End of Life

BACKGROUND

Gravely ill patients admitted to the intensive care unit (ICU), and their families experience acute spiritual and existential needs and often require complex decisions about their care. Little is known about what constitutes chaplaincy care for patients or families in ICUs. Chaplains report that participation in medical decision-making is part of their role.

OBJECTIVE

To describe the spiritual care provided to patients and their families in the ICU.

METHODS

This was a retrospective observational study of spiritual care for patients and families in the medical ICUs (MICUs) at 4 medical centers over a 3-month period. Inclusion criteria were death in the MICU or discharge to palliative care or hospice. Measures included medical, treatment, and spiritual care information (number of visits, length of visit, chaplain categories, and type of spiritual care provided).

RESULTS

Of the 254 patients, 197 (78%) received a total of 485 spiritual care visits. Seventy-seven percent of visits included provision of emotional/spiritual support; only 15% included decision-making support such as family meetings or goals-of-care conversations. The proportion receiving spiritual care increased as patients neared death or discharge. Staff chaplains were involved in goals-of-care conversations to a greater extent than student or part-time chaplains (P < .05).

CONCLUSION

Spiritual care was provided to most patients and/or families at the end of life. Low chaplain involvement in decision-making in the MICU suggests opportunities to improve chaplains' contributions to ICU care.

Intensivists' Religiosity and Perceived Conflict During a Simulated ICU Family Meeting

CONTEXT

Conflict is frequently reported by both clinicians and surrogate decision makers for adult patients in intensive care units. Because religious clinicians view religion as an important dimension of end-of-life care, we hypothesized that religious critical care attendings (intensivists) would be more comfortable and perceive less conflict when discussing a patient's critical illness with a religious surrogate.

OBJECTIVES

The objective of this study was to assess if religious intensivists are more or less likely to perceive conflict during a simulated family meeting than secular colleagues.

METHODS

Intensivists were recruited to participate in a standardized, simulated family meeting with an actor portraying a family member of a critically ill patient. Intensivists provided demographic information including their current religion and the importance of religion in their lives. After the simulation, intensivists rated the amount of conflict they perceived during the simulation. The association between intensivist's self-reported religiosity and perceived conflict was estimated using both univariate analysis and multivariable logistic regression.

RESULTS

Among 112 participating intensivists, 43 (38%) perceived conflict during the simulation. Among intensivists who perceived conflict, 49% were religious, and among those who did not perceive conflict, 35% were religious. After adjusting for physician race, gender, years in practice, intensive care unit weeks worked per year and actor, physician religiosity was associated with greater odds of perceiving conflict during the simulated family meeting (adjusted prevalence ratio = 2.77, [95% CI 1.12-7.16], P = 0.03).

CONCLUSION

Religious intensivists were more likely to perceive conflict during a simulated family meeting.

End of life in acute hospital setting-A systematic review of families' experience of spiritual care

AIMS AND OBJECTIVES

To systematically review qualitative studies exploring families' experiences of spiritual care at the end of life in acute hospital settings.

BACKGROUND

Although there is a widespread belief that the consideration of spiritual and religious needs is outdated in the context of secularism, from a practical perspective patients and families appear to benefit from spiritual support at the end of life.

METHODS

Six key databases, CINAHL, MEDLINE, EMBASE, Global Health Library, Web of Science and Applied Social Sciences Index and Abstracts (ASSIA), were searched, and three reviewers independently extracted the data and coded them into themes and subthemes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used as a reporting framework.

RESULTS

Five main themes emerged: anticipating needs; honouring the family by honouring the patient; personal connection; lack of sensitivity; and making space for religious and spiritual practices.

CONCLUSIONS

Families experiencing end-of-life care in acute hospital settings may benefit from spiritual care. While this can also be considered as fundamental care, understanding this through the lenses of spiritual care allows for incorporation of religious and spiritual practices that many seek at this time, irrespective of their faith perspectives.

