Respecting religion in the hospital

Communication from the start is key.

A dying patient's family asked that the body of their loved one be left untouched for several hours after death to allow her spirit to transition, in accordance with her Buddhist faith. The treating medical team wanted to honor the request but also meet the requirements to pronounce death.

Image by Getty Images
Image by Getty Images

“We decided to leave a stethoscope on the patient so the physician could listen for breathing without touching the body,” said Meg Randle, NP, a member of the palliative care team at Salt Lake City-based Intermountain Medical Center, the flagship hospital of Intermountain Healthcare. “That way we could follow correct hospital procedure while still honoring the family's faith tradition.”

Similar scenarios are common in busy hospitals that treat patients from a wide variety of spiritual and religious backgrounds. Accommodations based on religious beliefs and traditions range from the relatively straightforward, such as providing spaces for prayer or meditation, to more complex or urgent, such as obtaining consent for necessary treatment.

“The most important thing is understanding how individual families function,” said George Handzo, MDiv, director of health services research and quality for the HealthCare Chaplaincy Network, based in New York City. “Issues related to decision making and gender roles are common across many faith traditions but may be interpreted differently by individual families within that tradition.”

Initial assessment

At Intermountain Medical Center, physicians typically request palliative care consults soon after admission for patients diagnosed with life-threatening conditions or nearing the end of life, said Rosemary Baron, MA, a hospital chaplain who serves on the palliative care team with Ms. Randle, along with one other nurse practitioner, two physicians, and a social worker.

“Our initial assessment gives patients and families a chance to talk about how they're processing the medical information they've been given,” she said. “At the same time, we offer to talk about their faith or belief system and how we can help honor those beliefs during their treatment process.”

Upfront communication goes a long way toward avoiding problems that can arise due to misunderstandings or misconceptions, said Rev. Handzo.

He recalled one case in which a single man of Christian faith was asked to sign a consent form so he could be discharged to hospice. The man signed the form several times but kept changing his mind and withdrawing consent minutes after physicians left his room.

“We finally realized that he and other family members were deliberately delaying the process in order to wait for the eldest sibling to arrive,” he said. “In this particular family, the oldest brother was a key decision maker but we would not have suspected that just by knowing their religious affiliation.”

Problems can arise when clinicians make assumptions about patients' religious beliefs based on their appearance, language, or cultural background, notes Danish Zaidi, who holds a master's degree in theological studies and bioethics and is in his last year of medical school at Wake Forest University in Winston-Salem, N.C.

That's particularly true with patients from Middle Eastern countries, he noted. Muslims are often assumed to be Arab, and vice versa, when in reality many Arabs are Christian or have no Muslim background.

“An Indian family might be Hindu, Christian, or Muslim,” said Mr. Zaidi, who authored a paper on caring for Muslim patients that was published in 2015 in the Journal of Pastoral Care and Counseling. “Regardless of their religion, there might be other cultural factors that affect how many family members patients want at the bedside or who in the family makes decisions.”

In addition, Muslims vary widely in how strictly they follow the laws of their religion, he said. For example, most observe religious prohibitions against eating pork, but only some also refuse to take medications containing pork products, such as gelatin. Muslims also vary in how strictly they keep a halal diet, which excludes any food specifically prohibited by the Qur’an.

Information like this can be ascertained in an initial open-ended conversation that allows patients and families to bring up issues and concerns, said Paula Teague, DMin, MBA, senior director in the department of spiritual care and chaplaincy at Johns Hopkins Health System in Baltimore.

“Communication is more important than getting everything right,” she said. “Families typically are very appreciative when clinicians ask questions and try to accommodate their religious beliefs, and tend to be very understanding when we unintentionally make missteps.”

Faith-based rituals

Members of The Church of Jesus Christ of Latter-day Saints, or Mormons, who make up the majority of patients at Intermountain Medical Center, frequently request special priesthood blessings at the bedside, said Ms. Baron. The ritual involves laying on of hands by a Melchizedek priesthood holder, often with the patient's large extended family in attendance.

In order to accommodate such requests, hospitals must be flexible in allowing more visitors into the area, she said. For example, the hospital recently admitted a well-known Mormon businessman who was nearing the end of life.

“Within hours of admission, his family—which included six children and many grandchildren—was gathered around his bed, filling his room, and lined up in the hallway,” she said. “Everyone prayed and witnessed the priesthood blessing so he would be at peace as he died.”

Other common requests from families include a Buddhist tradition to leave a white string tied around the patient's wrist symbolizing hope, purity, protection, and good health, said Ms. Randle. Native American families often ask to perform a purification ceremony that involves smudging oils for sage, cedar, and sweet grass.

At Johns Hopkins, the care team sometimes brings prayer rugs to Muslim patients who request them and figures out how to position them to point toward Mecca, said Rev. Teague.

Some accommodations are simple to perform but may not be obvious to clinicians until patients point them out, noted Rabbi Tsvi Schur, a board-certified chaplain at Johns Hopkins. For example, several years ago, several orthodox Jewish patients noted that it was difficult for them to observe prohibitions against using electricity on the Sabbath.

In response, Johns Hopkins installed two elevators that stop on every floor on Friday and Saturday nights. The hospital also removed sensors from some bathrooms so that the lights do not switch on in response to motion during the Sabbath.

Common issues

Certain issues tend to span many religions and should be anticipated by hospitals and hospitalists, experts say. Some of the most prevalent include the following:

Gender. Many patients request same-sex clinicians due to their religious beliefs, said Rev. Handzo. Such requests can often be accommodated unless an appropriate staff member isn't available. Any interaction between genders is problematic in some religions, he noted. For example, an orthodox Jewish woman may be uncomfortable shaking hands with a male clinician and will often defer to her husband or son to make decisions. “If you know about these issues upfront, you can avoid causing offense or conflict around getting consent for treatment.”

Language. It is sometimes impossible to understand patients' preferences around religion without dealing with language issues, said Mr. Zaidi. For example, regardless of the decision maker in the family, there may be only one family member who speaks fluent English and is therefore the point person for communicating with the clinical team. It's preferable to use professional interpreters whenever possible to avoid misunderstandings, said Ms. Randle. Prognoses and medical terminology are less likely to get misconstrued or misunderstood if everyone hears the same information at the same time, versus a family member or religious leader relaying it second-hand.

Nutrition. Many hospitals have special menus to accommodate religious-based diets. Some also make special meals around religious holidays, such as the Jewish Sukkah and Passover. Islamic (halal) and Jewish (kosher) dietary laws also dictate how food is prepared and how cooking equipment and utensils are cleaned. For example, both types of diets prohibit pork and pork products and require that other meat be drained of blood before cooking.

Prayer. Most hospitals offer chapels or meditation areas so that families have a quiet area to reflect and pray. Intermountain Healthcare has a team of volunteers, led by Ms. Baron, who stock the meditation room with printed materials from the major religions. They also take suggestions from patients, said Ms. Randle. One simple innovation that follows a Native American custom has become especially meaningful to both patients and staff. People are invited to write down whatever is burdening them on a piece of paper and place it into a basket. The volunteers later hold a ceremony (off-site from the hospital) where they pray over the burdens, burn the papers, and spread the ashes in a garden. “People feel like their burdens go full circle,” Ms. Randle said. “They express their most earnest, heartfelt suffering on those papers—it really transcends all religions.”