Learn to spot spiritual conflict

Teach caregivers to accept patients’ opposing views

As the 70-year-old man lay unconscious, hovering near death, his wife and family stood at his bedside. The wife, who was raised Lutheran, agonized over her husband’s soul. He had never been baptized and she believed her husband would be go to hell unless the sacrament was performed.

The young hospice chaplain who was called to the family’s home inquired about the man’s wishes. The wife said he was active in the church, and on several occasions — usually when grandchildren were baptized — he would express a desire to do the same. He was to be baptized on several occasions, but backed out each time at the last minute. He was embarrassed because he was an adult accepting the sacrament, the wife told the chaplain.

Would the chaplain baptize her husband before he dies?

"The wife’s religious belief taught her that you have to be baptized or you will go to hell," says the Rev. Jeanne Brenneis, MDiv, STM, chaplain with the Hospice of Northern Virginia and director of the Bioethics Center, both in Falls Church, VA, and the chaplain who was called to the home years ago. "He clearly did not want to be baptized when he had the opportunity."

But the wife persisted and Brenneis was left with the decision to either perform the sacrament for the family’s sake or follow the patient’s lifelong decision not to be baptized. Unable to ask the man what his wishes were, she decided to honor what the patient had wanted in his own lifetime. "What I did was do everything except the baptism," Brenneis recalls. "I told them in good conscience I couldn’t give them exactly what they wanted. I don’t think the family was very happy.

"I have talked with other chaplains since this happened and some said they would have done it. You could say it wouldn’t do any harm, but it would be treating the sacrament lightly. I don’t think there is a right or wrong answer."

Understand patients’ wishes

In retrospect, Brenneis isn’t sure if she would do things differently. But her story highlights the spiritual conflicts that can occur between dying patients and their families. With the many nuances family relationships can take, hospice workers must learn to spot potential conflict and work toward a resolution to ensure the patient’s spiritual care is not undermined by family members who have conflicting views about spirituality and religion.

There are a number of situations in which family members can be at odds: children caring for a dying parent, a parent caring for a dying adult child, or a sibling caring for another sibling. Regardless of the familial makeup, hospice workers should approach resolving the conflict by helping caregivers understand the patient’s wishes, says Kevin O’Brien, MA, director of education and outreach services for the William Wendt Center for Loss & Healing in Washington.

Reasons for conflict

Simply enough, spiritual conflict can occur when one family member has an opposing religious belief from the other. But there can also be more complicated dynamics at work. Those types of conflict can manifest themselves in a number of ways: the ability to forgive particular family members, how medication should be used, and how much physical suffering should be endured.

A dying woman is compelled to reduce her pain medication, despite the objections of her husband, so that she feels lucid enough to pray continually in the days before she dies. At the root of this conflict is the woman’s desire to exercise her religious practices and her husband’s desire to make his wife comfortable.

Often, spiritual conflict is a symptom of a larger problem that needs to be resolved before the two sides can reach a spiritual understanding. For example, two siblings who worship under different denominations and caring for a dying parent may disagree about which sacraments and prayers to perform prior to their mother’s death. Instead of spiritual issues driving the conflict, it may be the manifestation of a power struggle between the two siblings.

Be aware of underlying factors, Brenneis advises. "Don’t get too distracted by spiritual issues. Look for underlying reasons."

In fact, Brenneis says conflicts that are truly about spiritual matters are often the most difficult to resolve. "When you start talking about religion, it can be an inflammatory discussion. You can get caught in a theology debate."

What hospice workers need to communicate to caregivers is that spirituality is an individual concept. Caregivers frequently make the mistake of assuming spirituality and religion are synonymous.

Hospice workers should counsel caregivers on the difference by explaining that religion is a set of standards and beliefs that accompany a religious practice, while spirituality is the collective wisdom an individual has gained over a lifetime about his or her own existence and place in the universe. Spirituality, caregivers must be told, is what gives meaning and purpose to life. While it is often the primary component of religion, spirituality can exist among those that do not have a set religion.

Consider this: A dying 30-year-old man tells his Catholic mother, who is his primary caregiver, that he doesn’t want a priest to counsel him. Instead he wants to spend time in his garden. The mother needs to be counseled so that she can understand her son’s view of his relationship with the universe and at some level she must learn to accept his wishes rather than impede his spiritual yearning.

O’Brien identifies three components to hospice workers must address to help resolve spiritual conflict:

1. understanding family relationships;

2. taking a long-term approach;

3. using prayer.

Familial relationships provide the basic information from which the hospice worker will approach the conflict. For example, parents often view themselves as an authority, no matter the age of their children, and are unwilling to relinquish that authority. Grown children may have trouble asserting themselves when parents are imposing their beliefs on them. Or, just the opposite, adult children may show little respect for their parent’s wishes and impose their own beliefs on the patient.

Identifying those dynamics at work will allow workers to get to the heart of the problem and come to a quicker resolution.

Power struggles among siblings can manifest themselves as spiritual conflict. A disagreeable and outspoken sibling can try to impose his or her religious practices as part of the struggle to gain control overall of the decision making responsibilities.

"Rather than avoid conflict, use it to your advantage," O’Brien advises.

Using conflict in controlled forms can help facilitate understanding on both sides, he says. For example, a parent and her dying adult child can re-enact religious rituals that were common when the child was younger, allowing mother and son to reconnect using shared pleasant experiences.

Opening a dialogue

Using the existing conflict allows the disagreeing parties to establish a dialogue, O’Brien says. But he reminds hospice workers that establishing a dialogue is only the beginning.

"It’s not going to be resolved in single session," he says.

Prayer, plays an important role in bringing down barriers. O’Brien says. Often, the chance to pray as a group will help heal the chasm that exists between family members. In cases, where family members have different views about God and the universe, a simple quiet pause that allows both sides to reflect upon their own beliefs is appropriate.

In instances where the patient refuses to accept religious practices of caregivers, Brenneis says praying with just the family is helpful. "It’s important that you support the family," she says. "I have counseled families that conversions can occur during times when we think someone is gone."

If the patient can no longer make his or her own decision and family members want to impose their religious practices on the dying loved one, praying with the family in the presence of the patient is appropriate, as well, she says. "I feel saying a prayer won’t harm the patient, but it certainly helps the family."

Brenneis is also sympathetic to the prevailing regulatory challenges the hospice industry faces and how that affects their time addressing every patient need. And O’Brien adds that hospice workers should be realistic about the results they should expect.

Today’s industry trends suggest that most patients will be under hospice care for just a few weeks, sometimes just days before the patient dies. That leaves little time to tackle all spiritual conflicts between patient and caregiver.

"We get patients who are so much sicker these days," Brenneis says. "There can be so much anger and so little time. If there’s an openness to talk about, then great."

"You can’t expect to change relationships in such a short time," O’Brien adds.