RELEVANCE TO CLINICAL PRACTICE

Although hospice care is well established internationally, many families experience end-of-life care in acute hospital settings. Nurses usually get to know families well during this time; however, the demands of the clinical environment place restrictions on family care and perceptions of lack of communication, limited support and/or limited sensitivity can compound families' suffering. Consideration of families' spiritual needs can help to support families during this time. Nurses are ideally placed for this and can anticipate and plan for patient and family needs in this regard, or refer to a specialist, such as the Healthcare Chaplain.

Spiritual care in the intensive care unit: An integrative literature research

PURPOSE

The aim of this study is to review the literature for three major domains in relation to spiritual care in the ICU, namely Quality of Life (QoL), Quality of Care (QoC), and Education (E).

METHOD

An integrative literature research.

RESULTS

The 113 selected articles reveal that spirituality is an essential component of QoL and that complementary and effective spiritual care (SC) relieves distress of patients and their relatives. Furthermore, the contribution of SC to quality of care is: 1) diagnosing and addressing spiritual and emotional needs among patients and their relatives; 2) offering spiritual comfort to the patient in distress; 3) increased spiritual well-being of both patients and their relatives; 4) increased family satisfaction in general and by shared decision-making. Finally, the literature reveals the necessity to improve SC knowledge and skills of ICU healthcare professionals (IC HCPs) through relevant training courses.

CONCLUSION

SC contributes to QoL and QoC. The literature indicates that IC HCPs acknowledge the need to improve their SC knowledge and skills to enhance complementary, effective SC. Further research on SC as an integrated part of daily ICU care is necessary to improve QoL and QoC of patients and their relatives.

Organ Donation at the End of Life: Experiences From the 3 Wishes Project

PURPOSE

The 3 Wishes Project (3WP) promotes holistic end-of-life care in the intensive care unit (ICU) to honor dying patients, support families, and encourage clinician compassion. Organ donation is a wish that is sometimes made by, or on behalf of, critically ill patients. Our objective was to describe the interface between the 3WP and organ donation as experienced by families, clinicians, and organ donation coordinators.

METHODS

In a multicenter evaluation of the 3WP in 4 Canadian ICUs, we conducted a thematic analysis of transcripts from interviews and focus groups with clinicians, organ donation coordinators, and families of dying or died patients for whom donation was considered.

RESULTS

We analyzed transcripts from 26 interviews and 2 focus groups with 18 family members, 17 clinicians, and 6 organ donation coordinators. The central theme describes the mutual goals of the 3WP and organ donation-emphasizing personhood and agency across the temporal continuum of care. During family decision-making, conversations encouraged by the 3WP can facilitate preliminary discussions about donation. During preparation for donation, memory-making activities supported by the 3WP redirect focus toward personhood. During postmortem family care, the 3WP supports families, including when donation is unsuccessful, and highlights aspirational pursuits of donation while encouraging reflections on other fulfilled wishes.

CONCLUSIONS

Organ donation and the 3WP provide complementary opportunities to engage in value-based conversations during the dying process. The shared values of these programs may help to incorporate organ donation and death into a person's life narrative and incorporate new life into a person's death narrative.

Compassionate End-of-Life Care: Mixed-Methods Multisite Evaluation of the 3 Wishes Project

BACKGROUND

The 3 Wishes Project (3WP) is an end-of-life program that aims to honor the dignity of dying patients by creating meaningful patient- and family-centered memories while promoting humanistic interprofessional care.

OBJECTIVE

To determine whether this palliative intervention could be successfully implemented-defined as demonstrating value, transferability, affordability, and sustainability-beyond the intensive care unit in which it was created.

DESIGN

Mixed-methods formative program evaluation. (ClinicalTrials.gov: NCT04147169).

SETTING

4 North American intensive care units.

PARTICIPANTS

Dying patients, their families, clinicians, hospital managers, and administrators.

INTERVENTION

Wishes from dying patients, family members, and clinicians were elicited and implemented.

