AMA Journal of Ethics. July 2018, Volume 20, Number 7: 621-629.
Case with Commentary
How Should Clinicians Respond to Requests from Patients to Participate in Prayer?
Physicians can respond to patient requests for prayer by first pausing, listening respectfully, and reflecting back their understanding of the request.
Commentary by April R. Christensen, MD, Tara E. Cook, MD, and Robert M. Arnold, MD
The night before a scheduled bypass surgery, Mrs. C meets with her surgeon, Dr. Q.
Mrs. C is calm and seems emotionally prepared for her morning procedure. Dr. Q discusses the procedure and briefly touches upon the postoperative care plan, assuring Mrs. C that she will have a more thorough discussion with her following the surgery. Dr. Q asks Mrs. C if she has any questions.
“None—thank you very much, Dr. Q. I’m ready for tomorrow morning and am looking forward to getting back home. But can we pray together before you leave?”
Dr. Q identifies as a secular Jew and as an atheist and finds no value in prayer. She knows Mrs. C is a devout Catholic and that prayer is important to her right now. Dr. Q considers “faking it” for the sake of just getting through the awkwardness of the request but decides against it since she feels that doing so would be disingenuous and disrespectful to Mrs. C.
“Would you like me to call the chaplain?” asks Dr. Q. “I know that Rev. P is in clinic today, and he can be here soon.” Mrs. C looks visibly annoyed: “But Rev. P is not performing my surgery tomorrow morning. You are.” Dr. Q wants to make sure Mrs. C feels well cared for but does not want to be insincere. She wonders what to do.
Like Mrs. C, the majority of patients believe that spiritual care by physicians is important.1-7 Approximately half indicate they would like their physicians to pray with them.7-9 Faith can play an even greater role in the lives of people facing serious illness, as patients turn toward religion for guidance or support.4,6-8,10 In the setting of severe illness, religious and spiritual support from the medical community significantly impacts patient-reported quality of life.6,11-13
Despite the significance of religion in patients’ lives, physicians often avoid engaging in these conversations.14-15 Believing the question is outside their expertise, worrying that they will say the wrong thing, or having discordant beliefs regarding religion, physicians are not sure what to say.3,7,16,17 Moreover, physicians do not want to lie or misrepresent their spiritual beliefs.8,16,17 Finally, physicians might even be reluctant to offer to refer to a chaplain, as Dr. Q does, because it might be heard by the patient as reflecting the clinician’s discomfort and as attempting to avoid the topic. How can Dr. Q respond in a way that is true to her religious views and builds a stronger relationship with Mrs. C?
Here, we are going to suggest a nuanced way of dealing with a patient’s request for prayer. First, it is important to understand why this request makes Dr. Q uncomfortable. A physician’s capacity for understanding requires introspection.10,18,19 By practicing introspection, a physician is better prepared to pause and explore the many potential motivations behind the request. We show that once Dr. Q understands her discomfort and what Mrs. C is asking, she is better suited to respond. We will also describe Dr Q’s potential responses to Mrs. C’s request for prayer. In general, a physician’s responses to a patient’s request for prayer will likely vary based on two factors: (1) the physician’s comfort disclosing her religious beliefs, and (2) the physician’s views about the role of prayer in health care.
Dr. Q’s Discomfort with a Request for Prayer
When Mrs. C makes a request for prayer, Dr. Q’s emotional reaction makes it hard for her to respond. Like Dr. Q, many physicians are often caught off balance when patients make a request to pray with them. Anxiety and discomfort could lead Dr. Q to want to avoid the topic. (“Would you like me to call the chaplain?”) As patients can view discussion of their spiritual beliefs as a way to build a stronger relationship with their physician, Mrs. C might perceive this response as abandonment.3,8,20 The first step for Dr. Q toward overcoming her discomfort in responding to Mrs. C’s needs is to understand her reasons for this reaction.
Several potential explanations for Dr. Q’s discomfort exist.7,8,16,17 First, Dr. Q might be ill at ease because Mrs. C is asking her to reveal more about her private life than she is comfortable with.21 (My personal life and beliefs are separate from my physician role. I don’t want to talk about that.) Second, Dr. Q could be afraid of upsetting Mrs. C because they have different beliefs.16,17 This fear could be a source of discomfort even if Dr. Q was very religious. (Mrs. C might not want a physician who is Protestant.) In addition, Dr. Q could be uncomfortable because, as a scientist, she might not believe in religion.17,20,22,23 (Ugh. I think religion is just a myth, but I can’t say that.) Finally, Dr. Q might not be accustomed to patients making religious requests of her; such requests could be heard as a challenge to her authority and training. (What does this have to do with my doctoring ability?)
