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Making a Spiritual Assessment

by Susan J. Richardson, RN, MS, CS and Verna Benner Carson, APRN/PMN, PhD
CE249-60 | 1.00 contact hrs

Course Objectives

The goal of this continuing education program is to provide nurses with practical guidelines for performing a comprehensive spiritual assessment of patients. After studying the information presented here, you will be able to:

Compare and contrast spirituality and religion and identify three key areas of spiritual need in patients.
Describe the relationship between spiritual practices and physical health.
Relate two nursing interventions that may be used to address patients’ spiritual needs.

Spirituality encompasses the whole of a person’s being.^1-3 It’s about relationships and connections — to other people, to the community and to God. Spirituality is much like the root word spirit. It’s within us, around us, about us — every aspect of life has a spiritual component. Spirituality does not have a specific face, name or denomination. Spirituality is individualistic, subjective, emotionally oriented and internally unifying.¹ Religion represents our outward actions in response to our spirituality. Religion is the formal expression of God that is experienced in relationships with others through education, worship, fellowship and so forth. Religion wears the face of denominations with their various rules, regulations, creeds, rituals, ceremonies and sacraments. Religion is community focused, objective, oriented to outward practices, and rooted in doctrine.

As nurses, we need to be aware that not all patients requiring care are religious; they may not belong to a faith tradition, they may not attend regular worship services, and yet they may be deeply spiritual. Does this mean that we should not be concerned about religion? Absolutely not!³ In fact, most of the research that exists in this field examines the overwhelmingly positive relationship between religious practices, such as praying and attending religious services, and various outcomes, such as lowered blood pressure, less depression and anxiety, improved coping, shorter hospital stays, ability to resist drug and alcohol use, less death anxiety, increase in positive health behaviors and the use of preventive health services.³

Understanding the importance of religion is essential because, for many individuals, spirituality is expressed through the structure of their faith tradition. Our focus as nurses must be inclusive enough that we recognize and respond to the spiritual needs of those who are not religious as well as those who are.

Reread the scenarios of Opal and John. Opal’s hopelessness is a spiritual need most likely expressed within the structure of her Baptist faith. We don’t know anything about John’s religious beliefs or lack thereof, but we can surmise that perhaps his torment stems from unmet spiritual needs. What then are spiritual needs? How do we assess these needs? And is there scientific data to support this assessment? Let’s start with the research findings.

The Science Behind Spirituality

During the past 30 years, both nurse and physician researchers have sparked renewed interest in spirituality, complementary therapies, and the mind-body connection. In the 1970s, 1980s, and continuing into the 1990s, Herbert Benson, MD, pioneered hallmark research in the power and biology of belief and the positive effects of such practices as prayer and meditation.^4,5 In 1979, the therapeutic effects of using prayer in a psychiatric setting were studied.^{6 (Level B)} In 1986, the relationship of the nurse’s personal sense of spiritual well-being as a predictor of the nurse’s willingness to address spiritual needs of patients was examined.^7-10 Throughout the late 1980s and early 1990s, nurse researchers examined the relationship of hope to spiritual well-being; more specifically, they examined the importance of hope and spiritual well-being to the patient with AIDS and the relationship of spiritual well-being as a predictor of hardiness in the AIDS patient.^{11 (Level B)}

In 1988, a physician researcher performed a double-blind study to evaluate the effects of remote intercessory prayer on the clinical outcomes of a coronary care population. He found that patients who received daily intercessory prayer suffered from significantly fewer complications during their hospital course, evidenced by the need for less ventilatory assistance and fewer antibiotics and diuretics than those without prayer.^{12 (Level A)} In 1999, a team of investigators replicated the study with similar results.¹³ In 1993, researchers followed 700 cardiac patients in a Veterans Administration hospital over a 30-month period. Those who received daily visits from a chaplain left the hospital an average of three days earlier than those who saw the chaplain only for a few minutes during their hospital stay. Study author Elizabeth McSherry, MD, MPH, former associate professor of clinical pediatrics at the University of California, San Francisco, and affiliated with the National VA Cost Effectiveness Center, Boston, estimated that the provision of a daily chaplain visit (at a total cost of $100) saved the hospital about $4,000 per patient.^{14 (Level B)}