MEASUREMENTS

Patient characteristics and processes of care; the number, type, and cost of each wish; and semistructured interviews and focus groups with family members, clinicians, and managers.

RESULTS

A total of 730 patients were enrolled, and 3407 wishes were elicited. Qualitative data were gathered from 75 family members, 72 clinicians, and 20 managers or hospital administrators. Value included intentional comforting of families as they honored the lives and legacies of their loved ones while inspiring compassionate clinical care. Factors promoting transferability included family appreciation and a collaborative intensive care unit culture committed to dignity-conserving end-of-life care. Staff participation evolved from passive support to professional agency. Program initiation required minimal investment for reusable materials; thereafter, the mean cost was $5.19 (SD, $17.14) per wish. Sustainability was demonstrated by the continuation of 3WP at each site after study completion.

LIMITATION

This descriptive formative evaluation describes tertiary care center-specific experiences rather than aiming for generalizability to all jurisdictions.

CONCLUSION

The 3WP is a transferrable, affordable, and sustainable program that provides value to dying patients, their families, clinicians, and institutions.

PRIMARY FUNDING SOURCE

Greenwall Foundation.

Top Ten Tips Palliative Care Clinicians Should Know About Psychosocial and Family Support

Palliative care (PC) is perhaps the most inherently interdisciplinary specialty within health care. Comprehensive PC is delivered by a core team of physicians, nurses, social workers, spiritual care providers, pharmacists, and others who address the broad range of medical, psychosocial, and spiritual needs of those living with serious illness. While PC clinicians are typically skilled in screening for distress, the best path to follow when patients screen positive for psychosocial distress or exhibit mental health challenges may not always be clear. This article brings together the perspectives of experienced social workers practicing across PC and hospice settings. It seeks to identify opportunities and rationale for the integration of palliative social work (PSW) in the provision of quality, person-centered, family-focused, and culturally congruent care for the seriously ill. Increasing recognition of the impact of social determinants of health highlights the critical importance of including PSW if we are to better understand and ultimately address the broad range of factors that influence people's quality of life.

Spiritual Distress in Family Members of Critically Ill Patients: Perceptions and Experiences

Background: Spiritual distress among family members of patients in the intensive care unit (ICU) has not been well characterized. This limits clinicians' understanding of how to best offer support. Objective: To explore how family members experience spiritual distress, and how it is recognized and support offered within the ICU context. Design: A qualitative study involving interviews and focus groups between May 2016 and April 2017. Setting/Subjects: Family members of ICU patients (n = 18), spiritual health practitioners (n = 10), and an interprofessional group of clinicians who work in the ICU (n = 32). Measurements: Transcribed data were analyzed using interpretive description. Results: The experience of spiritual distress was variably described by all three groups through concepts, modulators, expressions and manifestations, and ways in which spiritual distress was addressed. Concepts included loss of meaning, purpose and connection, tension in beliefs, and interconnected distress. Modulators were related to the patient and family context, the ICU context, and the relational context. Expressions and manifestations were unique and individual, involving verbal expressions of thoughts and emotions, as well as behavioral manifestations of coping. Clinical strategies for addressing spiritual distress were described through general principles, specific strategies for discussing spiritual distress, and ways in which spiritual support can be offered. Conclusions: Our study provides a rich description of how spiritual distress is experienced by family members of ICU patients, and how spiritual health practitioners and clinicians recognize spiritual distress and offer support. These findings will help inform clinician education and initiatives to better support families of critically ill patients.