Self-Reflection and Intentional Pause
There are two ways for Dr. Q to deal with her emotional reaction to her patient’s request for prayer. First, Dr. Q can engage in anticipatory self-reflection.18,19,24-26 Second, after being asked to pray, Dr. Q can pause for a moment, internally acknowledging and dealing with her emotions.
Given the importance of religion in patients’ lives, physicians should expect to be asked questions about prayer or their religion. Thinking about how she is going to respond to these questions ahead of time (ie, anticipatory self-reflection) would help Dr. Q to have a more considered response in future interactions. In addition, self-reflection has several demonstrated benefits for physicians, including increasing insight into personal feelings, increasing capacity for empathy, and enhancing the ability to differentiate between a patient’s and a physician’s needs.25-28
Following a request for prayer, an intentional pause could enable Dr. Q to process her initial emotional response, as otherwise her emotional response might cloud her understanding of Mrs. C’s request.28 Dr. Q can take a deep breath and consciously let it (and her anxiety) out. Rather than answer when she is off balance, she can internally acknowledge her anxiety and discomfort. (Oh my… I did not expect that question…. Breathe deeply and slow down.) Then, rather than responding emotionally, she can slow the conversation down and try to better understand why Mrs. C is making this request. This approach would allow her to attempt to both build her relationship with Mrs. C and be true to her core beliefs, as has been found for other physicians.29-31
Exploring the Request for Prayer
The request for prayer could be simply a question about whether Dr. Q will pray with Mrs. C. However, in our experience, these sentinel questions are more complex, with layers of emotions and underlying questions. For instance, Mrs. C could be scared or anxious about her upcoming surgery. She might also feel alone and vulnerable, lacking control of the situation.8,20 In these situations, prayer can be an important coping mechanism.8,32 Alternatively, Mrs. C might want to know that the doctor is a believer, as many patients believe that God acts through physicians33 and view positively spiritual discussions with medical personnel.8,31
To ensure that Dr. Q addresses the questions and emotions underlying the request for prayer, she should step back to understand exactly what is being asked. To investigate the above possibilities further, Dr. Q could say, “I see that it’s important for me to be here with you; tell me more.”29,30 This response both acknowledges the significance of Mrs. C’s request and nonjudgmentally invites her to share her concerns.
Reflecting Mrs. C’s Concerns
As Dr. Q learns more about Mrs. C’s underlying reasons for request for prayer, she should reflect back what Mrs. C is saying. The request for prayer could be a request for a human connection that an empathic response might satisfy.34 Listening respectfully in this manner does not require Dr. Q to agree with Mrs. C’s religious beliefs.30,35,36 Rather, reflection tells Mrs. C that Dr. Q is listening and allows Mrs. C to feel acknowledged.29,37
For instance, in response to Dr. Q’s question, “I see that it’s important for me to be here with you; tell me more,” Mrs. C could say, “I am so afraid that I will not make it.” Dr. Q should then acknowledge this fear. (“This is a scary situation.”) Mrs. C might also specifically elaborate on the reason for her prayer request: “This is a big surgery; I’ve never been through anything like this before and need to know God will be with me.” In this case, Dr. Q could reflect back, “I hear this is a lot to think about.”29,30 In both responses, Dr. Q has empathized with Mrs. C’s concerns, potentially strengthening the physician-patient relationship.
Responding to the Request for Prayer
After exploring Mrs. C’s concerns and reflecting back her reply, Dr. Q will need to respond to Mrs. C’s original request in the context of her concerns. This response should be guided by two principles. First, a clinician should not lie about her religious beliefs.8,35 Trust forms the cornerstone of the patient-physician relationship and is particularly important for views that are central to one’s belief system, like religion. Hence, if Dr. Q were to misrepresent her beliefs to Mrs. C, it would severely undermine the relationship. Dr. Q does not need to explicitly state her beliefs regarding prayer to support Mrs. C. For example, her response could focus on addressing the psychological basis of Mrs. C’s request for the physician’s presence while she prays.