Several longitudinal studies have also demonstrated the positive effect of certain spiritual practices on overall physical health and longevity. A six-year study by a multidisciplinary team looked at the question, “Does religious health prolong survival?” Team members surveyed a probability sample of 3,968 community-dwelling adults, ages 64 to 101 years, in the Piedmont area of North Carolina. At the end of the study, fewer than 23% of those who were initially categorized as frequent attendees (going to religious services once a week or more) had died, as compared with 37% of those classified as infrequent attendees (going to religious services less than once a week).¹⁵ ^{(Level B)}The lead researcher, Harold Koenig, MD, led a similar investigation of a group of 3,963 elders regarding the relationship between religious attendance and prayer or Bible study with hypertension. Cross-sectional analysis revealed small but consistent reductions in both systolic and diastolic blood pressure for those who frequently attended religious services, compared with those who attended services on an infrequent basis.

Similarly, those who prayed or studied the Bible on a daily basis experienced small but significant decreases in both systolic and diastolic blood pressure, compared with those who prayed or studied the Bible less often. For those subjects who both frequently attended religious services and participated in daily prayer or Bible study, the likelihood of having a diastolic blood pressure of 90 mm Hg was 40% lower than for participants who practiced these spiritual disciplines on a less frequent basis.¹⁵

In 1998, researchers assessed the relationship between intrinsic religiosity and the remission of depression in medically ill older adults. Intrinsic religiosity was measured by a scale, validated through two earlier studies that consisted of 10 statements about religious belief or experience. Depressed patients with high intrinsic religiosity scores had more rapid remission than patients with lower scores. A 2007 study investigated 1,000 patients over the age of 50 with CHF/CPD who were systematically diagnosed with depressive disorder using a structured psychiatric interview. Of the 1,000 depressed patients identified at baseline, follow-up data on depression course was obtained on 87%. Patients who attended religious services and participated in other group related religious activity experienced shorter time to remission.^18-20

Several studies have demonstrated that religious beliefs or practices can enhance one’s ability to cope with the stresses associated with illness, particularly in an older population.²¹ In fact, in certain parts of the U.S., nearly 90% of medical patients report that religious beliefs and practices are important ways that they cope with and make sense of physical illness, and more than 40% indicate that religion is the most important factor that enables them to cope.²¹

One study investigated 5,000 Israeli men and women age 60 and older from 1997 through 2004, during which time 38% had died. The death rate was 75% higher among the group that did not attend synagogue compared to those who attended synagogue regularly.²² In studying the rate of cognitive decline in Alzheimer’s disease, investigators assessed 70 subjects with probable AD and MMSE scores of 10 or higher for cognitive function over 12 months. The researchers found a significantly slower rate of cognitive decline in subjects scoring higher on self-reported spirituality and private religious practices.²³

Critical to Promoting Spiritual Care

Prior to assessment, acknowledge the sensitive and personal nature of spirituality and religiosity to the patient.
Complete a basic spiritual assessment for all patients and a more detailed assessment when spiritual distress is observed or reported.
Recognize that an effective spiritual assessment is a process that is ongoing and one that evolves as a trust develops between the nurse and the patient.
Take advantage of interactions during physical assessment and procedures to evaluate a patient’s spiritual state and needs.
Remember there is no single approach to spiritual care — individual and cultural diversity must be considered for interventions to be meaningful and effective.
Recognize that family; significant others; and care providers, including you, suffer spiritual distress and can benefit from spiritual assessment and support.

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What Are Spiritual Needs?

Human beings have a need for meaning and purpose.^1,2,24 What makes life worth living? What is sacred? Some patients find meaning in the roles they fill. For these patients, a spiritual crisis may occur when physical illness leaves them unable to work or assume usual roles within their families or communities.

Human beings also have a need for love and belonging^1,2,24 that is reflected in the way they relate to themselves, significant others, and God or a higher power. Illness can have a profound effect on these relationships. For example, do your patients accept themselves as worthwhile beings? Has this been altered in any way by their current illnesses or conditions? How do they relate to family, friends and members of their community (religious or secular)? How has illness affected those relationships? How do they relate to God in everyday life? What role do they believe God plays in illness? Is God disinterested? Does God use illness to test or to punish? Does God have power over illness? Can God heal? Just as important, is God willing to heal?

