All doctors have gone through end-of-life situations with our patients and close relatives. In some specialities, it's very common. The general population identifies us with healing and life, but it does not escape us that we are also very close to death. It’s something that unfortunately we approach very often.
It is normal for us to indicate a surgical procedure or to reveal a diagnosis. We usually do it fluently and try to explain it plainly, without technicalities, so that the patient can assimilate it. We show that we are technically prepared. We answer questions to build confidence in the planned procedure. However, we often lack the courage to talk to the patient about the end of life. Not only do we not encourage these conversations, but most of the time we avoid them. It has been reported that only half of the patients who wanted to express their transcendental concerns could discuss this with their doctor. As stated in this paper, clinicians tend to change the subject and redirect the conversation to medical aspects when addressing the religious issue with relatives of serious patients. In general, we are unprepared to address an issue that concerns many of our patients as noted very well in this post.
Despite trying not to get involved, many patients care a lot. Up to 70% of those approaching the end of life wanted their doctor to know their spiritual tendencies according to a recent paper published in JAMA. This made them feel better-taken care of. Patients who don’t meet their spiritual needs rate the care received as of lower quality. It’s an essential parameter to consider now that we care about the patient experience.
The gap between what the patient wants and receives is a mirror image of what happens to clinicians. In this article, 80% of ICU physicians believed that investigating patients' religious concerns was their responsibility. In addition, they acknowledged not feeling uncomfortable when addressing these issues with the patient or family. However, despite all this, only 14% put it into practice. This work showed that the smaller the number of years of experience, the more difficult it was for clinicians to discuss spiritual aspects. Once again, I am convinced that part of the solution is far behind: we should consider whether our students, in the faculties, are being taught to approach communication with the patient well.
The benefits of having a spiritually assisted end go beyond the patient's experience. Relatives are also more comforted in grief and have a lower rate of depression after death. There are also side benefits to the health care system as these patients have a lower ICU mortality rate and fewer aggressive procedures at the expense of increased use of palliative care. Overall, they are less expensive patients and, when treated more adequately, the average cost of care at the end of their life is lower.
From this blog, the importance of shared decisions making has been exposed on multiple occasions (posts 1, 2, 3). It’s an appropriate way to compensate for the knowledge imbalance between the two parties and avoid a flawed response. In healthcare decisions, the clinician's knowledge is far superior to the patient's, but in many cases, we know little about what matters to them. Sometimes we decide for them and other times we don't let them do it. It seems that more patients than we imagine need us to help them in the most difficult time of their illness and often we don’t make it easy for them. In a JAMA article, 94% of respondents agreed that, at the end of their days, the doctor would ask them about their beliefs and whether they wanted spiritual assistance. I think asking is not an offence and perhaps we should keep in mind that many patients want and expect us to ask them. We may let them down if we don't.
1. It’s a real clinical case. The patient's name is not real. I thank their family for the permission granted to me for publication.
Link to blog Doctor Miralles
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