Development of a Clinical Guide for Identifying Spiritual Distress in Family Members of Patients in the Intensive Care Unit

Background: Spirituality is important for many family members of patients in the intensive care unit (ICU). Clinicians without training in spiritual care experience difficulty identifying when family members are experiencing distress of a spiritual nature. Objective: The purpose of this study was to develop a guide to help clinicians working in the ICU identify family members who may benefit from specialized spiritual support. Design: Cross-sectional study. Setting/Subjects: A national sample of spiritual health practitioners, family members, and ICU clinicians. Subjects: A panel of 21 spiritual health practitioners participated in a modified Delphi process to achieve consensus on items that suggest spiritual distress among family members of patients in the ICU through three rounds of remote review followed by an in-person conference and a final round of panelist feedback. Feedback on the final set of items was obtained from an end-user group of four family members and six ICU clinicians. Measurements: Quantitative data were summarized with descriptive statistics. Content analysis was used to analyze written comments. Results: A total of 220 items were iteratively reviewed and rated by panelists. Forty-six items were identified as essential for inclusion and developed into a clinical guide, including an introduction (n = 1), definitions (n = 2), risk factors (n = 10), expressed concerns (n = 12), emotions (n = 7) and behaviors (n = 7) that may suggest spiritual distress, questions to identify spiritual needs (n = 6), and introducing spiritual support (n = 1). Conclusions: We have developed an evidence-informed clinical guide that may help clinicians in the ICU identify family members experiencing spiritual distress.

Improving End-of-Life Care in the Intensive Care Unit: Clinicians' Experiences with the 3 Wishes Project

Background: End-of-life (EOL) care is an important aspect of practice in the intensive care unit (ICU), where approximately one of every five patients may die. Objective: The objective of this study was to describe clinicians' experiences with the 3 Wishes Project (3WP) and understand the influence of the project on care in the ICU. Design: The 3WP is a palliative care intervention in which clinicians elicit and implement final wishes for patients dying in the ICU; it had been implemented for seven months at the time of this study. This mixed-methods study includes quantitative data from clinician surveys and qualitative data from clinician focus groups. Setting: A 24-bed medical ICU in a tertiary academic center. Subjects: Perspectives of 97 clinicians working in the ICU during the study period were obtained by self-administered surveys. Five focus groups with 25 nurses and 5 physicians were held, digitally recorded, transcribed, and analyzed. Measurements and Results: During the 7-month period, 67 decedents and their families participated in the 3WP. The overarching concept identified through analysis of the survey and focus group data is that the 3WP improves EOL care in the ICU, which was supported by three main themes: (1) The 3WP facilitates meaningful EOL care; (2) The 3WP has a positive impact on nurses and physicians; and (3) clinicians observe a positive influence of the 3WP on families. Conclusions: This patient-centered and family-partnered intervention facilitates meaningful EOL care, favorably impacting the ICU team and positively influencing family members.

Modifiable elements of ICU supportive care and communication are associated with surrogates' PTSD symptoms

PURPOSE

To identify specific components of ICU clinician supportive care and communication that are associated with increased post-traumatic stress disorder (PTSD) symptoms for surrogate decision makers of patients with chronic critical illness (CCI).

METHODS

We conducted a secondary analysis of data from a randomized controlled trial of palliative care-led meetings to provide information and support for CCI surrogates. The primary outcome for this secondary analysis was PTSD symptoms at 90 days, measured by the Impact of Event Scale-Revised (IES-R). Caregiver perceptions of clinician support and communication were assessed using a version of the After-Death Bereaved Family Member Interview (ADBFMI) instrument modified for use in non-bereaved in addition to bereaved caregivers. The association between ADBFMI items and IES-R score was analyzed using multiple linear regression.

RESULTS

Ninety-day follow up was complete for 306 surrogates corresponding to 224 patients. Seventy-one percent of surrogates were female, and the mean age was 51 years. Of the domains, negative perception of the patient's physical comfort and emotional support was associated with the greatest increase in surrogate PTSD symptoms (beta coefficient 1.74, 95% CI 0.82-2.65). The three specific preselected items associated with increased surrogate PTSD symptoms were surrogate perception that clinicians did not listen to concerns (beta coefficient 10.7, 95% CI 3.6-17.9), failure of the physician to explain how the patient's pain would be treated (beta coefficient 12.1, 95% CI 4.9-19.3), and lack of sufficient religious contact (beta coefficient 11.7, 95% CI 2-21.3).

