By Kathryn Radigan, MD

Attending Physician, Division of Pulmonary and Critical Care, Stroger Hospital of Cook County, Chicago

Dr. Radigan reports no financial relationships relevant to this field of study.

SYNOPSIS: In mechanically ventilated, critically ill patients without delirium or dementia, chaplain-led, picture-guided spiritual care is feasible and shows the potential for reducing anxiety and stress during and after an ICU admission.

SOURCE: Berning JN, Poor AD, Buckley SM, et al. A novel picture guide to improve spiritual care and reduce anxiety in mechanically ventilated adults in the intensive care unit. Ann Am Thorac Soc 2016;13:1333-1342.

Chaplains have been instrumental in providing spiritual care for hospitalized patients that are facing serious illness. Unfortunately, mechanically ventilated patients, who are potentially at highest risk of stress due to their inability to communicate, typically are not offered spiritual support. To determine the feasibility and effectiveness of chaplain-led spiritual care for mechanically ventilated, critically ill patients, Berning et al conducted a quasi-experimental study at an urban, tertiary care medical center. From March 2014-July 2015, 50 mechanically ventilated adults without delirium or dementia in a medical or surgical ICU received spiritual care from a hospital chaplain. Spiritual care included using an illustrated communication card to assess the patients’ spiritual affiliations, emotions, and needs. For the first 25 patients enrolled in the study, investigators performed semi-structured interviews with eight ICU survivors to identify how spiritual care affected their ICU experience. For the remaining 25 participants, researchers measured anxiety on 100-mm visual analog scales (VAS) immediately before and after the first chaplain visit. They also conducted semi-structured interviews with 18 ICU survivors with added measurements of pain and stress (±100-mm VAS).

Participant mean age was 59 (±16) years, median days of mechanical ventilation was 19.5 (IQR 7-29) days, and in-hospital mortality was 30% (n = 15 patients). With the use of a communication card, all 50 participants were able to communicate spiritual affiliation, 47 (94%) acknowledged one or more emotions, 45 (90%) were able to rate the severity of their spiritual pain, and 36 (72%) selected the form of chaplain intervention they preferred. Immediately after the first chaplain visit, patient anxiety decreased 31% (mean score change -20; 95% confidence interval [CI], -33 to -7). Of the 28 ICU survivors, 26 (93%) recalled their chaplain visit and underwent the semi-structured interview. Eighty-one percent felt more capable of dealing with their hospitalization, and 0% felt worse. Among the 18 survivors who underwent additional VAS testing during follow-up interviews, there was a 49-point reduction in stress (95% CI, -72 to -24) and no significant change in physical pain as a result of the picture-guided spiritual care. In summary, researchers concluded that chaplain-led, picture-guided spiritual care not only is feasible but also shows potential for reducing anxiety and stress after an ICU admission.

COMMENTARY

Critically ill patients often deal with the intense emotions of pain, isolation, depression, fear, anxiety, and/or confusion.1 Historically, hospital chaplains and palliative care teams have been instrumental in providing patients with spiritual care that helps them cope with their symptoms and prognosis.2 One can imagine that experiencing these emotions in isolation without the ability to communicate due to the need for mechanical ventilation may be even more challenging. Within the past decade, it has become widely recognized that mechanically ventilated, critically ill patients experience substantial psychoemotional stress, and survivors often are plagued with anxiety, depression, and PTSD.3,4 With this new understanding, improving outcomes in our critically ill patients has taken on a new meaning. Researchers are interested in improving the quality of life of ICU patients and are actively investigating the mental and physical sequelae of ICU survivorship. However, despite this interest, the area of spiritual care in our mechanically ventilated patients as a topic of research is almost non-existent.

To investigate the benefits of spiritual care in mechanically ventilated patients, Berning et al conducted a trial to determine feasibility and measure the effects of chaplain-led, picture-guided spiritual care for mechanically ventilated adults in the ICU. The ICU chaplain developed an illustrated spiritual care communication card that included four different sections addressing the main domains of spiritual assessment typically assessed by a chaplain: identification of spiritual or religious affiliations, identification of a range of feelings, rating of spiritual pain, and selection of a desired religious, spiritual, or non-spiritual intervention that a chaplain may offer. The chaplain then provided all the picture-guided spiritual care. Through these interventions, researchers demonstrated that chaplain-led, picture-guided spiritual care was feasible and that it reduced both anxiety and stress after an ICU admission.

In support of these findings, previous studies have demonstrated that patients and families in the non-ICU setting have found religion to be the single most important factor enabling them to cope with a serious illness.5 Critical illness is a catastrophic event for an individual’s whole being and affects physical, mental, and spiritual health. During critical illness, patients and their loved ones frequently reflect on spiritual, religious, or existential questions. Surveys have shown that 70% of patients in a death-and-dying setting welcome a spiritual inquiry from their physician, and 50% of terminally ill patients would find active prayer by their physician acceptable.6 Despite all this research, clinicians often are unable to address spiritual care as a priority in the overall care of their patients. Hurdles include the time associated with these discussions, burnout and fatigue, and the fear of not broaching the subject appropriately or appearing to “give up.”

This study was helpful in highlighting that chaplain-led spiritual care is not only feasible among mechanically ventilated adults but also helpful in reducing anxiety and stress. Future studies are needed to address the health of ICU survivorship, including how spirituality in the ICU may benefit quality of life. For now, asking our mechanically ventilated patients and their families if they need spiritual care is a great place to start.

REFERENCES

  1. Tate JA, Devito Dabbs A, Hoffman LA, et al. Anxiety and agitation in mechanically ventilated patients. Qual Health Res 2012;22:157-173.
  2. Wall RJ, Engelberg RA, Gries CJ, et al. Spiritual care of families in the intensive care unit. Crit Care Med 2007;35:1084-1090.
  3. Mikkelsen ME, Christie JD, Lanken PN, et al. The adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological function in survivors of acute lung injury. Am J Respir Crit Care Med 2012;185:1307-1315.
  4. Wunsch H, Christiansen CF, Johansen MB, et al. Psychiatric diagnoses and psychoactive medication use among nonsurgical critically ill patients receiving mechanical ventilation. JAMA 2014;311:1133-1142.
  5. Koenig HG, Bearon LB, Hover M, Travis JL 3rd. Religious perspectives of doctors, nurses, patients, and families. J Pastoral Care 1991;45:254-267.
  6. MacLean CD1, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality. J Gen Intern Med 2003;18:38-43.