Second, to the degree possible, and while remaining truthful, a clinician should promote trust in the relationship.31 Building trust means reaffirming one’s dedication to the patient’s well-being and staying present.20,38,39
Below are examples of how Dr. Q could respond to Mrs. C’s request for prayer based on her comfort in talking about her religion and how well her religion aligns with Mrs. C’s. In this case, Dr. Q identifies as an atheist, while Mrs. C is a devout Catholic. Dr. Q could respond, “I hear this is really scary, and your faith is an important source of strength for you. I will keep you in my thoughts and do everything that I can for you.” This response is also appropriate for those who are uncomfortable discussing religion further. Alternatively, if Dr. Q is willing to be present with Mrs. C, she could say, “I hear this is really scary, and your faith is an important source of strength for you. Let’s spend a few moments of silence together.”29-31,40
For physicians who do not share the same faith or faith background with their patients or are not religious, such as Dr. Q, the above responses demonstrate how physicians can still support patients and meet their needs.41 Regardless of whether Dr. Q stays for Mrs. C’s prayer, she has shown respect for Mrs. C, acknowledged the importance of prayer, and not abandoned Mrs. C. More generally, this type of response allows physicians to remain present with patients while also remaining true to their own beliefs by not committing to prayer.29,31,40,41
One concern is that Mrs. C could respond by questioning Dr. Q’s beliefs. (“But don’t you pray?”) In this case, Dr. Q could respond, “I see how important prayer is for you and am glad to be with you while you pray.” For physicians who are uncomfortable discussing their beliefs, this response articulates both respect and returns the focus to the patient. In the rare case in which the patient persists, the clinician can either say “I do not, and I am more than willing to stay with you while you pray” or “I am uncomfortable talking about my faith. I will, however, be with you while you pray.”
For physicians who are religious and comfortable talking about their beliefs, there are two possible scenarios. First, assume that Dr. Q is spiritual but does not share the same religion. (For example, Dr. Q is Southern Baptist and Mrs. C is Catholic.) Dr. Q could say, “I hear this is really scary. I am glad to silently pray with you.” This response respects the fact that different religions pray differently and allows the patient to pray within the context of her faith.29-31 Second, assume that Dr. Q has the same religion as Mrs. C. One way she could respond is this: “I hear this is scary. I can pray with you.” When a physician is comfortable praying with a patient, it is most appropriate to pray silently. If the patient requests the physician to lead the prayer, however, the physician should be cautious to avoid imputing specific beliefs to the patient, as even those of the same faith can differ in their beliefs. If the physician chooses to lead a prayer, nondenominational prayer is the safest; asking God for support is safer than requesting specific outcomes, given (1) potential differences in beliefs regarding the purpose and practice of prayer and (2) risk of spiritual distress if the requested outcome does not occur.40 For instance, Dr. Q could pray, “We ask God for support and for presence with Mrs. C during the surgery. May God ease her fears during this time of uncertainty.”
Dr. Q’s decision of whether to pray with Mrs. C is a personal decision. Introspection can enable physicians to offer a carefully considered response as opposed to an instantaneous emotional reply. In addition, a response that acknowledges and explores Mrs. C’s request for prayer can make her feel heard. While Mrs. C could still express disappointment depending on Dr. Q’s ultimate response, following this approach both respects Mrs. C’s emotional needs and Dr. Q’s boundaries.
April R. Christensen, MD, is a second-year palliative care fellow and clinical instructor of medicine in the Section of Palliative Care and Medical Ethics in the Division of General Internal Medicine in the Department of Medicine at the University of Pittsburgh Medical Center. She completed medical school at Vanderbilt University School of Medicine and an internal medicine residency at Vanderbilt University Medical Center. Her academic interests include spirituality in health care, medical education, and narrative medicine.
Tara E. Cook, MD, is a second-year palliative care fellow and clinical instructor of medicine in the Section of Palliative Care and Medical Ethics in the Division of General Internal Medicine in the Department of Medicine at the University of Pittsburgh Medical Center. She completed medical school at the University of Maryland School of Medicine, an internal medicine internship at the University of Maryland Medical Center, and a neurology residency at the University of Iowa Hospitals and Clinics. Her academic interest is education for palliative care and communications skills in the management of neurologic disease.
Robert M. Arnold, MD, is a Distinguished Service Professor of Medicine in the Division of General Internal Medicine in the Department of Medicine at the University of Pittsburgh Medical Center (UPMC) and in the University of Pittsburgh Center for Bioethics and Health Law. He also is the director of the University of Pittsburgh School of Medicine Institute for Doctor-Patient Communication and the medical director of the UPMC Palliative and Supportive Institute. Dr. Arnold has published on end-of-life care, hospice and palliative care, doctor-patient communication, and ethics education. His current research focuses on educational interventions to improve communication in life-limiting illnesses and on understanding how ethical precepts are operationalized in clinical practice.
Conflict of Interest Disclosure
The authors had no conflicts of interest to disclose.
The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
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