At the end of life, some patients may think more about spiritual issues and wish to discuss these issues with others. Patients who do not want to talk about spiritual issues may still make medical decisions based on their spiritual beliefs. Lo and colleagues for the Working Group on Religious and Spiritual Issues at the End of Life suggest ways for physicians to work with patients to determine how best to use beliefs to improve end-of-life care. Most physicians have not received any training in these issues and may feel uncomfortable discussing them.

Various phrases may be used to elicit patient's concerns about faith-related issues (see accompanying table on page 1680). For example, instead of disregarding a patient's attempts to bring spiritual matters into medical decisions, a physician could reflect back to the patient his or her beliefs and try to clarify how it seems to the patient that God is involved in the medical situation. The patient's faith may provide clues for the physician about what is important during end-of-life care. When the patient expresses religious concerns, it may be therapeutic for the physician to be empathetic and show understanding of these matters. At the end of life and during times of spiritual distress, it will probably not be possible for the physician to fix the problem, but being supportive of the patient's spiritual statements may help. It is not helpful to provide immediate reassurance (e.g., your cancer is not punishment from God), because this might seem dismissive and make the patient reluctant to talk about other concerns.

If the patient inquires about the physician's religious or spiritual beliefs, it may be best if the physician deflects the question with a comment such as, “I'd like to keep the focus on you.” Or the physician may decide to answer such questions in a way that explores the patient's beliefs: “I am curious about why you ask.”

When religious reasons are given for rejecting the physician's recommendations (e.g., not wanting to extubate a family member because “God will perform a miracle”), it is best not to attempt to persuade family members that they are wrong, but rather to try to understand their point of view. It may be useful to use “I hope so” statements, not to reinforce unrealistic hopes, but to show alignment with the family and, possibly, the limits of medical interventions. The authors advise that physicians not discuss theologic issues unless they are trained to do so, and also advise against inviting patients to engage in religious rituals.

editor's note: Other studies have shown significant improvement in health care outcomes when even small changes are made in the way the physician approaches spirituality (see the Matthews article referenced above). Even an act as small as asking about the place of religion or faith in a patient's life may be greatly beneficial.—g.b.h.