Code Krishna: An Innovation to Synthesize Spirituality in the Intensive Care Unit during End of Life Moments
Innovation: Code Krishna is an innovative healthcare practice, aimed at introducing a culturally relevant fabric comprising of collective prayer, ﬂoral tribute and observation of silence in a solemn atmosphere at the bedside of a deceased patient, by the healthcare team along with family members. The prayer is religion-speciﬁc and is either recited by the team or played on an audio device. Constructs: The spiritual view of human existence states that life and its experiences do not end with death; the body is a sheath of the inhabiting soul. We believe that creating a solemn atmosphere around the departed individual, in a busy critical care unit, facilitates the ‘journey beyond’ to a state which transcends mortality. Secondly, every human being reaches out for wider, deeper dimensions of existence which stem from religious-cultural-spiritual beliefs, that form a stable platform to bear the loss, from a philosophical perspective. Context: In an era of impersonal healthcare, dignity of death is a casualty. The near and dear ones also are beset with emotional and physical exhaustion. We believe that the depersonalization of a technology driven medical care aﬀects the grieving process in a negative way. Contribution: Code Krishna attempts to blend current care practices with spirituality in a tangible process, and ensure that the ﬁrst commiserations to the grieving family are oﬀered by the treating team with warmth and openness. This also opens the communication channels between the family and the medical team, to facilitate the grieving process in a comforting way. This innovative practice serves the non-materialistic yet tangible and deeply rooted beliefs of the society we serve. For the medical institution, Code Krishna enables development of human centric competencies for its employees, as well as de-stressing of the ICU staﬀ. The spontaneous feedback received from family members of the patients has been enormously gratifying.
Clinicians provide treatment encompassing surgical and medical care, and healing of disease which induces illness and suﬀering. Clinicians are trained with an emphasis on the biophysical model of health as per the modern health care system that most of the world follows. The current system pays little attention to other aspects of health such as mental and spiritual health, although it is even mentioned in the WHO deﬁnition of health.
Patient-centered care is deﬁned as “care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient’s values guide all clinical decisions.” Patient centered-care encompasses the “individual experiences of a patient, the clinical service, the organizational and the regulatory levels of health care.” At the individual patient level, patient-centered care is care that is provided in a respectful manner, assures open and on-going sharing of useful information in an ongoing manner and supports and encourages the participation of patients and their families.
The present paper describes few metaphysical and practical points pertaining to the innovation of Code Krishna described earlier. Among a cohort of surrogate decision makers with a high degree of religiosity, discussion of religious and/or spiritual considerations occurred in fewer than 20% of goals-of-care conferences in the ICU, and health care professionals rarely ventured to explore the patient’s or family’s religious or spiritual ideas.
Although a healing experience is necessary at every stage of an illness, its necessity is urgent in moments of death since the loss of wholeness and connectedness experienced by the bereaved family is acute and intense. A clinician is placed in a unique position to give a healing experience by helping an individual ﬁnd deeper meaning in existential issues of life and death. Since this is not part of the conventional care paradigm, it is necessary and even ethically demanding to turn to resources, which provide a healing experience for fulﬁlling one’s professional obligations. Incorporation of a spiritual dimension is of great relevance in situations where medical treatment reaches an endpoint, with life in its biological form ceases to exist.
The concept of care tenor needs to be used which is deﬁned as the attitudes and behaviors of those interacting with the patient so that the patients value and dignity is upheld. This includes physical, emotional as well as spiritual care-tenors. Physical care tenor is aimed at enhancing physical comfort; emotional care tenor is aimed at providing emotional support to patients and to treat all patients with compassion. Spiritual care tenor aims to provide access to spiritual support to patients and has been perceived as a very vital factor in fostering patient dignity and support to culturally driven wishes of patients and their families in end of life situations.
Aims and Objectives:
Code Krishna was designed to address speciﬁc objectives (i) to create an atmosphere of calm and quietness surrounding the death of the patient and to express a respect for the cultural and spiritual beliefs of the family in the moments of death (ii) to sensitize the treating team about the need to address the grief of the relatives of the deceased patients.
