Religion and clinical relationships

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Recently a patient of mine (who had in the previous few days received a new diagnosis of metastatic cancer) began talking about her faith.

She paused for a minute, though, and said "I know you doctors aren't supposed to talk about god and religion with patients, though, you have to maintain that clinical relationship and all."

I had an immediate response for her that she very much liked and took positively to, though I'm not sure it would work with everyone. But to not leave you hanging TOO much, my response began "It has nothing to do with whether we're supposed to talk about religion or not..."

But before talking about how I approached (and how I usually approach) that situation, I'm interested to hear what people here would say if they were in that situation.

The reason I'm interested is that I think about patient care a whole lot more than I think about religion, but I'd bet it's the opposite for most of you. So this exercise forces you to step away from pure philosophical dialogue, and even to step away from philosophizing about doctor-patient relationships, and to consider how one approaches this when one is the doctor in such a relationship.

Also realize that while Christians (in my experience) are far more likely to express their faith out loud than people of any other religion I've encountered, people of all religions have done so -- so you need to consider that you might not share the same beliefs as any given patient.

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@Aedes,

No idea what I would say. I'm not sure I would be the best sort of person to handle your job.

Though, spiritual health is not something to be ignored, I would think, especially when the patient is facing a life threatening medical issue, like cancer. In my extremely limited experience with terminally ill people, spirituality and faith are important factors in those people staying positive about their condition. If their faith can help them keep up the fight, keep care of themselves, then that faith is... or at least seems to be quite healthy.

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@Didymos Thomas,

Didymos Thomas;37877 wrote:

Though, spiritual health is not something to be ignored, I would think, especially when the patient is facing a life threatening medical issue, like cancer.

Absolutely true. Though it's not unique to life threatening diagnoses. Remember that a patient at the very least is entrusting you with his/her privacy. In other words, medical settings are always a position of vulnerability for patients, whether or not they have an important disease (and whether or not they realize it), and this brings out feelings and expressions of spirituality (or also overt religion with no "spiritual" aspect) in even the most trivial clinical encounters. And when people realize that they need to have faith in the 1) character and 2) competence of a physician, they often root themselves in the things that they have MORE faith in than their doctors: 1) themselves, 2) their family, and 3) god.

Rest assured that I did not dismiss the importance of religion. That's the best way to burn any chance of having a patient's trust!

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@Aedes,

I'd have to say that compassion is far more important than any religious belief, or any rule about whether or not you should talk about something. Giving someone the chance to express their feelings and beliefs shows them that you care, and I think that will matter to them more than whether or not you share their beliefs. Perhaps they just feel a compulsion to reach out to someone before they die. So to answer your question, I do believe that I'd give them as much time as I could to share what they want to. They'll feel better for having done so and I would feel better knowing that they feel better.

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@Aedes,

Yeah, not very many people truly care what I believe in as long as they feel like I'm on their side. I'm the type of person who will sit on the edge of a patient's bed, show them photos of my son, listen to them tell me all about their plumbing business or their world travels, and I'll go get them a Heath bar if they're craving it and it doesn't affect their care.

So it's not like I'm off to the side wearing an astronaut suit with my arms folded, I mean there are lots of ways to connect with people. But you're right that giving them a chance to say what's important to them is what matters.

A critical element of patient care is not to appear to be in a hurry. I mean for god's sake I'm ALWAYS in a hurry at work, but the trick is to never look like it. That means sitting down, or at least leaning casually against the wall, letting them get out some complete sentences without interrupting them, and asking if there's anything else they'd like to understand or talk about before I leave. And if religion is really pressing on their mind, then by all means let me hear it if it helps them.

(Though none of this is quite how I answered her when she implied that we're not supposed to talk about faith with patients)

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@Aedes,

Quote:

I mean for god's sake I'm ALWAYS in a hurry at work,

Ya I don't doubt. I almost added something of the sort, that doubtless you are always busy, when I said "give them as much time as I could" in my first post. Certainly you know better than any of us the nuances of dividing your time between getting to as many patients as possible, but also giving every patient the necessary time and atmosphere to feel comfortable and cared for. I can't begin to imagine how difficult that must be.

