Addressing Spiritual Belief
[Name of the Writer]
[Name of the Institution]
Addressing Spiritual Belief
A patient 67 years of age diagnosed with a Colon cancer which from past one year has affected her lungs and liver. She has been widower from the previous 3 years, with 3 children left behind. Her husband died because of Parkinson disease. He was 15 years older than her. Her children are grown and left the home getting married. She used to bathe her husband, take him to the toilet, and dress him. From his breathing, she gets an idea that he gets pneumonia. The doctor who uses to treat him inspects his lungs and wrote antibiotics as a prescription. She didn't fill the prescription. A few days later her husband died. She did not tell anybody what she had done or had not done. She told everybody who asked that he died because he slipped in the bathroom in the middle of the night.
She is a resident of a small town which is a birthplace of herself and her husband. They married in the same, town and in the same town they raised their children. She remained the member of Pentecostal church of that small town all her life. Her physician who is also her oncologist visits the town every week once to treat his patients. In the 50-bed hospital of the small town, he sees his patients in the clinic room. She gets diarrhea from previous some days. She waited for his visit to the hospital to tell him about the issue. She used to tell the nurse in his office about all her private matters and did not like calling him directly. The previous afternoon she fainted and passed out while trying to get into the bathroom. At that time his oldest son, who lives with her after his divorce which makes him penniless, took her to the small town hospital in his pick up as fast as he could.
The doctor in the emergency room who is an independent contractor comes every week to complete his shift of 48-hours, did not have access to her medical case history. The records were kept by her oncologist in his clinic office. Her doctor in the emergency room did not know that she was on bevacizumab and irinotecan. The only information he received from her son is that she had bad diarrhea. It could not be seen by the doctor without any aid from a computed tomography scanner that she had a perforated bowel because of bevacizumab. But he is sure that she was hypotensive and had a fever. He had a suspicion that she has got an infection, so he calls oncologist who suggests that it would be better to shift her to city cancer hospital as soon as possible. She arrived into the hospital by ambulance around midnight with disseminated intravascular coagulation clinical (DIC) signs. Fluids were hung, antibiotics are given, and the monitoring system has begun. After that vasopressor was given to her.
On the second day morning, at nurse station stood the respiratory therapist. The night nurse called her who is now gone off shift. In her call, she told him that the patient needs to be put soon on a ventilator. She had told him to come now as we are waiting for anesthesia and it would be arriving as soon as you come and act accordingly to the order. The therapist asked the day nurse of the patient who is going to make the decision whether to put the patient on the ventilator or not. The day nurse told that the night nurse told her that her son came after some time when she arrived. Patients other two children are on the way. So she has no idea who would make the decision.
At noontime, the condition of the patient worsens and the nurse called the intensivist. Intensivist inquired the nurse about when the family is coming and told her that without taking the consent of her family, he did not take the decision to intubate the patient. He told that we have to wait for the family.
After a while, her family arrived in the ICU directly. The eldest son who lived with mother looked to be in his 40’s, while his both younger sister and brother look to be in their 30’s. He told the patient family that they had a meeting with them to plan for further course of action. They all including family, intensivist, nurse, oncologist, and hospital chaplain all sit in the consultation room. All of them introduced themselves to the patient’s family. After that intensivist told patients family that their mother is not well. She had bowel hole which is because of the massive infection. And signs from her body show that due to bowel infection her brain is damaged. Her chance of getting recovered is very low. Her daughter ignored the intensivist and asked the oncologist that as you are her doctor, so you tell me about her condition, is there any chance of recovery? The oncologist replies that if we can recover her from this stage, there might be a chance but a slim chance it is.
She looks at the intensivist says that you know as the oncologist says that there is a chance of recovery, let do everything possible and let God heal her. The chaplain tried to influence her decision by leaning toward her and said that “I know you loved your mother and I know that you want to see her better, but it is a God’s greatest miracle to resurrect the body and also afterlife.” From her looks, her daughter looks to be of religious background and she told the chaplain that the God I believe in said that with His word we are all healed. She then told the intensivist and the nurse to do everything possible and then led her siblings out of the room headed towards ICU.