Intervention and Results:
Code Krishna is a set of actions performed by the treating team, that attempts to provide a culturally and spiritually appropriate milieu for the emotional support of the aggrieved family. Simultaneously, it oﬀers respect and homage to the departed soul at the very site where the body- covering of the soul has ceased to exist. The ‘outward’ or ‘visible’ or ‘action items’ are various components of the practice that include assembly of the members of the treating team at the bedside of the expired patient, oﬀering a tribute of ﬂowers, by the team members and patient’s relatives, on the body of the deceased and observing a moment’s silence after reciting a prayer. The selection of the prayer is done keeping in mind the religious faith of the family. The ‘inward’, or the ‘non-visible’ components which constitute this practice are a sense of respect for the deceased, a sense of sharing grief with the bereaving family, a respectful attitude or invocation to a Divine Presence for the welfare of the departed soul and healing of the bereaved family, all these carried out in a solemn environment and ‘silent space’ within the often-intense environment of the ICU.
Creating a milieu by the medical team to enable the bereaved family to ﬁnd the philosophical aspect and spirituality of death in this moment of grief is the very purpose of this ennobling practice, named ‘Code Krishna’. It is aimed at shortening the period of grief and helping the bereaved family transition to a more stable or tolerable mental stage.
Code Krishna was expected to fulﬁll the needs of the caregivers. While atheism is on the rise in the west with God often being excluded from the socio-cultural environment, it is noted that in India, God in various forms and all religions remains central to the socio-cultural ethos. A related but unpublished study by the author showed that 99% of a patient’s parents in pediatric wards turned to prayers when their child was admitted and that they believed that prayers were important in the curative process. This conﬁrms our belief that Code Krishna will be well received by Indian patients.
Code Krishna also allows the treating physician and the patient/caregivers to come to a common platform to seek succour in the spiritual tenor. This humane commonality between doctor and patient and extending solace in this plane does the job of comforting to all involved. The practice enables one to turn to inner means of healing, founded in spirituality and not otherwise found in conventional care. Bernie Siegel, the author of ‘Peace, Love and Healing’ talks about disengagement from patients. He discusses how professionals today know “how to treat but have forgotten how to heal.” Elaborating further, he says a professional is either a non- healer or an untrained healer, i.e. one who does not know how to communicate and empathize. Still worse is a hurtful healer, who not only disengages from the patient abruptly, but also traumatizes the family.
As our experience with Code Krishna is growing, we realize that the practice oﬀers a unique means of inner healing to the bereaved family as well as the healthcare professionals. Despite the growing importance of spiritual care, the need for the delivery of spiritual care still is an area of disagreement among various healthcare providers. The “trust building” theory can be used as a guide for describing and expanding nurses’ roles in spiritual care delivery, developing care documentation systems and clinical guidelines, and planning educational programs for nursing students and staﬀ nurses.
- From the perspectives of family members: No formal feedback from family members of the deceased patients have been obtained. However, the spontaneous feedback received from family members of the patients has been encouraging. Relatives have felt that the practice provides the much-needed humane touch in this era of technology-laden medicine and the solace it oﬀers far exceeds expectations. “My grief vanished” and “respect to the departed has always to be like this” are some of the statements made by family members.
- Perspectives from health professionals: The practice of Code Krishna enables development of human centric competencies for its employees as well as de-stressing of ICU staﬀ. It is recognized to serve the non-materialistic yet tangible and deeply rooted needs of the society in moments of death. One doctor who observed this practice in a brain-dead patient mentioned that he had no words to express the fullness and connectivity that this practice gave him. Many nurses have cried during the Code Krishna practice and this has helped in establishing a bridge with the family members during the profoundly painful moments surrounding death, and has created a distinctly peaceful environment which transcends time and pain!
- From the institutional perspective: the practice conveys the institution’s commitment to value-based humane care, synchronous with local cultural and spiritual beliefs.
As our experience with Code Krishna is growing, we realize that the practice oﬀers unique means of inner healing not only to bereaving family members but also to the involved healthcare professionals. We have documented in a study (unpublished) that 100% of family members of patients admitted to an ICU believe in God; their reliance in God surpasses the faith they have in other individuals, family members and even that in the doctors. As they pray intensely to God more so during the end of life moments, they would also appreciate if the doctors would join in the prayers. Praying together with patient’s relatives oﬀers a common platform of oneness and solidarity, which may help in decreasing some grief. This practice also serves to bring the healthcare professionals and families closer and this could possibly bring about a reduction in verbal abuse towards doctors, a phenomenon that is on the rise.
