Intervention, Ethical Decision-Making,
and Spiritual Care By Keith A. Evans
Spirituality is a dynamic and intrinsic aspect of humanity through
which persons seek ultimate meaning, purpose, and
transcendence, and experience relationship to self, family, others,
community, society, nature, and the significant or sacred.
Spirituality is expressed through beliefs, values, traditions, and
practices. (Puchalski, Vitillo, Hull, & Reller, 2014, p. 646)
Essential Questions
• How does spirituality affect advance care planning?
• What are the similarities and differences between hospice and palliative care?
• How would a nurse explain the Christian principle(s) for administering spiritual care to
patients? Why is this worldview important to the nurse and patient?
• How would a nurse complete a spiritual care intervention with a patient? What type of
open-ended questions should be asked?
Introduction
All human beings seem to be born with an intrinsic desire for meaning, transcendence, purpose,
and belonging. This desire is what drives all of human life from beginning to end. Any and every
worldview is essentially an attempt to decipher and live out one’s ultimate meaning and purpose.
Four fundamental points follow from this observation. First, all human beings desire to discover
what their ultimate meaning and purpose might be. An easy way of beginning to decipher where
one derives his or her ultimate purpose is to simply notice the things that one considers to be
priorities in everyday life. For some, it is to make as much money as possible or to further one’s
career at the cost of all else. For others, it may be family or the pursuit of comfort. Ultimate
purpose is linked to what a person considers to be the most valuable and to be sought after above
all else. The term worship, often relegated to only describe religious practices, can actually
describe all of human behavior because worth-ship, the root word from which the
term worship comes, refers to ascribing ultimate value and meaning to something or someone. In
short, whether religious or not, people can view that human beings are worshipers by nature.
Secondly, every person has a spiritual nature, whether he or she realizes it or not. Spirituality is
informed and developed within the context of a person’s worldview. A person’s spirituality is
reliant upon his or her faith, lack of faith, theological interpretations, and even how they view the
origins of creation and humanity. What they value above all else is once again dependent upon
what is truly real and what it means to live fully as a human being. A person’s worldview shapes
his or her inner life and character, such that it is not purely an academic or intellectual question
but will involve his or her emotions, thoughts, feelings, desires, and will. In the same way that all
people have a worldview, all people will have or express a particular kind of spirituality, even if
it is not always recognizably religious.
Thirdly, a person’s worldview and, in turn, what they come to worship shapes, informs, and
transforms them spiritually. It is not a question of whether or not they will be spiritually formed
because all are being formed or developing internally in one way or another, rather the question
is what exactly are they being formed into? Dallas Willard (2002) addresses this idea as follows:
We may be sure of this: the formation, and later transformation of the inner life of
[human beings], from which our outer existence flows, is an inescapable human
problem. Spiritual formation, without regard to any specifically religious context or
tradition, is the process by which the human spirit or will is given a definite “form” or
character. It is a process that happens to everyone. The most despicable as well as the
most admirable or persons have had a spiritual formation. Terrorists as well as saints are
the outcome of spiritual formation. Their spirits have been formed. Period. (p. 19)
Finally, given the first two points above, the importance of a person’s spirituality and inner
workings must be considered. That is, what considerations each individual has internally, what
one values, especially when it comes to serious matters he or she may have not been exposed to
or confronted with. When people have to face fears and unknown questions, people then rely on
their real person deep down inside, their human spirit. This is where an understanding of the
importance of the concept of spirituality and how it relates to patient care begins. It is a serious
mistake to think of spiritual care as simply a last-ditch effort to provide emotional comfort to
patients after all other medical treatments have failed. Nor is it accurate to relegate spiritual care
to the realm of simply facilitating the performance of religious rituals and rites, void of
compassion and empathy. As a matter of fact, if human beings are spiritual in nature, spiritual
care truly encompasses all care, medical or otherwise.
When a health care provider does his or her job with skill, competence, and understanding, most
people will be shaped by gratitude, joy, and trust. On the other hand, if a patient’s experience
with a health care provider is characterized by indifference, belittling, or even technical
negligence, such a patient’s inner world will likely develop an aversion to and distrust of health
care providers. Equally disturbing is the damage caused to what a Christian worldview would
call the soul, the inner being that experiences real emotional wounding. This means that helpful
interventions and ethical decision-making flow out of a person’s spirituality and not the other
way around. The core of a person’s being, what he or she values pours into these important
decisions.