Quote:

(Though none of this is quite how I answered her when she implied that we're not supposed to talk about faith with patients)

Well, we'd all love to hear it. Smile

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@Solace,

Solace;37895 wrote:

I can't begin to imagine how difficult that must be.

Unfortunately patients are fairly cynical and I think they expect less of us than they deserve. And if we DO spend too much time with one patient it really can compromise our care of a different patient.

So it's a matter of judgement really. Well, and efficiency -- I mean a meaningful patient visit doesn't always have to be a lengthy social visit. Sometimes it's a matter of going in there, spending 2 minutes to draw a picture of the lungs on the whiteboard in their room and explain what's going on with them, etc, and you can make an impact with a short visit.

As for what I told her, I said that it's not really a matter of what we're supposed to talk about (or not) with patients. I said that I've voluntarily chosen a job in which I'm meeting people in some of the worst times in their lives; and what matters in those moments are what THEY believe and not what I believe. If it works for them, and gives them strength or hope, then that matters to me more than anything else. So what I believe in my heart about god and faith isn't really important in moments like that; and that's why I don't talk about my own beliefs in front of patients.

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@Aedes,

Aedes wrote:

But before talking about how I approached (and how I usually approach) that situation, I'm interested to hear what people here would say if they were in that situation.

I would listen to her for one and not seem too fanatical about your son, even though rightfully so.

And does metastatic cancer mean you probably have to tell her how much time she has left (if she asks)? This is why I could never do your job, I couldn't bare it.

If I had cancer and were given a time span that was uncertain but possible to beat, I'd rather be talking to my doctor about how to (in an optimistic mindset) change my lifestyle so as to defeat the cancer, and the medication is sort of at the sidelines of importance.

If the days were surely limited then I'd want my doctor to talk about whatever I want to talk about. I suppose as a physician the main idea is how to get the person to continue to live; if anything one can possible do to prolong life doesn't work then professional advice is not what I'd want.

I would also not want to be contradicted or argued with, in fact.. I agree that philosophy should stay out of it and not be encouraged, but to just encourage whatever it is the patient wants to pursue. I would rather feel I'm getting somewhere, but this is not my place to say because I have not had cancer.

I agree that compassion is the best way, and that hope may not be always the best virtue to give to a patient. If I sensed hope of life I'd pursue it, but if it is false then it is ultimately a waste of time and could put me in a poor state which could lead to poor choices about how to deal with family matters and such.

Faith is good in this way because the hope that one gets from this fully acknowledges that everyone will inevitably die.

Hopefully I'm understanding the extremity of the situation here; too much or too little.

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@Holiday20310401,

Holiday20310401;37897 wrote:

I would listen to her for one and not seem too fanatical about your son, even though rightfully so.

It came up in some conversations with her, though not in that moment -- but aside from the fact that I can't help but talk about him, patients (generally) LOVE it when doctors talk about themselves, just to show that we're all thinking, feeling people too.

Quote:

And does metastatic cancer mean you probably have to tell her how much time she has left (if she asks)? This is why I could never do your job, I couldn't bare it.

At that point we didn't even know what kind of cancer it was (nor had we even confirmed the diagnosis). That is FAR harder to talk about with people than to give them raw numbers.

Honestly the only way to break news like this is to 1) know your stuff before you go and talk about it (including knowing what you don't know), 2) know how you want to say what you have to say before going in there, and 3) being able to compartmentalize it. I had a far more emotionally devastating (to me) case a month or two ago and I nearly broke down in front of the family (and they all knew it). And worse yet my subspecialty (which I only get to do part time these days) is pediatric infectious diseases, so I see a lot of dying children (AIDS, cancer, transplant, etc).

But I don't think there's something unique to doctors that makes us good about delivering terrible news -- but we choose to have a job in which we work around pivotal moments for people and for families, and we need to learn ways of doing this. A few months ago a patient of mine had a new diagnosis of HIV, and I allowed the intern (at that time just a few weeks out of med school) to deliver the news -- but we talked about it for a long time in advance to make sure she felt prepared.

Quote:

If I had cancer and were given a time span that was uncertain but possible to beat, I'd rather be talking to my doctor about how to (in an optimistic mindset) change my lifestyle so as to defeat the cancer, and the medication is sort of at the sidelines of importance.

