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If you have not already done so read the following case study which was presented earlier in Section 1, and identify what issues this raises in relation to personal belief and professional practice.

Case study 5: Who knows best?

A young woman is brought into the accident and emergency department with a massive gastrointestinal bleed presumed to be oesophageal varices. Immediately the medical and nursing teams start to resuscitate the woman and the consultant asks for four units of blood to be transfused. However, the woman interrupts and states that she does not want the blood transfusion because of her personal beliefs. Therefore other volume-expanding agents have to be used. Unfortunately the woman dies from the haemorrhage several hours later. Talk around the department is ‘if only the woman had not refused a blood transfusion’. Others say ‘what a waste of life’. Yet the woman’s husband says ‘God’s will was done and she approached death as she believed was right’.

This case study raises some important issues about the relationship between personal beliefs and professional practice. In this situation the apparent loss of life was deemed a waste. However, this is the health care professional’s interpretation of the apparent loss of life from their specific world view and not from that of the individual. We need to be aware of imposing our own world view upon others and strive to be more receptive and sensitive to their needs. This requires self-awareness on our part as carers.

Crucially this case study emphasises the importance of individual choice, consent and the right to refuse treatment. Within nursing and health care we may adopt a paternalistic attitude to care, thinking we know what is best for the individual.

This case study highlights the importance of self-awareness, sensitivity to individual need and the dangers of imposing our own world view upon others. Case Study 6 will enable you to explore these issues further.  

Case study 6: In whose interest?

Mr Francis was admitted to the ward having suffered a very dense left-sided CVA (cerebrovascular accident, or stroke). For two days he was deeply unconscious and unresponsive, and was given intravenous fluids for hydration. Several days passed and slowly Mr Francis gained consciousness and became more alert. Prior to admission he had been a very active man who had had an excellent quality of life, free of any major illness or hospitalisation. Mr Francis’ wife and family stayed with him and supported him throughout the acute phase of the illness. Mr Francis’ condition improved, and the process of rehabilitation was initiated. It soon became apparent that Mr Francis was aphasic, having a marked dysphagia.

It was decided by the medical and nursing staff, in consultation with Mr Francis and his family, to pass a fine bore nasogastric tube and to commence enteral feeding. However, Mr Francis showed dissatisfaction with this by pulling out the tube. Again the tube was passed, and again Mr Francis pulled out the tube, to the displeasure of his family.

The nurses and consultant caring for Mr Francis discussed the matter with him, and it emerged that he did not want to be fed. However, when his family were present he would change his mind in an attempt to keep the peace. Mr Francis’ family was rightly concerned that he would possibly starve to death, and asked for a gastrostomy tube to be inserted. Mr Francis agreed and consented to have the procedure performed.

Several days later he pulled out the gastrostomy tube, and categorically refused to have it reinserted. Again when approached by the consultant and nursing staff Mr Francis indicated non-verbally that he did not want the gastrostomy tube reinserting. The consultant explained, in detail, informing him of the consequences of his decision, and that he would die if he were left without nutritional support. Mr Francis was adamant in his decision, and even persuasion from his family failed. Consequently Mr Francis died some days later.

This is a very complex and demanding situation ethically, morally, professionally and spiritually. It demands health care professionals to use advanced communication skills such as empathy to listen to more than just the spoken word.

The major challenge is doing what is in the best interests of the patient (Mr Francis) while providing support to the family and listening to their concerns and wishes. It is clear that Mr Francis has the mental capacity to make decisions and to consent to or refuse treatment.

The nurse must stay impartial and non-judgmental and their own personal beliefs about life, death and continuation of treatment must not be used to influence the decisions of Mr Francis or his family.

A further challenge is supporting individuals with questions of mortality and meaning in life. It is clear that Mr Francis has decided that he wants to die because his life had been so significantly affected by the stroke.

The nurse may be the mediator between Mr Francis and his family. The dynamics of this relationship will draw upon all the nurse’s knowledge, skills and expertise in dealing with very emotionally charged situations. Other health care professionals such as chaplains, psychologists (the psychosocial team) may help support the nursing team and provide further clinical expertise.

Some considerations for integrating personal belief and professional responsibility:
It may become apparent that the individual for whom the nurse is caring requires some intervention to support them with their spiritual or religious beliefs, before taking any action you should consider the following:

Reflective exercise: What should I do?

In an article for the Nursing Times Mooney (2009) reviews the findings of a Nursing Times survey which asked participants ‘Has a patient ever asked you to pray for them?’; 48 per cent of responders replied ‘Yes’, while 57 per cent said ‘No’. The finding demonstrates that nurses are encountering requests for prayer from patients.

Read the following scenario and, using the above guidance, consider how you would respond:

While providing personal care for a patient the conversation moves to the question of personal belief and religious practice. The patient asks you to pray with/for them.
In this instance the request has been initiated by the patient. In responding you would need to consider the following:

When integrating personal beliefs and professional practice you may sometimes feel that you are out of your depth in terms of your knowledge, skills and expertise (out of your comfort zone). In such situations you should acknowledge these limitations and then consider asking for help and support from different sources, depending upon the situation. Potential sources of support include:

Reference: Mooney H (2009) Can the NHS cope with God? Nursing Times, 105 (7), pp.8–10.

Case studies reproduced with kind permission from McSherry W (2006) Making sense of spirituality in nursing and health care practice, London: Jessica Kingsley Publishers.

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