Acute illness often sparks a need for forgiveness or reconciliation in patients.²⁵ For some, a need to accept their own functional limitations emerges from illness. For others, a need to reconnect with family members or estranged close friends becomes paramount. A patient with AIDS once commented, “Since I have been ill, I can no longer afford to hold onto grudges.” Others need to “forgive” God for allowing illness or disability to happen to them. Patients often comment, “I was a good person. What have I done to deserve this?”

Profiling the Spiritual Dimension

Although several assessment tools have been developed, we can easily assess patients’ spirituality in the context of daily patient care by carefully attending to the patient’s verbal and nonverbal communication. One may comment, “I feel useless since I’ve been ill,” or may ask, “Is God punishing me?” Another may make judgmental statements, such as “I just need to have more faith.” Still others may make statements indicating a wish for death, such as “My family would be better off without me” or “I pray every night that God will take me.”^1,2,21,24

Some patients will ask for a visit from clergy or to participate in spiritual practices or rituals that are especially meaningful to them. Some may request religious objects or books.

Even when patients do not volunteer the information, many believe that their healthcare providers should ask about the role of spirituality in their lives.^1,2 Questions such as “Is God or spirituality important to you?” may open the door to further dialogue. For patients who seem to be having difficulty coping with their illness, you may ask, “What bothers you the most about being sick?” or “What helps the most when you feel afraid or need special help?” For those who indicate the importance of faith or spirituality in their lives, it may be appropriate to ask, “Is prayer or meditation important to you?” or “What happens when you pray?” or “Has being sick changed your feelings about God or the practice of personal spiritual practices?” The purpose of asking these questions is to obtain an accurate religious history to provide the most holistic care possible. In no way should we attempt to convert patients or coerce them into talking about spirituality. We are also advised to ask patients if religion is a way they cope with health problems. If they say no, do not force a discussion on spirituality.^1,2,24

Observing your patient’s behavior can provide insight into the presence of spiritual needs. A patient who is constantly on the call bell may be afraid of being left alone or dying while asleep. A patient, whose pain, anxiety or insomnia remains unchanged or worsens, even after appropriate medication is given, may be suffering from spiritual distress in which he or she feels abandoned by God or loved ones. Be especially sensitive to patients who deny feelings of sadness, depression, or anger, while displaying these emotions through nonverbal communication.

Making the Assessment

A variety of subjective and objective data may indicate the presence of a spiritual need. Some patients will verbalize anger, sadness, blame or hopelessness in their relationships with God, self or others. Some will be unable to participate in spiritual practices that are meaningful to them. These may include private experiences, such as prayer or public worship. Still, others will identify a conflict between their spiritual beliefs and the reality of their current physical condition (e.g., a terminal patient who believes God always heals) while some patients will be unable to fulfill a role that normally brings spiritual fulfillment and meaning (e.g., a mother who is unable to care for her children).^1,2,21,24

Culture plays a significant role in the expression of spirituality and in turn, both play a significant role in healthcare. For instance, cultural beliefs may include spiritual explanations for the causes and treatment of illnesses. Some cultures believe that the human soul can be lost, dislodged or captured as a result of a traumatic experience or witchcraft. Cultural factors also affect the perceived need for health services. For instance, Italians and Jewish people more readily recognize and express somatic concerns than those of Irish and English descent, who tend to minimize or deny symptoms.

FICAA

FICA was developed by Dr. Christina Puchalski, founder and director of The George Washington Institute for Spirituality and Health.

F — Faith and Belief. Do you consider yourself spiritual or religious? Or do you have spiritual beliefs that help you cope with stress? If the patient responds “No,” you might ask, “What gives your life meaning?”

I — Importance. What importance does your faith or belief have in your life? How have your beliefs influenced how you take care of yourself in this illness? What role do your beliefs play in regaining your health?

C — Community. Are you part of a spiritual or religious community? Is this of support to you? If so, how? Is there a group of people you really love or who are important to you?

A — Address in Care. How might we address your spiritual needs?

Source:Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med.2000;3(1):129-137.

The Plan

All members of the treatment team can help meet patients’ spiritual needs. Patients who have trouble believing that God cares may take great comfort when members of the healthcare team demonstrate that they care.