Puchalski et al.’s (2014) comprehensive definition of spirituality reveals the complex nuances of
humanity’s spiritual nature. This definition can be well supported by diverse faith and spiritual
traditions, but also by Christian beliefs and biblical principles. If a person believes he or she was
created by God, then this person must assume that his or her spirituality was given by God to be
used for God-glorifying purposes (Psalm 29:2; 1 Corinthians 10:31). The quality of a Christian’s
spiritual experiences is connected to the depth of his or her relationship with an interactive,
redemptive, and holy God who gives peace, joy, and deep life satisfaction when one’s life and
faith beliefs are aligned with godly principles of living and purpose (Colossians 2:6; 3:1–17;
Ephesians 2:4–10; Galatians 5:16–25; Philippians 2:13; 4:13).
This chapter will review the key role that personal beliefs play in informing ethical and end-of-
life-decisions. In the next section, a Christian theological basis for spiritual care will be
established to serve as a foundation for a discussion of how health care providers can utilize
practical spiritual screens, histories, and specific assessments to better understand and care for
their patients and their families. Building upon this discussion will be an overview of the key
aspects of surrogacy laws, hospice and palliative care, and how a patient’s beliefs play into their
decisions.
Christian Spiritual Care
As discussed earlier in this book, worldview questions (e.g., “Where did I come from?”)
correspond to the basic Christian narrative acts of creation, the fall, redemption, and restoration,
as people make sense of God, their relationship with God, and their role and actions in this world
according to the Bible. This understanding also guides how important decisions are made. With
the context that human beings are inherently spiritual beings, then they have a need for spiritual
care in whatever stage of life. For nurses and other health care providers, understanding a
patient’s internal worldview is at the core of how providers approach their administration of
health care, their ability to respect that worldview, and the belief system of the patient. Being
intentional and attentive to a patient and his or her family’s spiritual needs leads to positive
holistic health care outcomes.
Nursing has long been associated with spirituality and how it helps to inform and make meaning
of life situations to patients. Nursing educators Timmins and Caldeira (2017) state that for
religious people, “spirituality refers to the soul and its protection and nurturing during life …
‘protected’ through correct moral thought and by living as directed through sacred texts” (p. 50).
Research continues to demonstrate that there is a positive relationship between spirituality,
health, and well-being (Hall, Hughes, & Handzo, 2016). Spirituality affects every aspect of a
person’s life, so offering emotional and spiritual care support should be an important focus for all
health care providers.
Even though The Joint Commission (TJC) requires all patients be asked about how their spiritual
and religious preferences may impact their health care, only 54-63% of hospitals fulfill these
requirements through employing professional health care chaplains (Hall et al., 2016). Nurses
who understand the importance of spirituality and faith can effectively fill in the gap and
administer effective soul care to those in need. By understanding and providing interventions that
help relieve spiritual distress, nurses can help reduce the patient’s worries and concerns, which
allows for more complete physical, emotional, and social well-being. Often a nurse can promote
this by asking simple questions such as, “What has helped you cope well in the past?” or “What
gives meaning to your life?” and “Do you have any spiritual or faith preferences?” If a nurse is
truly attentive, he or she can easily see what may bring comfort or angst as a patient provides
answers to these questions.
A patient’s spiritual needs, even if unspoken, should always be a primary focus for treatment in
this area, not the spiritual ideals or specific religion of the nurse. Nurses should not assume they
must be religious or steeped in a specific faith tradition to give quality spiritual care, attending to
the whole person inwardly. Although many patients will follow formal religious and theological
doctrines, and often express those beliefs through traditional religious rites and practices, many
others will seek to express their spiritual beliefs, morals, and life values in other diverse ways.
These can sometimes be determined by looking at a patient’s overall demeanor. Similar to a
hospital chart that identifies levels of pain through simple facial expressions, with some practice,
a health care professional can also look for expressions of sadness, gloom, depression, concern,
and fear, among others.
Because of the complexity of spirituality, “nurses feel underequipped to provide spiritual care”
and often “struggle to articulate a functional or ‘actionable’ definition of spirituality, and are
‘uncertain about what constitutes spiritual care’” (Hughes et al., 2017, p. 3). Most patients and
their families “do not anticipate in-depth, specialized spiritual care from their nurses, but they do
have a strong expectation for some basic spiritual care connections including interventions such
as active and empathic listening, proactively communicating, and expressing compassion”
(Hughes et al., 2017, p. 8). Another way to view this is to consider what the person is
experiencing internally even as nursing care primarily focuses on physical care.
