Saturday, June 20, 2009
1) The first article discusses an approach to families who "expect miracles" in patients with very poor prognoses in the ICU. The author attempts to juggle the need to support surrogates' spiritual and emotional needs (as well as their substituted judgment) with the physician's obligation to avoid non-beneficial treatments when possible.
After a case presentation of an elderly woman who has multisystem organ failure, the author establishes a rudimentary differential diagnosis for the circumstance where a family brings up the possibility of a miracle. The differential listed includes:
- Hope/faith (trying to maintain a positive attitude in the face of an admittedly poor prognosis).
- Denial (due to lack of understanding about prognosis and/or reaching a different conclusion than the health care team about prognosis).
- Let's further parse out the "reaching a different conclusion about prognosis" etiology: This could be related to past family experience where the patient or another loved one made a seemingly miraculous recovery, but could also be related to mistrust of the health care team.
- A mechanism of control for family in the face of anger, disappointment, or frustration over some aspect of care.
The initial inclination for many practitioners is to tackle the miracle statement on an intellectual level, refuting the possibility of a miracle. The author correctly recommends clinicians avoid this approach. As he states, this approach will only alienate families. Why? Besides being a generally adversarial approach, it does not deal with the emotions underpinning the miracle statement. Families expressing hope for miracles in dire circumstances are not making an intellectual argument to begin with. The author gives some good suggestions for responding to miracle statements. His recommendations include (with some examples and comments from me):
- Ask family what a miracle means to them (i.e. what it might look like).
- Emphasize non-abandonment (which speaks to yet another item in the differential--fear of abandonment if goals of care are shifted towards comfort).
- Reframe the manifestation of miracles (i.e."miracles come in all shapes and sizes"). Better yet, try to have the family reframe the manifestation of miracles (e.g. "While we all hope for the miracle of recovery, are there other miracles you hope for or have already witnessed?)
- Suggest that if a miracle occurs, the physicians will do nothing to prevent it. (Perhaps it's better to phrase this in a more positive light and combine it with the statement of non-abandonment, such as "We will continue to monitor your loved one very closely and reevaluate his situation on a regular basis. Should a miracle occur, we will certainly embrace it and see where it takes us." For example, reassuring a family member if a loved one miraculously "woke up" after a severe anoxic brain injury, the medical team would
certainly entertain changing the code status back to full code.)
- Cite professional obligations to honor the patient's preference, or when that preference isn't clear, to act in the patient's best interest.
The article acknowledges some of these scenarios will lead to an impasse in decision-making. The suggestions provided should help to avoid this, but sometimes it's inevitable. A tincture of time can be helpful, too.
2) The second article is a general review of spirituality and religion in clinical care by Dr. Dan Sulmasy. It also addresses the issue of miracles both directly and tangentially:
Scientific medicine made it possible to reconcile belief in God as healer with the practice of medicine by physicians through an understanding of God as the inspiration and source for the physician's knowledge, and as the Creator of the world's healing resources, such as medicinal herbs (Sirach [Ben Sira] 38:1-15).
The rest of the second article is a decent review of the general topic of religion and spirituality. It includes an eloquent description of the difference between religion and spirituality:
I define spirituality as the ways in which a person habitually conducts his or her life in relationship to the question of transcendence. A religion, by contrast, is a set of beliefs, texts, rituals, and other practices that a particular community shares regarding its relationship with the transcendent. Spirituality is thus simultaneously a broader concept than religion and a narrower concept than religion. It is broader in the sense that all religious and even nonreligious persons confront the question of transcendence, and so the term is compatible with all forms of religious belief and even the rejection of religion. Spirituality is narrower than religion, however, in the sense that, because only persons can engage questions of transcendence, each relationship with the transcendent will always be unique and spirituality ultimately personal. Even within a given religion, there will be as many spiritualities as there are individuals.