Responding to spiritual needs is a form of ministry — the heart of which is service, comfort, relief of pain, healing and support when healing is not possible.¹ According to researchers, there are three types of ministry: ministry of presence, ministry of word and ministry of action.^1,2 Ministry of presence requires more than just showing up when someone is sick or standing by the bedside, although these actions are important. To fully demonstrate the ministry of presence, we need to be active listeners to demonstrate empathy, humility, vulnerability and commitment.

Active listening is a learned skill that involves hearing, not just the words being spoken but also those that are not spoken. Frequently, people hint at their real concerns and openly reveal them only when we go beyond their words to their feelings and the deeper meaning behind their communication. This requires that we develop sensitivity to our internal barriers to active listening. These barriers include our own anxiety and personal defenses, judgments about patients and their behaviors, and the fact that words can have many meanings and differing interpretations and can build walls instead of bridges.^1,2

Ministry of word requires great sensitivity to the patient’s belief system. Words are incredibly powerful. They can be life giving or they can be destructive, so care must be used in choosing what to say. Included in this ministry are:

Having a willingness to discuss spiritual/religious issues
Giving verbal support and encouragement of spiritual beliefs
Making a referral to a chaplain or pastoral care professionals
Using religious literature
Using prayer

The act of taking a spiritual history or assessment is really the first aspect of this form of caring. The very act of engaging in a conversation about spirituality conveys to the patient and family that we are willing to discuss spiritual/religious beliefs and issues. This initial spiritual conversation may very well lead to other opportunities to talk about the impact of spiritual matters on the patient’s current health-situation issues, such as how the patient will cope, what impact this health crisis will have on the patient’s sense of purpose and meaning in life, what adaptations or changes need to be made to accommodate the current health problem, and what difficult choices face the patient/family. Every one of these issues is spiritual in nature. We may not have the answers, nor is it necessary to. Even if we believe we have the answers, it is usually best to encourage the patient and family to talk openly about these issues until they are able to arrive at their own answers.¹

The third ministry, that of action, refers to how we do what we do. The simplest acts are capable of conveying a powerful message of love and concern. The following example from a nurse demonstrates this:^1,2

There was a nun at the far end of our unit; I didn’t usually take care of her. No one wanted to take care of her. Everyone thought she was going to die, and she wasn’t the easiest person — kind of crotchety and grouchy. Anyway, one day we were short-staffed, and I was asked to take Sister’s medicine to her. I was told to take along applesauce to make it easier for her to take her pills. I did that, and when I was done, I offered her a glass of cold water, for which she seemed grateful. I never took care of her again. Two years later, I saw this very tiny nun walking toward our nurse’s station — it was Sister. She said, “I know that voice! Where is she? (I have a slight Boston accent, or so I am told.) Sister came up to me and hugged me. She said, “You gave me the glass of cold water. That was the kindest thing anyone did for me, and I have never forgotten it.” Can you believe that a glass of water could be that powerful?²⁶

Stoll Model

Considered a classic model that suggests four areas for spiritual assessment:

The patient’s concept of God or deity
Sources of hope and strength
Religious practices
The relationship between spiritual beliefs and health

Source: Stoll RI. Guidelines for spiritual assessment. Am J Nurs. 1979;79(9):1574-1577.

The Evaluation

The evaluation of spiritual interventions is done by listening to what patients say and by observing patient behaviors. For instance, patients may state that they feel better, more at peace or less anxious than before. Patients may be more responsive to or need less medication. Patients may become more cooperative with therapy and other treatments and may use the call bell less often. Any intervention that works should be added to the patient’s care plan.

Special Considerations

According to standards issued by The Joint Commission, a spiritual assessment should at least ascertain a patient’s religious preference, beliefs and any spiritual practices. The assessment must be documented in the patient record. The Joint Commission requires a spiritual assessment on all patients admitted to a general hospital, all psychiatric patients, patients in long-term care and patients receiving home care services. However, there are no rules or processes that specify how the assessment is recorded.²⁷

According to The Joint Commission standards, certain patients require a more comprehensive assessment. These patients include those receiving care at the end of life, parents who have experienced fetal demise, patients receiving treatment for emotional or behavioral disorders and those receiving treatment for alcohol or drug dependence.²⁷

In a recent study, inpatients in a psychiatric unit expressed frustration at their inability to convey to us the religious confusion they were experiencing in the midst of psychosis. They felt that by using God, spirituality or religion as a way to cling to reality, they were usually misunderstood and labeled as religious fanatics or characterized as delusional.^2,28However, it’s just as appropriate for patients who are in the midst of a psychiatric crisis to turn to God or other spiritual resources as it is for patients who are experiencing medical illness. In such cases, a complete spiritual assessment followed by appropriate intervention is an essential part of good patient care.