CONCLUSION

Modifiable deficits in ICU clinician support and communication were associated with increased PTSD symptoms among CCI surrogates.

Spiritual and Religious Coping of Medical Decision Makers for Hospitalized Older Adult Patients

BACKGROUND

Critically ill adult patients who face medical decisions often delegate others to make important decisions. Those who are authorized to make such decisions are typically family members, friends, or legally authorized representatives, often referred to as surrogates. Making medical decisions on behalf of others produces emotional distress. Spirituality and/or religion provide significant assistance to cope with this distress. We designed this study to assess the role of surrogates' spirituality and religion (S/R) coping resources during and after making medical decisions on behalf of critically ill patients. The study's aim was to understand the role that S/R resources play in coping with the lived experiences and challenges of being a surrogate.

METHODS

Semistructured interviews were conducted with 46 surrogates by trained interviewers. These were audio-recorded and transcribed by research staff. Three investigators conducted a thematic analysis of the transcribed interviews. The codes from inter-rater findings were analyzed, and comparisons were made to ensure consistency.

RESULTS

The majority (67%) of surrogates endorsed belief in God and a personal practice of religion. Five themes emerged in this study. Personal prayer was demonstrated as the most important coping resource among surrogates who were religious. Trusting in God to be in charge or to provide guidance was also commonly expressed. Supportive relationships from family, friends, and coworkers emerged as a coping resource for all surrogates. Religious and nonreligious surrogates endorsed coping strategies such as painting, coloring, silent reflection, music, recreation, and reading. Some surrogates also shared personal experiences that were transformative as they cared for their ill patients.

CONCLUSION

We conclude that surrogates use several S/R and other resources to cope with stress when making decisions for critically ill adult patients. The coping resources identified in this study may guide professional chaplains and other care providers to design a patient-based and outcome-oriented intervention to reduce surrogate stress, improve communication, increase patient and surrogate satisfaction, and increase surrogate integration in patient care. We recommend ensuring that surrogates have S/R resources actively engaged in making medical decisions. Chaplains should be involved before, during, and after medical decision making to assess and address surrogate stress. An interventional research-design project to assess the effect of spiritual care on surrogate coping before, during, and after medical decision making is also recommended.

Addressing religion and spirituality in the intensive care unit: A survey of clinicians

OBJECTIVE

Studies have shown that when religious and spiritual concerns are addressed by the medical team, patients are more satisfied with their care and have lower healthcare costs. However, little is known about how intensive care unit (ICU) clinicians address these concerns. The objective of this study was to determine how ICU clinicians address the religious and spiritual needs of patients and families.

METHOD

We performed a cross-sectional survey study of ICU physicians, nurses, and advance practice providers (APPs) to understand their attitudes and beliefs about addressing the religious and spiritual needs of ICU patients and families. Each question was designed on a 4- to 5-point Likert scale. A total of 219 surveys were collected over a 4-month period.

RESULT

A majority of clinicians agreed that it is their responsibility to address the religious/spiritual needs of patients. A total of 79% of attendings, 74% of fellows, 89% of nurses, and 83% of APPs agreed with this statement. ICU clinicians also feel comfortable talking to patients about their religious/spiritual concerns. In practice, few clinicians frequently address religious/spiritual concerns. Only 14% of attendings, 3% of fellows, 26% of nurses, and 17% of APPs say they frequently ask patients about their religious/spiritual needs.

SIGNIFICANCE OF RESULTS

This study shows that ICU clinicians see it as their role to address the religious and spiritual needs of their patients, and report feeling comfortable talking about these issues. Despite this, a minority of clinicians regularly address religious and spiritual needs in clinical practice. This highlights a potential deficit in comprehensive critical care as outlined by many national guidelines.

Spirituality at the end of life

PURPOSE OF REVIEW

There is increasing emphasis on medical care of the whole patient. This holistic approach encompasses supporting the spiritual or religious needs of the patient. Particularly at the end of life, spiritual concerns may come to the fore as patients recognize and accept their impending death. Physicians may also recognize this spiritual distress but may not be clear on how to provide spiritual support.

