Religion, Spirituality, and the Intensive Care Unit: The Sound of Silence

Visualizeforamoment thephilosophicalquandaryofatreefalling in theuninhabited forestandwhether itmakesasound—the dying tree, its surroundingsof fellow trees, foliage, andearth— withnoperson tohear its fall. This visualization hardly seemsrelevanttotheintensive careunit (ICU),particularlybecausetheseseemtobemanifestlyopposingenvironments—one isquiet, organic, andverdantwith lifewhile theother is characterizedby the soundsofhumanand technological activity, sterility, and illness.Andyet thequandaryposedby thisvisual exercise is central to thearticlebyErnecoff andcolleagues1 and to the question of the role of spirituality in caring for seriously ill patients and their families. InTheRebirth of theClinic, Sulmasy calls illness a “spiritual event” that “grasps persons by the soul as by the body and disturbsboth.”2(p17) Certainly,data supportSulmasy’s thesis,3with spirituality being important tomost ill persons, contributing to coping and quality of life and being a source of spiritual needs. Butwhatismeantbyspirituality?Spiritualityhasbeendisputably andvariablydefined.According to the2009SpiritualCareConsensus Conference, “Spirituality is the aspect of humanity that refers to theway individualsseekandexpressmeaningandpurposeandthewaytheyexperiencetheirconnectednesstothemoment, to self, to others, to nature, and to the significant or sacred.”4(p887)Religion,arelatedconcept, is typicallyunderstood asaspiritualitythatissharedbyagroupofpeople,oftenwithcommonbeliefsandpractices.Regardlessof thevaryingdefinitions, what is clear is that spirituality is found inmyriad forms, suchas the sacredness of family, nature, or a relationship to thedivine. Furthermore,what isalsoclear is thatspirituality is typicallyout of place inmedical environments, as foreign as the contrasting visualsof thelonelytreeandbustlingICU.However,strangerstill is thefact that,althoughwehealthcareprofessionalsstruggle to connectspiritualityandmedicineasevidencedbythemanyand mounting articles that refute or explicate their connection, our patientsandfamiliestypicallydonotstruggle.Formost,thoughts ofwhat ismostsacred,ofwhattranscendsthefinitudeofhuman life,comeflooding inthemomentthephysicianshares thenews of the serious illness or the telephone call comes urging the listener to the bedside of a critically ill loved one. ThearticlebyErnecoff andcolleagues1 discusseswithclarityandnuance thesilence regardingspirituality in thesettingof critical care.Thestudyuses rigorousqualitativemethodsand is embedded in a prospectivemultisite study of familymeetings at 13 ICUs across the United States. Using the audio recordings of 249 familymeetings, the authors explore the religious and/ or spiritual thematic contentof goals-of-care conversationsbetweenhealthcareprofessionalsandsurrogatesofcritically illpatients. Although religion was important to 77.6% of the surrogates, only 16.1% of the conferences included any reference to religionorspirituality.Furthermore,whentheydidoccur, these conversationswere initiatedbysurrogates65.0%of the time.A health care professional raised spiritual concepts (eg, spiritual histories) only 14 times (5.6%), and only 2 of the conferences (0.8%)wereattendedbyachaplain.Whensurrogatesraisedspiritualconcepts,healthcareprofessionals’mostcommonresponse was to change the subject to the medical realities at hand. Although empathic responses were the next most common response,healthcareprofessionals, ingeneral, “rarelydirectlyaddressedsurrogate’sspiritualorreligious language.”Only2health care professionals respondedby exploring the patient’s or surrogate’s spirituality.Notably, forconversations that includedreligiousand/orspiritual content,various themeswere identified, with miracles being one of several spiritual themes that intersectedwithmedical care. ThefindingsbyErnecoffandcolleagues1regardingthesilence surroundingreligionand/orspirituality in ICUconversationsare loudandclear. Still, there remain importantunansweredquestions.First,whatdefinitionsdid theauthorsuse todenotea religiousorspiritual theme?Basedonthequotesandthepredominanceof religious languageused in their keyword search, their conceptofreligionand/orspiritualityappearslargelytobeframed bywhat colloquiallymight be termed religious. Understanding thedefinitioniscriticaltointerpretingthesefrequenciesandplacingtheminpropercontext,particularlybecausethedefactodefiRelated article page 1662 Religious or Spiritual Statements During ICU Goals-of-Care Discussions Original Investigation Research