However, appropriate spiritual fears and concerns need to be distinguished from frank religious delusions. A delusion is a fixed personal belief held despite what the general population considers to be irrevocable evidence to the contrary.²⁹ A classic example is the patient who believes that he or she is Jesus Christ. In such cases, the spiritual assessment may need to be modified or delayed until the patient is more stable. The reason for the modification or delay should be noted in the patient’s record.³⁰

End-of-life issues present unique spiritual challenges for us as well as for patients. Edwin Cassem, MD, a psychiatrist and Jesuit priest who chairs Massachusetts General Hospital’s Optimum Care Committee, states his perspective on caring for the critically ill: “Sometimes the drama opens up a person’s soul. The final days of life are a time to search for meaning, and it’s the job of caregivers to draw that meaning out.” Cassem believes that we, as bedside nurses, have a unique opportunity to perceive the spiritual implications of the situation that are unlikely to be captured in the medical record. “Nurses never escape the emotional reality,” he says. “If there is hope, they will pick it up; if there is a sense of hopelessness, they will pick that up, too.” Because Cassem believes that faith is particularly important to people who are at the end of life, he regularly asks dying patients about their faith, how they see God, and God’s involvement in their illness.

Different religions bring unique issues to bear on end-of-life decisions. For example, for followers of Japanese Shintoism, the human body is a gift of the gods that must be treated with respect. For a person’s reincarnation into the next life, the body from the previous life must remain intact. Therefore, organ transplantation is thought to bring unnecessary harm to the body. Some Japanese Buddhists also believe that prolonging a life through the use of organ transplantation is a reflection of human attachment to life, which violates Buddhist principles.³¹

Simple truth telling can create conflict between us and the family members of a dying patient. For example, some Buddhists and Hindus believe that people need to enter the reincarnation phase in a peaceful state. They believe that telling patients the truth about their terminal condition may result in inner conflict for patients, interfering with their ability to pass on to the next life. Family members may be at odds with us as Western medical professionals who believe that patients have a right to know the full truth of their prognosis. All members of the treatment team need to understand the wishes of patients and their family regarding these issues.³²

Be Aware of Your Own Spirituality

Before attempting to make a spiritual assessment of patients, we need to examine our personal spiritual history, beliefs and practices. Do you believe in God or a higher power? What role, if any, do spiritual practices play in your life? What do you believe is the relationship between spirituality and illness or between spirituality and health? What happens after death? When are a patient’s basic beliefs or practices in conflict with what you believe or practice?^1,2

It’s important that you be especially cautious if you have had a negative experience with a particular religious tradition in the past. Spirituality is often a relationship between an individual and his or her God. No one is in a position to judge the nature or the quality of that relationship. It’s important that we acknowledge our own limitations. If we are uncomfortable with our personal spirituality, it may be difficult to help patients with spiritual issues. In cases such as these, the most therapeutic intervention is to refer the patient to a colleague or a religious professional.

Assessment of the spiritual needs of patients is a vital component of holistic nursing care. Patients commonly need meaning and purpose, meaningful relationships, and reconciliation. We can identify these needs from objective and subjective data. There’s no guarantee that we will solve every spiritual problem identified, but our presence, compassion, hopefulness, and recognition that the individual’s life has meaning provides spiritual comfort that promotes hope and healing.¹

References

1. Carson VB, Koenig HG. Spiritual Caregiving: Healthcare as a Ministry. Philadelphia, PA: Templeton Foundation Press; 2004:19-20.

2. Carson VB, Koenig HG. Spiritual Dimensions of Nursing Practice. Rev. ed. Philadelphia, PA: Templeton Press; 2008.

3. Koenig H, King D, Carson VB. Handbook of Religion and Health. 2^nd ed. New York: Oxford University Press; 2011.

4. Benson H, Stark M. Timeless Healing: The Power and Biology of Belief. New York, NY: Fireside; 1996.

5. Carson V, Huss K. Prayer: an effective therapeutic and teaching tool. J Psychiatr Nurs Ment Health Serv. 1979;17(3):34-37.