As reviewed, a person’s spiritual beliefs and values will guide day-to-day decisions as well as
critical health and end-of-life-treatment choices. Within that context, this chapter will discuss the
topics of advance care planning, end-of-life care options and decisions, a foundation for
Christian theology and holistic spiritual care, and how to use a spiritual needs assessment tool
to discover any spiritual needs of the patient or their family. On the surface, one might not see
how each of these connect, but underlying all these topics and decisions are the individual’s
worldview that really does inform how individuals view life and death. As previously
introduced, this understanding of one’s worldview both determines and distinguishes each
patient’s unique personal values, experiences, and spiritual beliefs.
Role of Spirituality in Clinical Care and End-of-Life
Decision-Making
A person’s spirituality and faith values impact his or her understanding of illness as well as
health care decisions. Several critical decisions informed and influenced by one’s spirituality are
advance care planning, self-autonomy preferences around treatment, and understanding of illness
and medication or treatment compliance (Puchalski et al., 2014). For example, does the
individual view his or her current diagnosis and illness as a blessing, a curse, or another form of
punishment from God? Understanding the person’s perception of the illness can aid the
clinician’s development of appropriate treatment plans. If someone thinks the illness is a
punishment, he or she may not be amenable to treatment. The nurse should consider: What is the
patient’s life story, and how does the illness and treatment choices fit into that story?
Spirituality, beliefs, and faith values will, in turn, impact a patient’s compliance to medical
treatment recommendations. For example, religious beliefs may impact choices about blood
transfusions and use of certain medical treatments. For example, a member of the Christian
Science faith tradition is highly discouraged against taking vaccinations, a Muslim patient may
want to be alert at the time of death and decline a palliative treatment of morphine, or a Jehovah’s
Witness is unlikely to consent to blood products because of religious views, even if the choice
leads to death.
Common Spiritual Screen and History Questions
Nurses can quickly assess a patient’s spirituality with a few questions during initial intake
assessment and through periodic check-ups. Common questions may include, “Do you have any
spiritual or faith preference?” (e.g., Catholic, Hindu, Muslim), or “Do you have any spiritual
needs or concerns related to your health?” (e.g., dietary or medical restrictions, grief,
hopelessness).
When it comes to spiritual history questions, they are more expanded, open-ended, and specific
as compared to the spiritual screen. The CSI-MEMO (Koenig, 2013, p. 56) is an easily used and
adaptable style nurses can use with patients. The key four questions of CSI-MEMO are:
1. Do your religious/spiritual beliefs provide comfort, or are they a source of stress?
2. Do you have religious/spiritual beliefs that might influence your medical decisions?
3. Are you a member of a religious/spiritual community, and is it supportive to you?
4. Do you have any other spiritual needs that you’d like someone to address?
The spiritual screen and spiritual history questions should be not asked in a robotic or impersonal
manner. Nurses should ask these open-ended questions in a personal and informal way as they
discover what the spiritual needs of their patient might be. Some informal examples are noted
below, but these questions could also be reworded in more direct ways with lead-in phrases of “I
would like to ask…,” or “May I ask you if …,” versus the more informal questioning method.
Social work professor David Hodge (2006) proposes the following questions as modified
versions of the TJC spiritual needs inquiry:
• I was wondering if spirituality or religion is important to you?
• Are there certain spiritual beliefs and practices that you find particularly helpful in
dealing with problems?
• I was also wondering if you attend a church or some other type of spiritual community?
• Are there any spiritual needs or concerns I can help you with? (p. 319)
Other ways a few spiritual needs questions could be expressed include:
• I was wondering what gives you inner strength and ability to cope?
• In what ways do you express your faith beliefs?
• Are there things that are worrying you at this time?
• How has your illness affected your family?
• Would you mind if a chaplain stopped by for you to talk with about your situation and
health decisions?
• Does anyone from your faith community know you are hospitalized?
See Appendices A and B for additional questions and spiritual assessment models that nurses
might use with patients and families as well as several case example transcripts with reflections.
Most importantly, ensure the patient has been given an adequate assurance that all aspects of care
and comfort are the maximum concern of the nursing staff and entire health care team. It is
important to remember that a nurse has the most contact with patients overall and should
maintain a high degree of visibility and direct interest in these matters. As nurses afford this
openness for spiritual discussions, their patients get the sense that their medical affliction and its
impact upon all aspects of their lives is of great importance. Accordingly, this helps to put
patients at ease, which contributes greatly to their sense of well-being and satisfaction with their
care.
Patient Advocacy and Intervention for End-of-Life
Decision-Making
Advocating for others requires understanding and respecting their values and wishes. This
section will consider spiritual aspects that are involved in ethical decision-making, the issue of
consent and competence, health care or medical power of attorney, and various documents that
express end-of-life wishes for an individual when treatment for sustaining quality life is no
longer an option. Each of these areas is crucial for nurses and other important health care
providers to understand and apply properly in order to fully respect the autonomy and end-of-life
wishes of the individual.