If we accept the concept of health as encompassing physical, mental, emotional, social, and spiritual dimensions, then as healthcare professionals we are expected to address all these dimensions. It is a well-recognized responsibility of health care professionals to provide support and care to grieving families. It is known that clinicians fall short of this obligation most of the time. Benjamin et al have reported that oncologists rarely participate in bereavement rituals mainly due to time constraints, attitudinal issues or other factors. Medical professionals entail care which is meant to treat and extend life. Hence, end of life is sometimes seen as a defeat or in the least as the termination of the doctor-patient relationship. However, socio-cultural beliefs often involve the belief that life extends beyond death in most cultures. Whatever may be the personal beliefs and attitudes of the healthcare professionals, it should be considered as an extended aspect of the relationship with the family and/or departed individual. As every healthcare professional may not have the ability and the aptitude to perform this aspect of care, it might beneﬁt those that lack this capability to have a set protocol for the ritual for guidance.
Our model of Code Krishna is unique in the fact that it ensures a semblance of care to the departed soul (for the believers) while at the same time improving the grieving process for the family that has been bereaved.
Our model is also unique in that it does not rely on inﬂuences that are external to the hospital environment. Traditionally, it is observed that the responsibility of providing healing care and emotional support has been entrusted to spiritual caregivers such as chaplains in hospital settings to traditional healers in the community. This practice of Code Krishna has helped with the bereavement process of the family. It has also been shown to have beneﬁcial eﬀects on caregivers who may have been stressed or may have formed strong emotional bonds with the deceased. Intensive care units are known to have high burnout of nurses and physicians due to death occurring on a regular basis in their ﬁeld of care. The processes that we have evolved may have long term implications in reducing these stressful outcomes in our staﬀ.
Individuals who deal with death frequently, as a part of their regular work or otherwise, must ﬁnd ways to make sense of dying and death. While most of the staﬀ may view the care of the dying as just one part of their duty to rationalize the event, it can lead to disenfranchised grief and preclude them from developing the appropriate attitude that the event of death demands. Beneﬁts of practices of grief management to the treating team have been documented in addition to the same for bereaved family. Such practices help the treating team to overcome their own suppressed grief, reﬂect on the meaning of life, prevent desensitization of death, help to improve the ability of providing compassionate care, and create an assurance among relatives about institutional commitment for value-based humane care.
The present work is aimed at reaching out to family members of deceased patients through a practice which honors the varied religious and cultural traditions and supports them in their moments of grief. Across various religions there are several beliefs that have a common ground. The Hindus believe that while death is the end of the physical covering of the body, the soul is eternal, and it moves on to a new cycle. This view of the atman or soul is important as it has a diﬀerent ending from that of the physical form. The atman may unite with the paramatma and achieve moksha which is the highest desired outcome for a Hindu while the less desirable outcome would be rebirth as a diﬀerent entity. Both outcomes for the soul suggest longevity beyond what the physical form oﬀers, and this concept allows relatives to grieve appropriately. Christians believe that death is the beginning of an everlasting life with God. It is essential for an individual who is dying to undergo the ﬁnal rites for salvation of the soul. Here too death is not a ﬁnality but instead a step towards eternity.
There is an international trend toward collaboration with traditional health systems.
In the light of our experience with ‘Code Krishna’ we hope that hospitals consider this practice and use it widely, after appropriate modiﬁcations to suit local cultures and customs. Dying should involve not only spiritual healers but the entire hospital team. It is important to recognize the role of the treating team of medical staﬀ to ensure success and so the team members need to be sensitized to the need, appropriately trained and mentored. The staﬀ needs to move beyond their own zone of comfort and make the eﬀort to improve the quality of spiritual health of all involved.
Helping, ﬁxing, and serving represent three varied ways of seeing life. When you help, you see life as weak. When you ﬁx, you see life as broken. When you serve, you see life as whole. Fixing and helping may be the work of the ego, and service, the work of the soul.
Lessons learned: Accepting collaborative wisdom of medical and humanistic sciences enriches standard care with attitudes which nurture healing. The previous feeling of discomfort and pain present when a patient has expired has been replaced by a feeling of understanding that the soul passes on, which is more in context with the religious-socio-cultural ethos of India; thus, making it acceptable to all relatives and staﬀ.
Based on our experience, we intend to move a step further in designing a protocol called ”Extended Code Krishna protocol”; which will oﬀer spiritual tenor of care throughout the period of terminal illness and thereby provide the healing touch to our patients, in the sometimes depersonalized, technology savvy medical world.
We would like to thank Dr. Amee Amin (BSc, MBBS) for editing this manuscript.
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