6. Soeken KL, Carson VJ. Study measures nurse’s attitudes about spiritual care. Health Prog. April 1986;67(3):52-54.

7. Carson VB, Soeken KL, Grimm PM. Hope and its relationship to spiritual well-being. J Psychol Theology. 1988;16(2):159-167.

8. Carson V, Soeken KL, Shanty J, Terry L. Hope and spiritual well-being: essentials for living with AIDS. Perspect Psychiatr Care.1990;26(2):28-34.

9. Carson VB, Green H. Spiritual well-being: a predictor of hardiness in patients with acquired immunodeficiency syndrome. J Prof Nurs.1992;8(4):209-220.

10. Carson V. Prayer, meditation, exercise, and special diets: behaviors of the hardy person with HIV/AIDS. J Assoc Nurses AIDS Care. 1993;4(3):18-28.

11. Byrd RC. Positive therapeutic effects of intercessory prayer in a coronary care unit population. South Med J. 1988;81(7):826-829.

12. Harris WS, Gowda M, Kolb JW, et al. A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Arch Intern Med. 1999;159(19):2273-2278.

13. McSherry E. The scientific basis of whole person medicine. J Am Sci Affiliation. 1993;35(4):217-224.

14. Koenig HG, Hays JC, Larson DB, et al. Does religious attendance prolong survival? A six-year follow-up study of 3,958 older adults. J Gerontol A Biol Sci Med Sci. 1999;54(7):M370-M376.

15. Koenig HG, George LK, Hays JC, Larson DB, Cohen HJ, Blazer DG. The relationship between religious activities and blood pressure in older adults. Int J Psychiatry Med. 1998;28(2):189-213.

16. Koenig HG, George LK, Peterson BL. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry.1998;155(4):536-542.

17. Koenig HG. Religion and remission of depression in medical inpatients with heart failure/pulmonary disease. J Nerv Ment Dis.2007;195(5):389-395.

18. Koenig HG, Kvale JN, Ferrel C. Religion and well-being in later life. Gerontologist. 1988;28(1):18-28.

19. Matthews DA, McCullough ME, Larson DB, Koenig HG, Swyers JP, Milano MG. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med. 1998;7(2):118-124.

20. Isaia D, Parker V, Murrow E. Spiritual well-being among older adults. J Gerontol Nurs. 1999;25(8):15-21.

21. Koenig HG. Spirituality in Patient Care: Why, How, When, and What. 2nd ed. Philadelphia, PA: Templeton Foundation Press; 2007.

22. Litwin H. What really matters in the social network–mortality association? A multivariate examination among older Jewish-Israelis. Eur J Aging. 2007;4(2):71-82.

23. Kaufman Y, Anaki D, Binns M, Freedman M. Cognitive decline in Alzheimer’s disease: impact of spirituality, religiousness, and QOL.Neurology. 2007:68(18):1509-1514.

24. Shelly JA. Spiritual Care: A Guide for Caregivers. Downers Grove, IL: IVP Books; 2000.

25. Ferrell BR, Coyle N, eds. Textbook of Palliative Care Nursing. New York, NY: Oxford University Press; 2001.

26. Carson VB, Koenig HG. Spiritual Caregiving: Healthcare as a Ministry. Philadelphia, PA: Templeton Foundation Press; 2004:108.

27. Spirtual assessment. The Joint Commission Web site. http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=290&ProgramId=1. Updated November 24, 2008. Accessed January 23, 2012.

28. Moller MD. Meeting spiritual needs on an inpatient unit. J Psychosoc Nurs Ment Health Serv. 1999;37(11):5-10.

29. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Publishing Inc; 2000.

30. Stein C. Ending a life: as a woman lies unconscious in the burn unit of Massachusetts General Hospital, her daughter faces the hardest question: is it time? The Boston Globe. March 14, 1999;12.

31. Andresen J. Patient Care for Japanese, Korean and Indian immigrant populations. Paper presented at: Healing and Spirituality: Ethics and Diversity Conference; March 24, 2000; Boston, MA.

32. Matzo M, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life. NewYork, NY: Springer; 2001.