The Spiritual Aspects of Ethical Decision-Making
An individual’s worldview is based upon their values, beliefs, experiences, culture, and how they
abide by societal norms, moral codes, and religious practices. This is how decisions are
determined to be right or wrong and how individuals believe they ought to think or act. For
people with a Christian worldview, these decisions are aligned to biblical concepts and Christian
principles of living. For those with a different worldview, other spiritual and religious beliefs
will inform them in what they determine to be proper ethical decisions. With respect to the four
ethical principles discussed in previous chapters, Table 4.1 lists how various Christian and
biblical principles would spiritually support the concepts of autonomy, beneficence,
nonmaleficence, and justice.
Table 4.1
Spiritual Support of Ethical Principles
Ethical Principle Biblical Principle/Scriptural Support
Autonomy Sanctity of life/imago Dei (Genesis 1:26-27; 9:5-6)
Humanity placed as steward of God’s creation (Genesis 1:28; 2:15, 19-20)
Humanity given free choice between right or wrong/good or evil (Genesis 2:16-17; 3:1-7)
“Choose this day whom you will serve” (Joshua 24:15)
Beneficence In all things, love and do good to self and others (Matthew 22:36-40; Mark 12:28-31; Luke
10:25-28)
Nonmaleficence Live in peace and harmony with others (1 Timothy 2:2-3)
Love mercy (Micah 6:8)
Turn the other cheek; forgive (Matthew 5:39)
Justice Respect other’s rights and dignity (Colossians 3:25; 1 Peter 2:17)
Love your enemies (Matthew 5:43-48)
Do not judge (Matthew 5:7, 7:1-5)
Act and live justly (Isaiah 10:1-4; Micah 6:8)
Consent and Competence
Patients usually possess full autonomy to decide what type of care they wish to receive. Under
federal and state laws and common medical ethical principles, all patient communication with
health care providers that include test results procedures, and diagnoses are considered strictly
confidential. Any conveyance of this information should only be made per the patient’s
knowledge and written, legal, informed consent. Individuals who are dying no longer have the
decision-making capacity or may be in a weakened cognitive state prior to severe decline,
resulting in a deteriorated mental capacity to make rational choices. The legal “right of consent
to treatment endures after the patient becomes incapacitated, even though the exercise of that
right by the patient…is no longer possible” (Foreman, Kitzes, Anderson, & Kopchak Sheehan,
2003, p. 110).
Assigning a surrogate decision maker or health care proxy is highly recommended prior to
when mental capacity and competence declines. In determining competence, one might ask,
“Can the individual hold a conversation—verbal or nonverbally—that expresses their desires and
understanding of the pros and cons of treatment?” If the person can do this in a rational manner,
then competence and mental capacity is in place. If there is a question about capacity and
competence, then a psychological evaluation should be considered to help make this
determination. If the patient does not possess adequate cognitive decision-making capacity, then
an appointed surrogate or health care agent should be appointed. Surrogates should know the
patient’s beliefs, values, faith traditions, and lifestyle well enough to make decisions that the
patient would have made while competent, not decisions as the surrogates might decide for
themselves. Normally, this would be a predetermined family member or someone the patient
trusts to make decisions for him or her. It is important to have this information in place should an
unforeseen emergency arise when a quick decision must be made.
Refusal of Medical Treatment
Patients have the right to refuse medical options or even withdraw their consent once given. This
may go against accepted medical advice, but patients have this autonomy. Religious beliefs may
restrict use of normally acceptable medical practices. For example, as previously mentioned,
patients who follow the Jehovah Witness faith tradition do not want whole blood transfusions,
even in the case of medical emergency because of religious faith practices. This medical
restriction is based upon the faith tradition’s interpretation of several biblical passages (Genesis
9:4; Leviticus 17:10; Acts 15:28–29).
End-of-Life Decision-Making
To avoid misunderstanding patients’ end-of-life wishes, crucial conversations regarding
advance-care planning with appropriate documents expressing their explicit wishes are needed
ahead of any crisis. These documents allow people to share treatment preferences in the event
they can no longer speak for themselves. In general, there are two kind of advance-care planning
documents: legal documents and medical orders.
Legal documents include advance directives, living wills, and health care power of attorney
(HCPOA). These documents are ideally completed by competent adults during noncritical times.
