Code Krishna: An Innovation to Synthesize Spirituality in the Intensive Care Unit during End of Life Moments

Article by

B. Vaishnav

S. Nimbalkar

S. Desai

S. Vaishnav

Abstract

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.

 

Introduction:

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.[1]

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.[2]

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.[3] 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.[4]

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.[5]

 

Results:

  • 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.

 

Discussion:

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.[6] 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.[7]

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.[8]  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[9] 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.[10]  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.[11]

There is an international trend toward collaboration with traditional health systems.[12]

 

Conclusion:

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.[13]

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.

 

Acknowledgements:

We would like to thank Dr. Amee Amin (BSc, MBBS) for editing this manuscript.

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