We talked about the medical stuff too, of course, I mean she still was waiting to get a biopsy at that point to confirm the diagnosis.

Quote:

If the days were surely limited then I'd want my doctor to talk about whatever I want to talk about.

One thing I reinforce with my patients all the time is that they need to set their own agenda for conversations with the doctor. I have to go in there and get a certain amount of information every day, and deliver a certain amount of information (like plans, results, etc), but my job is only half done if I haven't talked about what the patient wants, or if they haven't understood a word I've said. So whether someone is dying of cancer or they've got a nagging little pneumonia but they'll be home tomorrow, there are no rules governing when they can "change the subject" with me and talk about life instead of medicine. Yeah, I need to set some limits to keep myself efficient, but I do that covertly.

Quote:

I would also not want to be contradicted or argued with, in fact.. I agree that philosophy should stay out of it and not be encouraged, but to just encourage whatever it is the patient wants to pursue.

Well put, that's exactly what I believe.

Quote:

Hopefully I'm understanding the extremity of the situation here; too much or too little.

You certainly are, but also take note that the extremity of the situation is not necessary for us to come to the same conclusions. I mean people with trivial illnesses will talk about god -- but I have a feeling that if I brought up such a scenario, the lay audience in this forum might be less likely to appreciate how vulnerable (and often scared) patients are even when they only have a minor illness. The same situation applies.

My son, now 8 months old, has unequal pupils. His left pupil is a millimeter larger than the right. If I weren't a physician (pediatric subspecialist no less), I'd never have noticed. But I freaked myself out about it, knowing that in a tiny minority of cases there are life threatening diseases that can cause this. His pediatrician was sufficiently concerned that we got referred to a pediatric neuro-ophthalmologist who did a 4 hour long evaluation, which included putting cocaine drops in my son's eyes (yes, they're used diagnostically, and yes, they sting Sad

) -- and in the end it was felt to be just a trivial benign finding that didn't even need followup. But I can't even tell you how it tore me apart worrying about this little boy who is now the center of our lives. So if I talked to the doctor about something deep and personal to me, even when the diagnosis was nothing (well, it was benign congenital anisocoria), I'd expect the same attitude as if it had been something serious in the end.

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@Aedes,

Aedes wrote:

Recently a patient of mine (who had in the previous few days received a new diagnosis of metastatic cancer) began talking about her faith.

She paused for a minute, though, and said "I know you doctors aren't supposed to talk about god and religion with patients, though, you have to maintain that clinical relationship and all."

I had an immediate response for her that she very much liked and took positively to, though I'm not sure it would work with everyone. But to not leave you hanging TOO much, my response began "It has nothing to do with whether we're supposed to talk about religion or not..."

But before talking about how I approached (and how I usually approach) that situation, I'm interested to hear what people here would say if they were in that situation.

The reason I'm interested is that I think about patient care a whole lot more than I think about religion, but I'd bet it's the opposite for most of you. So this exercise forces you to step away from pure philosophical dialogue, and even to step away from philosophizing about doctor-patient relationships, and to consider how one approaches this when one is the doctor in such a relationship.

Also realize that while Christians (in my experience) are far more likely to express their faith out loud than people of any other religion I've encountered, people of all religions have done so -- so you need to consider that you might not share the same beliefs as any given patient.

Aedes,
Perhaps I can respond to your post by illustrating a very personal experience. My Dad died in 1984 as a result of kidney cancer. From the day of diagnosis to his death was about four weeks. He was what can be classified as a "man's man" and was highly respected by all that knew him. Upon diagnosis, they immediately took out his failing kidney which was a last resort procedure that was his only hope. The cancer began to spread throughout his body.

At no time did he show any signs of his impending death for no one had told him how serious his condition was in hopes his "oomph" for life would offer some resistence. It was well beyond that and there was nothing anyone could do. Yet, you would never know how serious his condition was by his attitude. He was fearless and assume he would pull through.

The night before he died as he lay in his bed in the hospital, he looked up at me and said, "Just how serious is this son?" I said "Dad, you are about to take a wonderful journey of the like I cannot describe". Though the words where coming out of my mouth, it was as though it was not me speaking them. He understood immediately and I recited a verse I had remembered from Psalms (that 23rd one) as I held his hand. You have to understand my Dad was not a "church going" man, but he was nevertheless a very good man. Upon completion of the verse, there was a calm that came over him and he went to sleep. The next morning he passed away with a peace that is hard to describe.

