What role, if any, should religion play in the operation of a secular institution such as a hospital? As hospital systems continue to merge, limiting patient choice in some rural regions, and the Trump administration seeks to expand conscience exemptions for health care professionals and institutions, patients for good reason may feel concern that religious strictures might threaten their well-being.
Yet, because religious outlooks may shape the experience of illness of patients in subtle and often overlooked ways, we hope, without minimizing the risks posed, to suggest how a religious presence through enhanced pastoral care services may improve the care of all patients, secular and religious, and advance the goals of patient centered care.
One of us is an attending hematologist/oncologist at a large Brooklyn teaching hospital where “spiritual but not religious” would describe the outlook of many patients and staff, and the other is Director of the Center for Pastoral Education at the Jewish Theological Seminary. We offer the following case history to suggest how the participation of a professional with training in pastoral care and counseling might defuse tensions between hospital staff and patient and family, even when no specifically religious issue is at stake. We will alter the details for patient privacy.
The patient was 90, a long time nursing home resident. He carried the diagnoses of heart failure and dementia and was referred into the hospital because of abdominal pain. In the emergency room, he was found to have low blood pressure and was admitted. His pain resolved, blood pressure normalized, and discharge was considered, but he suffered several episodes of severe hypotension requiring intravenous hydration.
The patient refused efforts at diagnostic evaluation and the palliative care team was consulted to clarify goals of care. Because of the patient’s dementia, he was not able to enter into discussion. His only relative was his elderly sister, also his health care proxy. None of the patient’s physicians or nurses, however, was able to engage with her, as she remained focused on her sense that her brother had been ill cared for at the nursing home. She would only state that “everything should be done,” though she could not elicit her brother’s cooperation for needed testing.
The patient’s blood pressure remained normal for several days; he appeared comfortable and was transferred back to the nursing home. Soon however, he returned to the emergency room in shock. An oxygen mask was placed over his face which the sister insisted be removed because, “You are torturing him.” She signed a DNR form but then rescinded it, stating, “It feels like I’m killing him.” He suffered a cardiac arrest and after a 25-minute attempt at resuscitation, was pronounced dead.
The patient’s physicians felt uneasy about what had happened. They wondered if anything might have been done so that the patient might not have suffered such a violent end, and so that the sister had not been left feeling so anguished. Could the ethics committee have helped, they asked, perhaps by having the sister declared incompetent to make decisions and replaced by a court appointed guardian? Most of us would see this as overly confrontational, unlikely to gain the assent of a judge, and not realistic given the need to make decisions in a short time frame.
The medical team knew little about the patient other than his list of medications and diagnoses. The physicians did know that the patient was Catholic, we suspect from information included on his nursing home transfer form. We can sympathize with the physicians, trying to care for an acutely ill, confused patient, and to reach an understanding with his overwrought and unhelpful sister.
Clearly these physicians were a conscientious group, recognized the nature of the problem, and had consulted palliative care early on. That they were troubled by the outcome only adds to our admiration for their efforts. Still, we can ask the same question that they had asked: is there anything else that might have been done?
The sister apparently was feeling both angry, at the nursing home, and guilty (“It feels like I’m killing him”.) These are understandable emotions that many experience, both clinicians and the patient and family, in end-of-life situations. Sometimes naming the emotion helps the patient or family see and get past it, but in the midst of an exasperating conflict, the subtleties of human relationships may be overlooked.
Though the hospital has a well-staffed pastoral care program, it had not been consulted. True, this was not an overt issue of faith or religious practice, the patient may have been Catholic in name only, and the patient’s sister was not asking for the assistance of a chaplain. We wonder, though, might the presence of a hospital chaplain have made more room for the whole person, reminded the disputing parties of what was at stake, acknowledged our all too human limitations, and created a more trusting atmosphere in which an understanding might have been reached?
The perspective of 20th century Jewish theologian Abraham Joshua Heschel may be helpful here. Heschel argued that religion has a special role in the clinician-patient encounter, tasked to safeguard the patient’s humanity or “the patient as a person”, to reinforce the physician’s professionalism and commitment to the patient, and to prod the physician’s conscience to see beyond where she might ordinarily see.
“A patient is a person in crisis and anxiety,” he wrote, “and few experiences have such a decisive impact upon our ability to understand the meaning of being human as the way in which the doctor relates to us at such times.”
Well trained chaplains do offer a potential advantage. While often employed by the hospital, their ultimate loyalties lie elsewhere. As they practice attuned listening, they offer patients, families and staff the opportunity to connect with the underlying beliefs and values that orient them amid chaos. They make space for reconciliation which is often needed at end of life. They bring the spiritual realm, with its attention to each individual soul, into the multidisciplinary team.
As Jerome Groopman wrote a number of years ago in the New England Journal of Medicine in his essay God at the Bedside, “There is a great imbalance of power between patient and doctor. A member of the clergy can speak to a doctor at eye level and act as an advocate for a patient who may be intimidated by a physician.” In fact, there is suggestive data that hospitals with chaplaincy services have higher patient satisfaction, fewer in-hospital deaths, and greater utilization of hospice services.
