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The Meaning of Life

April 17, 2009 -- Today the Cape Cod Times ran a very good article by Cynthia McCormick about the challenges nurses face in discussing spiritual issues with patients. The report describes a recent incident in which a per diem nurse at Cape Cod Hospital upset a patient's family by discussing "repentance" with the dying patient in a way that allegedly distressed the patient. "Spiritual talk by nurses spurs soul-searching" explores the nature of that incident through quotes from the nurse and others involved, but it also sets the issues in context by consulting a local nurse expert: Kathleen Geagan Ryan, a hospice nurse and ordained interfaith minister. Ryan explains that nurses can provide spiritual counseling by listening and letting patients take the lead, and being sure not to do anything that could be interpreted as imposing their own beliefs, a sensitive thing given the unequal power between nurse and patient. We thank McCormick and the Cape Cod Times for a sensitive report about a difficult aspect of health practice--one that would seem to be even more complex than the report indicates--for nurses who often confront the challenge of helping patients face their own deaths.

The article sets up the central challenge right away:  "Nurses who talk about God and spirituality with their patients can walk a fine line between comforting the ill and stepping on theological toes." The report describes the case of Julie Peterson, who was told in February she would not be asked back to Cape Cod Hospital as a per diem nurse after a dying patient's family complained about her talk of "repentance." The piece understandably does not include direct input from the now-deceased patient's family, but it gives a seemingly fair sense of what happened through quotes from Peterson.

According to a petition letter Peterson wrote in the hopes of getting her job back, she said she was trying to mirror the patient's comment "Christianity is narrow" by saying, "Yes, it is. If God were to be what the Bible represents then the access to him would be through repentance. Many other religions aren't so exclusive."

But the patient's family complained that the patient cried and said the nurse had told her, "There's only one way, you must go home and repent," Peterson wrote. ...

In her petition, Peterson says the patient ... had been talking about her decision to die and her guardian angel. Peterson wrote that she asked the patient whether she could ask her a personal question, "and upon getting a clear confirmation, asked the patient her thoughts on the afterlife."

Peterson's friends say she is a skilled and compassionate nurse who would not have knowingly caused harm or proselytized to a patient. But it's not hard to see how this situation--which is common with dying patients who want to discuss sensitive "Big Picture issues" like "God and the afterlife" at a very difficult time--could present a great challenge. Peterson suggests that the hospital overreacted because the situation involved religion; the hospital will not discuss the specific case except to say that it takes such complaints seriously. Spokesman David Reilly does note that (in the reporter's words) "hospital policy allows nurses to pray with patients -- at the patient's request," and that it "has consulting chaplains of different faiths on call day and night," though it has "laid off its staff chaplain." But nurse Marie Borland, a friend of Peterson's and "former member of a nurses ethics committee at Baystate Medical Center in Springfield," says patients often want to talk to their nurses about these issues, and she notes that doing so with the necessary mix of support and respect can be difficult.

Into this discussion the article weaves comment from Ryan, a hospice nurse and interfaith minister who has been spiritual director for several hospices. Ryan notes that nurses can avoid the pitfalls by calling for a chaplain or practicing "deep listening."

You cannot impose your belief in any way. My mantra is to listen and let the patient lead. ... It's not an equal relationship. If you have an agenda, patients pick up on that. I call it the truth serum of the dying person. They just see through anything.

Ryan reportedly suggests that Peterson erred by referring to repentance, "a loaded word." Ryan notes that "even a simple phrase can give away a caretaker's belief system," and given the power imbalance, "that can intimidate patients." As for Peterson's question about what her patient believed, Ryan urges nurses to let the patients ask the questions: "We can just try and listen, follow their lead, and if their lead leads to angels ... stick with the angels."

Few press pieces have taken such a serious look at the challenge of balancing nurses' duty to provide spiritual care to patients with their obligation not to impose their own spiritual views. Ryan offers sound advice that is plainly based on real expertise, and it seems clear that actually proselytizing (or wearing scrubs that do) would be imposing your own belief system, given the power imbalance.

But there would seem to be a gray area for which there would be no easy guidelines. It seems that the nurse can't just "listen" or offer automatic affirmations, or it will be essentially a monologue. Presumably at least some patients actually need an exchange with another human being. And while taking the initiative to ask a patient a "personal question" about his faith seems like a red flag, it is hard to imagine how a nurse could engage in even a supportive discussion with the patient who wanted to discuss "her decision to die and her guardian angel" without any questions at all. Would it be a problem for the nurse to ask, "How would you describe your guardian angel?" Or, "Why do you say your guardian angel has abandoned you?"

Good practice would seem to vary depending on the patient and the situation, and the piece might have explored just what practical training nurses get in handling these daunting situations, and whether more or different training would make sense to help nurses handle hard questions. What if the patient asks, "Am I going to hell?" Perhaps the nurse could consider the type of response often ascribed to therapists:   "What do you think?" But what if the patient asked, "What do you believe about God?" A question in response does not seem adequate there. Would any honest description of the nurse's own beliefs amount to imposing them? Should the nurse simply decline to describe his own beliefs, even if that distresses the patient? Or could the nurse describe his beliefs, so long as he was careful to stress that he was not suggesting the patient should share them, but instead explore her own? At times, the divide between helping the patient explore her spirituality and offering her spiritual guidance may dissolve in practical application.

We thank McCormick and the Cape Cod Times for exploring some of these important issues.

See the article "Spiritual talk by nurses spurs soul-searching" by Cynthia McCormick in the Cape Cod Times from April 17, 2009.

Further reading: "The Spiritual Care Perspectives and Practices of Hospice Nurses" Journal of Hospice & Palliative Nursing. 7(5):271-279, September/October 2005. Belcher, Anne PhD, RN, AOCN, FAAN; Griffiths, Margaret MSN, RN, AOCN.

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