Editor's Note: (Robert Klitzman is a professor of psychiatry and director of the masters in bioethics program at Columbia University. He is author of "Designing Babies: How Technology is Changing the Ways We Create Children." The opinions expressed in this commentary are solely those of the author. View more opinion articles on CNN. )
(CNN) "No one should ever have to die alone -- to take their last breaths and say goodbye to the world by themselves with no one beside them," a hospital chaplain recently told me. "With Covid, seeing patients dying alone has become the hardest part of my job. At the beginning of the pandemic, I saw even children dying alone."
In the initial surge of cases last year, hospitals commonly banned all visitors. Family members of Covid-19 patients could themselves be infected and spread the virus to others when visiting their loved ones. Last summer, some hospitals, like Northwestern's, started to let families visit to say goodbye if these loved ones agreed that doctors could write Do Not Resuscitate (DNR) orders, which mean forgoing so-called heroic measures. Yet this approach raises disturbing questions of whether families may feel coerced to agree to these terms in order to see their loved ones.
In trying times like these, chaplains, who provide spiritual care and support to patients, families, doctors and nurses, have bravely and tirelessly stepped up.
Struggling on the front lines, helping to fill the gaping void that health care workers couldn't, chaplains spoke to families, wrote these relatives' messages to their loved ones on pieces of paper and handed these to nurses to read aloud in the patients' rooms. Once chaplains were able to obtain appropriate personal protective equipment (PPE), they entered patients' rooms with disinfected iPads and iPhones to let more people communicate with those in the hospital. Chaplains still sit with innumerable dying patients to aid them and be there for families in decisive and painful moments. These spiritual care providers help patients and families alike to find meaning, purpose and hope when confronting death, and frequently mediate conflicts between patients and the medical staff.
Contemplating religious questions when confronting mortality is hardly new. In past epidemics, such as the Middle Ages' devastating Black Death, massive numbers of people facing widespread disease, fear and death commonly turned to faith. But over the past few decades, America's religious landscape has been dramatically shifting.
Across Christianity, Judaism and Islam, attendance at religious institutions has been steadily declining over the last two decades. Once, religions uniquely offered explanations for how species, the earth and the universe were created. But increasingly, science has provided reasons, with clear evidence. In addition, people now more readily question authorities, whether political or religious, and the Internet, social media and globalization, have exposed people to wide ranges of beliefs that differ from the traditional faiths with which they may have been raised. Moreover, whereas houses of worship once allowed people to interact and connect outside of work at set times, social media now serves similar functions any time or day.
Covid-19 has also transformed religious and spiritual practices. Many people cope with stress by spending time with family and friends, and going to gyms, churches, temples, restaurants, bars, theatres and stores. But the pandemic has stymied these activities and connections to others. Many of us have been forced to reconsider what is truly important in our lives, to question the meanings of our daily routines, work, relationships and goals. We have often relinquished activities and interactions that now, on reflection, don't feel as meaningful.
Religious services have also moved online and been reduced to two-dimensional electronic screens, lacking vital human touch.
Hospitalized patients and their families face these challenges even more acutely, and healthcare providers have had to devise new, creative responses and interactions. Especially in the pandemic's early days, doctors and nurses were stretched thin and frequently had little PPE. They tried as much as they could to address patients' spiritual and existential needs, occasionally filling some of the roles of hospital chaplains, arranging Zoom calls with shocked, grief-stricken family members. But doctors and nurses could not do it all, and many have felt burnt out themselves, making chaplaincy services critical.
Health care, however, is a big business and many hospitals still underappreciate, understaff and underfund chaplaincy departments, which insurers do not reimburse , and which therefore do not directly generate revenue. In 2015, 70% of over 4,000 US hospitals surveyed by the American Hospital Association offered chaplaincy and pastoral care services, up from 53% in 2002. But more are needed.
Many doctors also remain wary of addressing spiritual, religious and existential issues in medical care. Even with patients who have advanced cancer, 47% of physicians feel personally uncomfortable discussing spiritual issues with patients, and 45% think it is not their professional role to do so.
Sixty-two percent of doctors say they have not received adequate training in this area. Yet among US medical school deans, only 7% said that their schools offered required coursework dedicated to spirituality and health, and only 21% thought that it would be important to develop national standards for competencies in training on issues regarding spirituality and health. Even if they received funding and assistance, only 25% would make additional time available in the curriculum for these issues.
Research shows, however, that patients who see a chaplain during their hospitalization, whether they initially wanted to or not, rate their overall satisfaction with their hospitalization higher. And some research suggests the presence of such services is associated with fewer hospital deaths. Alas, many hospitals and physicians feel that these studies are not enough.
Much of what chaplains do, however, lies beyond financial metrics. Covid-19 has in fact shown how chaplains can play increasingly vital roles, and how patients' needs for meaning and hope extend beyond profit alone.
Recently, for instance, a chaplain told me of a dying 12-year-old who wanted to be an organ donor. After he was declared brain dead, the doctors would need to wheel him into the operating room, and then disconnect his life support to quickly "harvest" his organs while these tissues were still viable. The family wanted to be present when he took his last breath. But the doctors feared that the family would become upset, and thus delay the ability to remove the organs in a timely way. The family and the doctors argued and couldn't resolve the tension.
The chaplain spoke at length to the family, who agreed to be in the OR for only three minutes. Once in the room, all garbed in sterile gowns, she asked them whether their son had a favorite song. The mother said, Amazing Grace. The family then sang it, with the doctors and nurses joining in. Everyone cried, including the staff.
After that the family left. A few days later, the chaplain phoned the mother to see how she was doing. "Thank you for that gift," she said. "We will never forget that. We got to sing my son into Heaven."
Hopefully, none of us will ever forget the pandemic's lessons regarding the importance of chaplains and of patients' and families broader spiritual, religious and existential needs beyond the biomedical alone.