Religion and Coping in Late Life
Mrs. D is a 78-year-old widowed woman who recently moved in with her daughter, Mrs. F. Mrs. D comes to see Dr. R for a check of her blood pressure and diet-controlled diabetes. Dr. R has been caring for Mrs. F for many years and is pleased to meet her mother. He finds that unlike her daughter, Mrs. D is considerably more critical of his office staff, waiting time, and the cold temperature of his office. When he brings up the fact that her blood pressure is elevated to 150/100 mm Hg and her finger stick blood glucose is nearly 300 mg/dL, Mrs. D takes notes and asks for his recommendations. Dr. R suggests increasing her dose of enalapril from 10 to 20 mg daily for hypertension and starting her on metformin 500 mg twice daily for diabetes mellitus. Mrs. D thanks Dr. R and tells him that she will pray for him. She tells the office staff, “God bless you,” on her way out.
Mrs. F comes to see Dr. R several weeks later. She tells him that her mother was very pleased with his care. He reports that very few patients have ever offered to pray for him. Mrs. F describes that her father was a Pentecostal minister who served a very large congregation. Her mother is a deeply religious person who has always prayed about every situation in her life. Since moving to a large city from a far more rural area, Mrs. D has found a church and attends services regularly. She is disappointed in her daughter, who has chosen not to continue attending services, but still prays with her every morning.
Mrs. F also suffers from hypertension, but even on a regime of multiple antihypertensives, has difficulty achieving good control of her blood pressure. Dr. R refers her to a nephrologist for consultation.
Mrs. F does not keep her appointment with the nephrologist. Several months later, Dr. R receives an emergency telephone call. Mrs. F suffered a large hemorrhagic cerebrovascular accident. She is in the intensive care unit (ICU) with a very guarded prognosis. Dr. R sees her later that day. Mrs. F is on a ventilator with no spontaneous breathing. She does not respond to painful stimuli. The amount of damage done by the stroke is catastrophic, and the attending neurologist and ICU director feel that she may not survive the next 24 hours. Both specialists remark on the “bizarre behavior” of Mrs. D, who has come in to the ICU with several members of her church singing and praying in a loud voice. The ICU director expresses concern that the group will become too loud and that he may have to restrict their visits.
Dr. R goes out to the waiting area where Mrs. D and her friends are holding hands and praying. Mrs. D is very upset with the doctors in the ICU. She feels they are being disrespectful to her and her church. She tells Dr. R, “My baby grew up singing hymns and praying, and if God is going to take her, she will want to hear our prayers before she leaves us.” Mrs. D asks Dr. R to join them in a prayer for her daughter. Dr. R was taught to respect all religious beliefs but personally has never attended any organized religious services on a regular basis. With some initial discomfort, he joins hands with Mrs. D as the group begins to pray for the soul of her daughter. They sing a hymn, which Mrs. D later identifies as her daughter’s favorite. He realizes how vital this is to both Mrs. D and Mrs. F and indicates that he will find a way for the group to quietly spend time with Mrs. F. Dr. R contacts one of the hospital chaplains.
Older adults are highly likely to associate themselves with an organized religion and to utilize religious coping skills.1 This differs from persons born after World War II, who may have strong spiritual beliefs, but are less likely to identify or describe themselves as members of organized religious groups. Religion and an association with organized religious groups is a strong and positive factor in the lives of many older adults.2 Attendance at religious services and the use of prayer are among the strongest predictors of positive mental and physical health among the elderly.3
Nearly 75% of older adults report engaging in some form of daily prayer.1-3 Most older persons indicate that they would welcome questions regarding their faith and religious beliefs by physicians. This contrasts with surveys of physicians, who often feel reluctant to make inquiries regarding the religious beliefs and practices of their patients.4 Involvement in religious activities has been associated with better health status and health outcomes.5 Older persons who utilize religious coping skills have less heart disease, better control of hypertension, and improvement in immune status.3-5
Involvement in religious activity is a protective factor against suicide in late life. Use of prayer and attendance at religious services is associated with a lower incidence of depression in late life. If these religious older adults develop depression, they achieve remission more rapidly and are less likely to relapse than those who do not report having a religious affiliation.4
Knowledge about the patient’s spiritual history is important (Table).1-3,6 The religious beliefs of family members and caregivers are important as well. Most standard medical interviews include basic questions about religious affiliation. More important for both clinician and patient are questions related to membership in a religious group, attendance at organized services, and the role of religious beliefs in making medical decisions and providing comfort. Questions such as “Do you use prayer in your daily life?” will help the clinician understand the patient’s coping style. Some patients may practice spiritual beliefs but are not involved in organized religion. In addition, some patients may have spiritual beliefs that do not utilize traditional religious practices. The term spirituality is utilized to encompass all religious and spiritual beliefs and practices.1,6,7