Aedes, it is not so important what your personal beliefs are, but it is, at least to me anyway, to assume a faith that is recognize by most who inhabit this planet that will manifest "this is not the end". Granted there is no physical proof in either regard, but to not offer this comfort doesn't help their exit, regardless of how they lived their life.

Personally, I believe it. If one doesn't believe in our continuance, to offer any other sentiments that does not attribute to that doesn't help that exit unless it is express by the patient not to offer such positive affirmations. I can't imagine such occurrences at such a time, but they could exist. You would know more about that than I. I am lucky, I am not one that witnesses death on a regular basis.

So I guess what I am saying, is if it is not expressly established by the patient, assume them to be of faith for in most regards they are looking to you, the physician, for affirmation in this time, so give it. What damage could it possible do?
William

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@William,

William, thank you very much for that story.

William;37900 wrote:

Aedes, it is not so important what your personal beliefs are, but it is, at least to me anyway, to assume a faith that is recognize by most who inhabit this planet that will manifest "this is not the end". Granted there is no physical proof in either regard, but to not offer this comfort doesn't help their exit, regardless of how they lived their life.

Perhaps, though I wouldn't ever bring that up with the assumption that a patient believes something like that. Patients often ask me if I believe in the afterlife or in heaven. I usually just turn it around and ask them what they believe. If they press me on it, I just say I don't know -- and that seems to be ok.

Quote:

If one doesn't believe in our continuance, to offer any other sentiments that does not attribute to that doesn't help that exit unless it is express by the patient not to offer such positive affirmations.

Well, there are indeed other things that can help in moments like that, which we can discuss in more detail.

But do you think it's the role of a doctor to initiate a conversation about the afterlife?

And if so, when should one bring it up? At the time a diagnosis is given?

Quote:

So I guess what I am saying, is if it is not expressly established by the patient, assume them to be of faith for in most regards they are looking to you, the physician, for affirmation in this time, so give it. What damage could it possible do?

As I mentioned to my own patient, I do not talk about beliefs because what matters is what the patient believes. So I just don't bring it up independently (other than offering them pastoral services in the hospital), because I want them to have ownership of such a conversation.

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@Aedes,

Aedes,

Are there any codes in place regarding talking to patients about religious beliefs? Are there any guidelines for getting people diagnosed with terminal/very serious illnesses into counseling/therapy?

Personally, I wouldn't initiate discussion on religious beliefs, but if the patient did, I'd gladly try to go along with it. In fact, although I'm basically an atheist, I might be tempted to act as if I were a Christian with my Christian patients that have serious illnesses and that bring up religion and beliefs so I could better comfort them. People that are facing death deserve almost any peace they can get, and those that are facing serious, but not necessarily terminal illnesses need and deserve any source of strength they can get. If I were diagnosed with a serious illness, I'd wish I had comforting religious beliefs that would help give me strength in those times of struggle.

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@Deftil,

Deftil wrote:

Are there any codes in place regarding talking to patients about religious beliefs? Are there any guidelines for getting people diagnosed with terminal/very serious illnesses into counseling/therapy?

I doubt there are any codes, but there may be some resolutions (like from the American Medical Association or other advocacy groups) about the subject. But the emphasis in medical ethics is almost always on respecting patients' autonomy, which means talk about religion if the patient wants it, but never impose our own belief. There is certainly no rule of any sort prohibiting us to talk about anything barring something very inappropriate.

Quote:

I might be tempted to act as if I were a Christian with my Christian patients that have serious illnesses and that bring up religion and beliefs so I could better comfort them.

Yeah, within reason I can be as much of a chameleon as I need to to stay on someone's good side. The exact same thing is true of politics, though I'm even more cautious about that. I mean I've had some unapologetic racists and sexists as patients, and I'm not going to go along with that (and I'll even stand up to them if they're compromising the ability of other staff to care for them -- I laid down the law with one 23 year old man who was making sexual advances at the nursing staff, and he shut up after that).

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