RECENT FINDINGS

Tools to screen for spiritual concerns are available for physicians to use. Some physicians wish to go further, supporting patients at the end of life in their spiritual quest. Other physicians express concern about causing more distress to patients in a time of significant need. Descriptions of educational tools, as well as the difference between spiritual generalists and spiritual specialists have emerged. Integration of chaplains into the medical team caring for patients at the end of life will also enhance care of the whole patient.

SUMMARY

The increasing emphasis on whole patient care is leading to increasing focus on spiritual concerns of patients. Although not every patient has an interest in spiritual conversation, most do and medical teams will need to become more educated about appropriate spiritual engagement.

Spiritual Care in the Intensive Care Unit: A Narrative Review

Spiritual care is an important component of high-quality health care, especially for critically ill patients and their families. Despite evidence of benefits from spiritual care, physicians and other health-care providers commonly fail to assess and address their patients' spiritual care needs in the intensive care unit (ICU). In addition, it is common that spiritual care resources that can improve both patient outcomes and family member experiences are underutilized. In this review, we provide an overview of spiritual care and its role in the ICU. We review evidence demonstrating the benefits of, and persistent unmet needs for, spiritual care services, as well as the current state of spiritual care delivery in the ICU setting. Furthermore, we outline tools and strategies intensivists and other critical care medicine health-care professionals can employ to support the spiritual well-being of patients and families, with a special focus on chaplaincy services.

The role of religious beliefs in ethics committee consultations for conflict over life-sustaining treatment

Previous research has suggested that individuals who identify as being more religious request more aggressive medical treatment at end of life. These requests may generate disagreement over life-sustaining treatment (LST). Outside of anecdotal observation, however, the actual role of religion in conflict over LST has been underexplored. Because ethics committees are often consulted to help mediate these conflicts, the ethics consultation experience provides a unique context in which to investigate this question. The purpose of this paper was to examine the ways religion was present in cases involving conflict around LST. Using medical records from ethics consultation cases for conflict over LST in one large academic medical centre, we found that religion can be central to conflict over LST but was also present in two additional ways through (1) religious coping, including a belief in miracles and support from a higher power, and (2) chaplaincy visits. In-hospital mortality was not different between patients with religiously versus non-religiously centred conflict. In our retrospective cohort study, religion played a variety of roles and did not lead to increased treatment intensity or prolong time to death. Ethics consultants and healthcare professionals involved in these cases should be cognisant of the complex ways that religion can manifest in conflict over LST.

Organization-level principles and practices to support spiritual care at the end of life: a qualitative study

BACKGROUND

Though most models of palliative care specifically include spiritual care as an essential element, secular health care organizations struggle with supporting spiritual care for people who are dying and their families. Organizations often leave responsibility for such care with individual care providers, some of whom are comfortable with this role and well supported, others who are not. This study looked to hospice programs founded and operated on specific spiritual foundations to identify, if possible, organizational-level practices that support high-quality spiritual care that then might be applied in secular healthcare organizations.

METHODS

Forty-six digitally-recorded interviews were conducted with bereaved family members, care providers and administrators associated with four hospice organizations in North America, representing Buddhist, Catholic, Jewish, and Salvation Army faith traditions. The interviews were analyzed iteratively using the constant comparison method within a grounded theory approach.

RESULTS

Nine Principles for organizational support for spiritual care emerged from the interviews. Three Principles identify where and how spiritual care fits with the other aspects of palliative care; three Principles guide the organizational approach to spiritual care, including considerations of assessment and of sacred places; and three Principles support the spiritual practice of care providers within the organizations. Organizational practices that illustrate each of the principles were provided by interviewees.

CONCLUSIONS

These Principles, and the practices underlying them, could increase the quality of spiritual care offered by secular health care organizations at the end of life.