At their best, chaplains bring to the clinical encounter a different quality of presence, one of humility and of deep respect for the mystery of human existence and the pain of loss of a loved one. May we suggest that it’s worth a try?
Yet, because religious outlooks may shape the experience of illness of patients in subtle and often overlooked ways, we hope, without minimizing the risks posed, to suggest how a religious presence through enhanced pastoral care services may improve the care of all patients, secular and religious, and advance the goals of patient centered care.
One of us is an attending hematologist/oncologist at a large Brooklyn teaching hospital where “spiritual but not religious” would describe the outlook of many patients and staff, and the other is Director of the Center for Pastoral Education at the Jewish Theological Seminary. We offer the following case history to suggest how the participation of a professional with training in pastoral care and counseling might defuse tensions between hospital staff and patient and family, even when no specifically religious issue is at stake. We will alter the details for patient privacy.
The patient was 90, a long time nursing home resident. He carried the diagnoses of heart failure and dementia and was referred into the hospital because of abdominal pain. In the emergency room, he was found to have low blood pressure and was admitted. His pain resolved, blood pressure normalized, and discharge was considered, but he suffered several episodes of severe hypotension requiring intravenous hydration.
The patient refused efforts at diagnostic evaluation and the palliative care team was consulted to clarify goals of care. Because of the patient’s dementia, he was not able to enter into discussion. His only relative was his elderly sister, also his health care proxy. None of the patient’s physicians or nurses, however, was able to engage with her, as she remained focused on her sense that her brother had been ill cared for at the nursing home. She would only state that “everything should be done,” though she could not elicit her brother’s cooperation for needed testing.
The patient’s blood pressure remained normal for several days; he appeared comfortable and was transferred back to the nursing home. Soon however, he returned to the emergency room in shock. An oxygen mask was placed over his face which the sister insisted be removed because, “You are torturing him.” She signed a DNR form but then rescinded it, stating, “It feels like I’m killing him.” He suffered a cardiac arrest and after a 25-minute attempt at resuscitation, was pronounced dead.
The patient’s physicians felt uneasy about what had happened. They wondered if anything might have been done so that the patient might not have suffered such a violent end, and so that the sister had not been left feeling so anguished. Could the ethics committee have helped, they asked, perhaps by having the sister declared incompetent to make decisions and replaced by a court appointed guardian? Most of us would see this as overly confrontational, unlikely to gain the assent of a judge, and not realistic given the need to make decisions in a short time frame.
The medical team knew little about the patient other than his list of medications and diagnoses. The physicians did know that the patient was Catholic, we suspect from information included on his nursing home transfer form. We can sympathize with the physicians, trying to care for an acutely ill, confused patient, and to reach an understanding with his overwrought and unhelpful sister.
Clearly these physicians were a conscientious group, recognized the nature of the problem, and had consulted palliative care early on. That they were troubled by the outcome only adds to our admiration for their efforts. Still, we can ask the same question that they had asked: is there anything else that might have been done?
The sister apparently was feeling both angry, at the nursing home, and guilty (“It feels like I’m killing him”.) These are understandable emotions that many experience, both clinicians and the patient and family, in end-of-life situations. Sometimes naming the emotion helps the patient or family see and get past it, but in the midst of an exasperating conflict, the subtleties of human relationships may be overlooked.
Though the hospital has a well-staffed pastoral care program, it had not been consulted. True, this was not an overt issue of faith or religious practice, the patient may have been Catholic in name only, and the patient’s sister was not asking for the assistance of a chaplain. We wonder, though, might the presence of a hospital chaplain have made more room for the whole person, reminded the disputing parties of what was at stake, acknowledged our all too human limitations, and created a more trusting atmosphere in which an understanding might have been reached?
The perspective of 20th century Jewish theologian Abraham Joshua Heschel may be helpful here. Heschel argued that religion has a special role in the clinician-patient encounter, tasked to safeguard the patient’s humanity or “the patient as a person”, to reinforce the physician’s professionalism and commitment to the patient, and to prod the physician’s conscience to see beyond where she might ordinarily see.
“A patient is a person in crisis and anxiety,” he wrote, “and few experiences have such a decisive impact upon our ability to understand the meaning of being human as the way in which the doctor relates to us at such times.”
Well trained chaplains do offer a potential advantage. While often employed by the hospital, their ultimate loyalties lie elsewhere. As they practice attuned listening, they offer patients, families and staff the opportunity to connect with the underlying beliefs and values that orient them amid chaos. They make space for reconciliation which is often needed at end of life. They bring the spiritual realm, with its attention to each individual soul, into the multidisciplinary team.
As Jerome Groopman wrote a number of years ago in the New England Journal of Medicine in his essay God at the Bedside, “There is a great imbalance of power between patient and doctor. A member of the clergy can speak to a doctor at eye level and act as an advocate for a patient who may be intimidated by a physician.” In fact, there is suggestive data that hospitals with chaplaincy services have higher patient satisfaction, fewer in-hospital deaths, and greater utilization of hospice services.
At their best, chaplains bring to the clinical encounter a different quality of presence, one of humility and of deep respect for the mystery of human existence and the pain of loss of a loved one. May we suggest that it’s worth a try?
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