These legally binding documents identify the individual’s surrogate decision maker(s) and clearly
outline future, predetermined decisions regarding medical treatment and end-of-life instructions.
Advance Directive
An advance directive is a written statement that is witnessed and executed while the patient has
legal capacity. These may also be called health care directives. The document gives direction to
what type of care the patient would or would not want in the situation that they lose mental
capacity and decision-making capabilities. Often, a specific health care agent is listed who would
become the surrogate decision maker for the patient.
Many spiritual questions may arise with advance directive and end-of-life discussions. A few
examples might include:
• “What is the meaning of my life?”
• “Does my religion consider advance directives moral?”
• “How can I find meaning in planning for the final days of my life?
• “How will advance directives give me peace or mind or benefit my loved ones?”
• “Who can I rely upon to carry out my advance directives in a way that is true to my
wishes and respectful of my religious and spiritual beliefs?” (Blanchfield, 2011, para 8)
Living Will
A living will is a legal document that makes one’s end-of-life wishes known. The document
records the patient’s desires regarding medical treatment or action used in terminal conditions. It
may also outline wishes in the event of a persistent vegetative state or irreversible coma. While a
living will legally records the individual’s end-of-life wishes, it is not an active decision-maker.
If the individual loses competence, then the patient must have previously selected a specific
surrogate decision-maker to be the health care or medical power of attorney (MPOA). If a health
care agent is not assigned, then a court-appointed guardian would be selected.
The living will becomes binding on the attending physician when the individual loses decision-
making capacity. The document itself is not considered a medical order and is often not
completely followed by medical staff or the health care proxy. Living wills only become
operative when it is provided to the attending physician and the individual is incompetent and
has a serious illness (Levenson & Zucker, 2017). Of course, the living will documents are not
binding and operative when the patient is capable of making decisions or upon the individual’s
death.
Surrogates or Health Care Proxy
The HCPOA or MPOA is a legal document that identifies a specific surrogate decision-maker for
the individual in the event that he or she does not have the mental capacity to make treatment
decisions. The surrogate decision-maker should be aware of the individual’s beliefs and values,
so the surrogate’s decisions would mirror what the individual would have most likely decided if
he or she were still fully capable.
A few states have a psychiatric or mental health care power of attorney (MHCPOA). Often, the
HCPOA is not allowed to make decisions regarding psychiatric care. This document provides
instructions regarding treatment or services one wishes to have or not have during a mental
health crisis. A mental health crisis occurs when a person is unable to make or communicate
rational decisions. The surrogate agent named under a MHCPOA can decide for the individual to
be admitted into psychiatric facilities for treatment without a court decision.
If the individual is incapable of making decisions and has not previously selected a specific
HCPOA or proxy to speak for him or her, then a competent proxy is selected based upon a next-
of-kin hierarchy. In most states, the hierarchy follows this descending order for an adult patient:
• Spouse/significant other (if legally recognized by the state)
• Adult child
• Parent(s)
• Domestic partner
• Adult siblings
• Close friend
• If none of the above is available, then guardianship would be legally assigned.
The selected surrogate would be asked to consider the patient’s values and wishes and then offer
substitutionary judgment for the patient’s medical decisions. It is critical for any surrogate to
understand the individual’s spiritual, religious, and cultural beliefs and values that might impact
care decisions. It is important for surrogates to follow what the individual may have decided, not
what the surrogate thinks is right; therefore, these types of crucial conversations should be
completed with the individual and potential surrogates or health care proxy while the individual
is still mentally competent and can express his or her values and desires in a rational way.
The second type of advance-care planning documents are medical orders. Medical orders
involved do not resuscitate (DNR) and physician orders for life-sustaining treatment
(POLST). These medical orders translate the patients’ wishes into specific medical orders or
treatments specific to their situations. These orders are normally only completed once the
individual is seriously ill and may only have a year or less to live.
The DNR is a physician’s order to not provide cardiopulmonary resuscitation (CPR) or advanced
cardiac life support in situations when the patient’s heart or breathing stops. The DNR is decided
upon between physician and patient or the patient’s surrogate prior to a cardiopulmonary event
occurring.
Conflicts may come up for patients and families about their wishes and the religious or cultural
beliefs that inform decisions. The HCPOA or proxy may disagree with the patient’s religious or
cultural mores, which can be very difficult for patients, families, and health care professionals.
Having someone on the health care team who understands nuances of diverse spiritual and
cultural beliefs and expressions as well as diverse religious customs and practices can be
invaluable so that end-of-life discussions can be done in a respectful manner (Health Care
Chaplaincy Network, 2016).
Case Study: Robert …
