An 83-year-old woman with chronic illness and strong religious beliefs.

DR BURNS: MRS A IS AN 83-YEAR-OLD WOMAN WHO HAS MULtiple medical problems and, despite numerous medical interventions, chronic progressive pain and weakness. She feels that her faith offers the most help for coping with her illness. She lives in a senior residence near Boston and has 3 daughters, 2 sons, and many grandchildren. Mrs A attends church regularly and has a strong social support network through church. She has Medicare insurance, and her primary physician is Dr M, who practices at Beth Israel Deaconess Medical Center. Mrs A has a history of hypertension, diabetes, and goiter. In the late 1980s, she developed diffuse body pain. An evaluation found that she had polymotor and sensory neuropathy, most likely secondary to diabetes. Initially, she was treated with intravenous gamma globulin without improvement in her symptoms. She was subsequently treated with gabapentin, topiramate, mexiletine, tramadol, rofecoxib, celecoxib, acetaminophen with codeine, oxycodone/ acetaminophen, and fentanyl patch without improvement. Mrs A has also tried acupuncture and massage without benefit. The consulting neurologist does not have any further therapy to offer her. In 1999, Mrs A began experiencing worsening right lower extremity pain and weakness and was found to have spinal stenosis with L5-S1 radiculopathy. She underwent multiple lumbar epidural steroid injections without improvement in her symptoms. She has had recurrent episodes of right hip and bilateral shoulder pain from trochanteric and subacromial bursitis. She also had multiple local steroid injections with either no or short-term benefit. Her medications include losartan potassium, felodipine, hydrochlorothiazide, levothyroxine, metformin, omeprazole, and acetaminophen. She is allergic to penicillin, aspirin, and angiotensin-converting enzyme inhibitors. She lives alone and has a daughter who lives nearby. She is able to perform all her activities of daily living and independent activities of daily living and refuses any assistance from a homemaker or visiting nurse. On a recent examination, her blood pressure was 140/88 mm Hg, and she had mild restriction of motion of the left shoulder, pain with any motion of the right shoulder, pain to palpation of the small joints, and pain over the trochanteric bursa on the right. On neurologic examination, grip strength was decreased, sensation to pinprick was decreased in the digits bilaterally, and motor strength of the lower extremities was 2/5 proximally and 3/5 distally. Her reflexes were intact. Mrs A continues to have diffuse body pain as well as increasing weakness of her lower extremities. During the course of her illness, she has steadfastly maintained her independence and good spirit. She has consistently stated that her faith in God has enabled her to endure her chronic pain. She trusts that praying will help her continue to persevere. Mrs A and her physician, Dr M, continue to struggle with the lack of traditional medicine to provide her with any relief of her symptoms. Mrs A’s beliefs are her one source of comfort and strength. The role this should play in her ongoing medical care remains a question.