The intensive care unit (ICU) is an increasingly multiprovider, shiftwork-driven, technology-focused environment. These factors represent barriers to consistently addressing all patient and family needs near the end of life, including spiritual engagement. Yet evidence indicates patients near the end of life and their families want both to engage with providers about their spirituality and to incorporate their spirituality into their care (1). As such, spirituality is a key domain of palliative care quality (2). However, health care providers do not generally engage patients and families in spiritual matters (3).

In this issue of the Journal, Swinton and colleagues (pp. 198–204) present findings that extend our understanding of the importance of spirituality at the end of life (4). The authors present these results in the context of their Three Wishes Project, an intervention that assisted bedside clinicians and study staff in eliciting and addressing wishes “to dignify the patient’s death, honor and celebrate a patient’s life, and foster humanism in practice” (5). Seventy-six family members and 150 clinicians of 70 ICU patients expected to die during the hospitalization were interviewed about their perspectives and experiences with spirituality and spiritual care during the study. The investigators used a rigorous qualitative analysis scheme to iteratively code by consensus to thematic saturation.

Swinton and colleagues found that participants largely considered the end of life to have distinct spiritual components before, during, and after death (4). Furthermore, the Three Wishes Project was perceived by participants to aid both expressions and engagement of spirituality by stimulating conversations, allowing for personalization of spiritual engagement with death, facilitating emotional well-being, identifying spiritual goals (e.g., peace, comfort, connection, and tribute), and tailoring the environment to the spiritual needs of patients and families.

The investigators also applied evidence-based concepts, such as the desire to have clinicians engage with spirituality in the context of death and dying (5, 6). This intervention, which prompts palliative care generalists (i.e., ICU clinicians) to engage in an open way with the spirituality of patients and families, is relatively disseminatable and a timely adjunct to care. Although most hospitals have spiritual care services, these are often not used presumably because spiritual needs are commonly unrecognized (7). This study demonstrates ways that clinicians can inquire about spirituality and then conduct more robust conversations about it.

It is worth highlighting notable methodological elements of the nuanced qualitative work presented by Swinton and colleagues. The emphasis on spirituality rather than religion (a related concept) makes the project more relevant not only to patients and families of diverse religions but to nonreligious persons who take solace in other forms of spirituality, such as valuing nature. Also, the study presents a rarely heard perspective from health care providers including residents, fellows, attending physicians, nurses, chaplains, and allied health professionals at different stages in their careers. The largely positive quotes from clinicians show support for facilitated engagement with a topic that has historically been a source of discomfort. Last, the authors remind us that a small minority of participants do not want to engage in discussions about spirituality and that clinicians should be prepared instead to offer other support that best fits the needs of patients and families.

The study has some limitations. The investigators acknowledge that they did not measure quantitative metrics, including domains important to both patients and their families, such as dying processes (quality, comfort) and bereavement outcomes (post-traumatic stress, complicated grief, depression). The qualitative data provide a well-rounded picture of the potential benefits of the Three Wishes Project, although quantitative assessment will be necessary to determine the effects of the intervention. And although an early roadmap is provided, the authors also rightfully note that ICU clinicians generally do not possess the spirituality communication skills that trained spiritual care providers have. On the other hand, involving ICU clinicians earlier in the hospitalization or disease course with application of this strategy could address the common problem of delayed inquiry about unmet spiritual needs. And although many ICU clinicians may be able to offer only basic spiritual support, their front-line inquiries could serve to more proactively involve spiritual specialists (e.g., chaplains) when more complex issues arise. In this way, the intervention may present an opportunity to involve spiritual care providers more frequently and in a more robust, meaningful way.

Six million ICU patients are admitted to U.S. hospitals annually, whereas there are only 5,500 palliative care specialists (8). Therefore the field of critical care desperately needs to find ways to meet the palliative care needs of patients and family members, using not only enhanced intensivist care but also the skills of nonphysician care providers such as nurses, advanced practice providers, chaplains, and social workers (9). The work by Swinton and colleagues sheds new light on spirituality in the context of critical illness and also provides a new strategy by which “generalist” palliative care providers can consider patients’ and families’ spiritual needs. Although a clinical trial of the Three Wishes Project is necessary to persuade clinicians about its effectiveness and generalizability, these qualitative data show the intervention’s great promise to address a dimension of end-of-life care that is too often neglected.

References

Section:

ChooseTop of pageReferences <<CITING ARTICLES