Caregivers of older adults benefit from involvement in religious activities. Factors associated with a reduction in caregiver depression and lower rates of complicated bereavement include attendance at religious services, use of prayer or meditation, and placing a high value on religion and spirituality.6 Of interest is that samples of caregivers have shown that 77% report using prayer daily.6 Prayer is the most common mechanism used by caregivers to cope with the stress and demands of providing care. Attendance at religious services, meetings, and activities is associated with more positive mental health among caregivers and an improvement in overall health status.6
Grief and bereavement are significant issues facing older adults. The use of religious coping skills helps the bereaved older adult find comfort and meaning and reduces the morbidity associated with loss.1 Many older adults increase attendance at religious services and activities following a loss. Others may utilize pastoral counseling to deal with their grief. It is important that the clinician become familiar with available pastoral resources in the local community and healthcare facilities. Gaining awareness of religious resources and offering referrals to available clergy is a valuable intervention for the patient and family.2
It is important to note that the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision includes the entity “Religious or Spiritual Problem” as a condition that may be the major focus of clinical need and attention.7 This may include patients who are suffering from a loss of spiritual meaning, are questioning their faith following the death of a loved one, or are undergoing a religious conversion and have difficulty coping with change.
Patients and families welcome the opportunity to share their religious beliefs and practices with clinicians. It is important that the physician offer open communication regarding a patient’s religious or spiritual beliefs and practices.1-3 This is extremely valuable in helping with advanced care planning, identifying coping skills, and promoting positive experiences that overall lead to better physical and emotional health outcomes.
Information on major religions, religious practices, and spirituality is available at the website www.religionfacts.com.
Outcome of the Case Patient
Dr. R called the hospital chaplain’s office and was referred to the minister on call. Reverend B, the minister of a local Baptist church, arrived in the ICU and met with Mrs. D. He joined in singing one of their hymns and promised to return shortly. Reverend B was well known among the hospital staff for his empathic nature and ability to comfort patients and families. He met with the ICU physicians and the nursing staff. Mrs. F was unresponsive, with both pupils fixed and dilated. The ICU attending spoke with Mrs. D about performing the protocol to establish brain death. Mrs. D asked that her daughter be taken off the ventilator. Reverend B arranged for a private room to be made available for Mrs. D and her church friends to be with Mrs. F as the endotracheal tube was removed and the ventilator turned off. Mrs. F passed away with the sounds of her favorite hymn and her mother’s touch on her hands and forehead. Reverend B remained with Mrs. D for several hours as her friends slowly left and she gave her daughter a last kiss.
Dr. R leaves the hospital that night feeling that he must do something to help the hospital recognize and appreciate the spiritual needs of patients and families. He meets with Reverend B and forms a Spiritual Life Committee. Each month, the hospital recognizes a religion, spiritual practice, or form of worship. These are part of a cultural awareness initiative sponsored by the hospital, and each unit is provided with education materials and visits by clergy. Units that participate in the program are acknowledged by the hospital administrator and the monthly newsletter.
Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Avenue @ 16th Street 6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659; e-mail: firstname.lastname@example.org.
1. Daaleman TP, Perera S, Studenski SA. Religion, spirituality, and health status in geriatric outpatients. Ann Fam Med 2004;2(1):49-53. [Erratum in: Ann Fam Med 2004;2(2):179
2. Benjamins MR. Religious influences on preventive health care in a nationally representative sample of middle-age women. J Behav Med 2006;29(1):1-16. Epub 2006 Jan 6.
3. Koenig HG. Religion and remission of depression in medical inpatients with heart failure/pulmonary disease. J Nerv Ment Dis 2007;195(5):389-395.
4. Koenig HG. Religion and depression in older medical inpatients. Am J Geriatr Psychiatry 2007;15(4):282-291.
5. Bekelman DB, Dy SM, Becker DM, et al. Spiritual well-being and depression in patients with heart failure. J Gen Intern Med 2007;22(4):470-477. [Erratum in: J Gen Intern Med 2007;22(7):1066.]
6. Hebert RS, Dang Q, Schulz R. Religious beliefs and practices are associated with better mental health in family caregivers of patients with dementia: Findings from the REACH study. Am J Geriatr Psychiatry 2007;15(4):292-300. Epub 2006 Dec 8.
7. American Psychiatric Association. Additional conditions that may be a focus of clinical attention. In: American Psychiatric Association, eds. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000:739-742.