The number 11 is associated with miracles in the Hindu culture. So when the spouse of a patient clearly dying of untreatable cancer asked to continue full aggressive life support for two additional weeks to reach the 11th of the month, after extensive discussions, the doctors agreed.
When that date passed without significant improvement, however, the spouse asked for another eight days to give his Hindu prayer network more time to work. At that point, the care team balked.
“What could we live with?” asked Lachlan B. Forrow, MD, FACP, director of ethics and palliative care programs at Boston's Beth Israel Deaconess Medical Center, where the case took place.
It took a few additional days for the care team to help the spouse understand that since survival would require a miracle completely outside of Western medicine, it would violate the professional values of the doctors and nurses to cause any further burdens to the dying patient. The patient died shortly afterward.
Regardless of whether physicians share their patients' beliefs, from alignment of stars to alternative medicine, experts say it's more important than ever to recognize and understand cultures and spiritual needs, including and beyond end of life.
Spurring the issue are the increasingly multicultural makeup of the country and health reform changes that are poised to give access to vulnerable populations.
It's “imperative,” said David A. Fleming, MD, MA, FACP, to help physicians become more comfortable with cultural differences to deliver best care in our increasingly multicultural society.
Faroque Ahmad Khan, MB, MACP, agreed. “Demographics are changing, so it's important for providers to understand their patients' background and faith to provide effective care,” he said.
Last spring, 250 people attended the first-ever conference on “Religious Traditions and Health Professions Today,” sponsored by the Program on Medicine and Religion at the University of Chicago. The conference focused on the moral and spiritual dimensions of practice, including looking at the attendees' own spirituality.
The July 2012 5th Annual Spirituality and Health Summer Institute, sponsored by the George Washington Institute for Spirituality and Health in Washington, D.C., drew attendees from around the world, some of whom are developing courses or interventions at their clinical sites.
The American Board of Internal Medicine's knowledge self-assessment module now focuses on care for the medically underserved that includes cultural competency and health literacy.
“The ability to identify and address patient spiritual needs has become an important clinical competency,” said Daniel Sulmasy, MD, PhD, FACP, co-director of the University of Chicago conference.
Studies have shown that 50% to 90% of patients (depending on the setting) want physicians to address their spiritual needs, according to Dr. Sulmasy, Kilbride-Clinton professor of medicine and ethics in the department of medicine and divinity school at the University of Chicago.
Although 91% of physicians say it's appropriate to discuss religion and spirituality if the patient brings them up, according to a May 2006 Medical Care study, 45% believe it is usually or always inappropriate to bring them up before the patient does. While 17% would never pray with patients, 53% do so when patients ask. And 14% never talk about their own religious beliefs.
Other studies have shown a significant link between attention to spiritual needs and patient satisfaction with care.
“I think there was a period of a few decades in which doctors thought this was not important,” said Dr. Sulmasy. “But the tide is turning.”
Behind the beliefs
Patients may act on their beliefs without discussing them, for example by demanding or refusing treatment, said Dr. Fleming, who chairs ACP's Ethics, Professionalism and Human Rights Committee. Those beliefs often stem from the patient's culture.
Increasing cultural diversity is reflected in the physician's office, said Dr. Fleming. Some cultures may have mores and languages that may affect communication and ultimately physician-patient interaction. For example, he notes that Muslims have strong beliefs that women cannot be touched by men.
“We need to have the ability to articulate what the differences are and share our concerns about our ability to address health care issues when cultural differences occur,” he said. “Recognize them, be sensitive to them, and act in an appropriate way that will make the physician-patient relationship successful.”
Kesavan Kutty, MD, MACP, cited a study that showed how views of death and dying differ by culture. While almost all ethnic groups in the study acknowledged that the time to die was a celestial decision, patient suffering and family presence were what signaled that time for African Americans, he said.
Also, in his own personal experience, he felt that African-American families often are uncomfortable agreeing to a do-not-resuscitate order because of fear that the affected family member would no longer get needed care.
“The hard part is seeing the differences coming, being adept in knowing them, and dealing with them in a respectful way,” Dr. Fleming said. “We're here to meet every patient's needs ... and not provide different standards of care for different people simply because we have different beliefs.”
If patients' beliefs call for accommodations that can be met, they should be. For example, Dr. Sulmasy said, a patient in the hospital might want his bed to face Mecca.