After the final decision, the intensivist said to nurse to call respiratory and anesthesia and put the patient on the ventilation. The nurse was very angry and asked the intensivist why not he told the family that there is no chance of her recovery.
When we read this case history summary, three ethical issues may come in readers mind:
Issue related to direct decision making by the patient
The decision capability of the surrogates in advance directives absence
The religious belief-based decision that on the other hand may be thought by the physicians to be futile
We would cover the third aspect in detail here. First of all, have to address the problem that the patient is in a state of vulnerability. This means that the patient is not in sound health to make her own decision. She is dependent on her children and the health specialist to make a decision on her behalf. In such cases, it would be asked by the patients to tell the health care team their advance directives to lessen their vulnerability, but unfortunately, in this case, the patient does not have any advance directives. It might be possible if an advance directive is taken by the health care team, which might not be a possible solution for now, in this case, her daughter.
The Ethics Code by American Medical Association states that if no surrogate decision maker is chosen by the advance directive, and if there is a family member dispute about what to do, then it is the duty of the health care team to take a review of institutional ethics. But sadly, in this case, a sister made the decision and it cannot be known that what decision would the other two brothers would have made. The healthcare team should have poll the family who could make the decision from the family, by not doing this, the healthcare provider takes the brothers' sister as a unit.
Whenever patients are diagnosed with cancer or any other illness of the sort, they go through the phase of existential plight where they might ask them big questions of death and life. In this case, only her children are going through this phase. When the healthcare team, in this case, asked the children how they go through this phase, they would rely probably on faith. In one study, it has been noticed that when patients rely on their faith and the health care team, according to them, does not support their religious beliefs, more intensive end-of-life care is used by them. In other cases where it is reported by the patients that patients spiritual needs are supported, those patients used to agree more with doctors consent. While if look at this study, healthcare team uses the chaplain help to cater to the spiritual need of the patients' children. But is it the duty of health care provider to provide spiritual support? It is not included in their duty.
One can say that a healthcare team could provide this duty if there is a chance of reducing the cost of healthcare. It has been noticed that patients whose needs related to their spiritual belief are not supported, it results in more ICU care and consequently less hospice care. This has a higher cost related to end-of-life care than patients whose need for spiritual beliefs are supported. But the only financial outcome is not enough to reason the patients' spiritual needs.
It is the responsibility of the healthcare team to provide spiritual support to the patient and their family because it might help in lessen their vulnerability. Thus in order for the healthcare team to create an environment where decision making is easy and outcomes are positive, it would be better to support the patient religious needs. In case of spiritual support absence, the balance of morality bow towards healthcare team.
Now the question arises that if the healthcare team has decided to provide spiritual needs, how could they have to do it? A tool known as FICA could be used by the healthcare team which evaluates spiritual history. FICA is basically an open-ended conversation about the practices and beliefs of the patient and their family. In the present case study although it is noticed that the chaplain has provided the spiritual support but that support was without going into their spiritual history. Surely, the family, in this case, is felt unsupported spiritually by the whole healthcare team during the meeting, and no one in the team tried to re-address the issue. The healthcare team could have taken the religious history of the family after the family returned to the ICU and sing the religious hymns but they proved themselves incompetent, unreliable, and dishonest in patients' children eye by not redressing this issue. So it is a question that the children of the patient ask themselves why they put their belief in someone who is not trustworthy, while their mother is in a very vulnerable state? It is a moral question for the sake of the children. They seek their refuge in religion which would itself a trustworthy source for them.
Benner, P. (1997). A dialogue between virtue ethics and care ethics. Theoretical Medicine, 18(1-2), 47-61.
CEArticle. (2019). Nursingcenter.com. Retrieved 17 May 2019, from https://www.nursingcenter.com/cearticle?an=00129191-201508000-00003&Journal_ID=260877&Issue_ID=3139908
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