What can appear to be a clash of beliefs may actually be distrust of the medical system or may mask denial of illness, fear or misinformation.
One example is a spiritual belief in alternative medicine and aversion to medications. The key is respecting the patient's view while representing your concerns.
For example, Dr. Sulmasy recently had a patient on blood pressure medication whose numbers increased after he started taking a natural testosterone supplement.
“I asked him whether he wanted to do that given the increase in blood pressure,” Dr. Sulmasy said. “He decided to keep the other vitamins [he was taking] but stop the testosterone” to see what would happen.
Physician, know thy spiritual self
While a lot of attention has been paid to patients' spirituality, less has been given to physicians'. Yet being in touch with your spirituality makes it easier to recognize and work through situations where beliefs conflict, said Dr. Sulmasy.
It's not always necessarily about religion. “Spirituality is both wider than religion in the sense that a person can be ‘spiritual but not religious,’ but also narrower in that within each religion every individual has a particular spirituality,” he said.
Dr. Sulmasy defined spirituality as “the characteristics by which a person relates to questions of transcendence—ultimate answers to questions of meaning, value, and relationship.” By contrast, a religion, he said, “is a community of persons who share a particular set of beliefs about the transcendent along with shared practices, texts, rituals, and teaching.”
Some physicians may say they don't have any belief system, but Christina M. Puchalski, MD, FACP, disagrees.
“Whether they admit to it or not, science is our belief system,” she said. That explains the potential clash of what she calls a “body, body, body” perspective and the “body, mind, spirit” perspective of patients who prefer alternative medicine or whose religions give science less weight.
Dr. Puchalski, course director of the George Washington spirituality conference and professor of medicine and health sciences at The George Washington University School of Medicine in Washington, D.C., added, “I may be a religious or spiritual physician but if I haven't looked at spirituality as it relates to me being a doctor, then when it comes up in a clinical setting I haven't been thoughtful in how to deal with the patient.”
Doctors who are uncomfortable in those situations typically end them, she said. “It's not uncommon for a doctor to say, ‘I don't have time,’ and use body language to turn the conversation off,” she said.
Instead, Dr. Puchalski tries to bring science into the whole conversation by saying, “I respect your belief system but this is what I know about the illness from the scientific-medical perspective; I also know science isn't everything. I need to work in both of those worlds with you.”
Dr. Fleming said he danced around the topic of spirituality earlier in his career because he didn't feel comfortable relating to patients on that level. As he's grown more secure about his own belief system, he's more open to his patients.
“Now I'm not afraid to share that I do pray and have spiritual beliefs that are meaningful to me and that I respect their spirituality and need to pray,” he said.
Although it may be easier to incorporate spirituality in some communities where there are shared values, Dr. Sulmasy contends it can be done even in the context of today's short appointments.
Instead of just asking someone's denomination on a written form, he asks one open-ended question during new patient visits as part of the social history: “What role does spirituality or religion play in your life?”
In most cases, he said, the answer requires no more than a minute of conversation. It then becomes easier to bring up spirituality later when situations that connect with religious or spiritual concerns arise, such as coping with chronic illness or end-of-life planning.
“It's integrated [and] organic,” Dr. Sulmasy explained, “because the groundwork has already been laid.”
Dr. Puchalski recommends using the FICA Spiritual History Tool, which she helped develop and which is available online.
Drawing the line
Even when their values differ, physicians are “obliged to try to understand clearly the beliefs and the viewpoints of the patient,” according to the ACP Ethics Manual, 6th Edition (available online). But sometimes there will be a limit.
“There's a point at which a doctor can say, ‘I'll respect that but I'm not the right doctor for you,’” Dr. Forrow said.
After honestly assessing your own core values, determine your boundaries in dealing with patients with different belief systems and your options in those cases, advised Dr. Fleming.
Dr. Khan recalled a patient with cancer whom he had seen for years. He gave him painkillers but refused when the patient asked for something that would kill him.
“Euthanasia is not permitted as part of my belief system,” said Dr. Khan, now retired and a former professor of medicine at State University of New York at Stony Brook. “There are situations where one has to draw the line.”
It's not a cop-out, said Dr. Fleming. “To step over [your moral boundary] would be reprehensible personally and spiritually, and you have to know when that time comes,” he said. In those cases, if possible, call in an ethics committee consult.