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Arnold Tweed

 

During my penurious years of service as a junior medical officer in Her Majesties Armed Forces, I moonlighted in the Emergency Room of a local community hospital. It was a small hospital and the ER doctor on the night shift also covered the ICU. Since the worst disasters went directly to the larger General Hospital most of our ER work was routine. Occasionally, however, a serious emergency would arrive and require ICU admission. When that happened on my shift I would generally try to cope with both the ER and ICU until morning. That was the case the night Mr. Antonio was admitted.

Mr. Antonio was rushed to the ER, crumpled in the back seat of the family sedan, after collapsing at home. His was a classical history. A robust working man of about 50 years, in good health except for hypertension, he suddenly cried out that his head was splitting and fell to the floor. Although he had been mumbling incoherently when they carried him to the car, he was comatose on arrival in hospital. This was long before CT and MRI scans. Probably it was completely unnecessary, but I did a quick Lumber Puncture to confirm that there was fresh blood in his CSF. I’m not sure now whether the LP was done to allay my anxiety or strengthen my case when talking with his family. In either case, I wanted to be certain of my diagnosis that he had had a massive intracranial haemorrhage and the prognosis was hopeless.

He was quickly shifted to the ICU for observation. Meanwhile, the number of anxious relatives now overflowing our tiny waiting room was rapidly increasing. As delicately as was possible I prepared them for the worst, his teen-age daughter acting as my interpreter. There was little hope to offer them. It was my considered opinion that he would not live through the night. The message perhaps came through more bluntly in the interpretation than was intended and it triggered a chorus of wails and tears that continued unabated for the remainder of this episode. As the number in attendance increased so did the volume. They must have derived some comfort from each other’s company because they left my patient entirely to the care of the ICU nurses. Perhaps they realised that the sheer weight and volume of their support was the best they could do.

There was little more I could do so I returned to the ER where there was now a substantial backlog. Even there we could still hear the weeping of the grieving family.

The ICU nurses knew their job well and kept me posted with updates on his condition. When he became totally unresponsive to painful stimulation I was sure the end must be near. By now the disruptions of his noisy and restless retinue were beginning to grate on our nerves. When he developed Cheyne-Stokes breathing I briefly considered the life-support options, but immediately dismissed the notion. There was no need to write ‘Do Not Resuscitate’ or ‘comfort measures only’ orders. The nurses knew what to do and were not about to initiate futile attempts at CPR. That was just as well because the ER had become even busier and I had little time to devote to a hopeless case. Their family priest had arrived and he was quietly advised to administer the Last Rites. When they finally called to inform me that Mr. Antonio had stopped breathing I was relieved, hoping that would bring denouement to the tragic drama that was disrupting the routine of our small hospital.

A quick examination indicated absence of both respiration and radial pulse. I wanted to get the most unpleasant duty over first, to inform the family of his demise. Locating the immediate family members was less difficult than extracting them from their clinging support group but eventually we got them into a small private room where we could be heard. As expected they were devastated and their crescendo of grief was sufficient to transmit the message to the others. For several minutes anguish prevailed. Now they wanted to see him. Perhaps it was a premonition that held me back, the hot breath of my omnipresent evil genie on the back of my neck. I hesitated, “Just give the nurses a few minutes to make him look better”.

While I was sitting at the nursing desk completing his death certificate my genie struck. The practical nurse who was tidying the body for family viewing darted out of the room with a look and manner that I had come to recognize always presaged trouble. “You’d better come back quickly,” she said, “he’s still breathing.” Only after my re-examination confirmed her report did the full impact of my situation hit me. The nurse was mostly right; he wasn’t exactly breathing but he was gasping at a rate of 3 to 4 per minute, agonal breathing. And they weren’t gasps that could be ignored, they reverberated in that small room, accompanied by a heaving chest and flaring nostrils. Moreover he had a clearly palpable femoral pulse and a visible apex beat under his left nipple. It should be obvious to any fool that he was not dead; no lay person stepping into that room would have a moment’s doubt. Within moments his grieving family would expose me as just that fool.

I have since seen many patients undergo neurological death and have come to understand that the exact timing is uncertain and the physical signs deceptive. The medullary brain-stem centres that control breathing do not shut off like an electrical switch; they wind down like a potter’s wheel. Agonal gasping can continue for minutes, sometimes hours. If the heart is basically healthy it requires only a little oxygen to keep beating, and I have seen strong hearts continue to contract for 30 minutes after breathing has ceased entirely. Blood pressure, pulse rate and force of cardiac contraction vary unpredictably. Electrical activity of the heart, the ECG, may continue long after pulse and heart sounds have ceased.

At that moment the reasons for my misjudgement were unimportant; I feared that I was on the verge of more than just embarrassment. The noisy throng milling in the corridor were a sturdy lot of bricklayers and plasterers. They were of an ethnic origin noted for volatility and mistrust of official institutions. When they discovered that their dear relative, who I had just declared dead, was perceptibly alive I wanted to be somewhere else. It would be uncomfortable enough to be identified as the perpetrator of a morbid hoax, but, more seriously, they might immediately conclude that his treatment had been careless.

I needed time and the first necessity was to divert the approaching wife and children. Nurses were dispatched to delay them by any means, using any excuses necessary. With the door firmly closed and locked I had time to consider my plight. What were my options? One: I could slip out the back door and leave town. Two: I could admit my error and face the consequences, but I knew that he was bound to die soon and my humiliation might be averted. Three: I could hold a pillow over his face till he stopped breathing, but my good intentions might be misinterpreted. Four: I could sweat it out.

The next thirty minutes were among the longest of my life. I counted each gasp, I anguished, and I waited. When there had been no gasps and no pulse for a full 15 minutes I came out. His family was restive and didn’t understand my strange ritual. Thankfully they were respectful enough not to enquire. It was the nursing staff that saved my reputation. I never learned what they told the wife and children that kept them pacified for a half-hour, or how they explained my need to be alone with the patient for so long. But they made it appear as if it were part of the routine and hospital routine is inviolate.

Now, when I am called to pronounce a patient dead, I get very busy. For at least a half-hour I am engrossed in another task, cannot be located, or am otherwise urgently engaged. After all, on a scale that stretches to eternity it makes little difference if the patient’s official departure time is delayed for a half-hour. For me that experience was a half-hour that seemed like eternity.

Arnold Tweed 

This story is not about surviving the physical ravages of disease, it is about mental and emotional survival. I am attaching Harold’s own account of his illness. It should be read in full and sympathetically because only someone who has walked that road can fully appreciate the emotional as well as the physical pain. (Go back one to Harold’s Story). Harold describes some of that, but he focuses more on the positive, on the comfort and hope that he drew from his family and his Christian faith. His is a story about hope, love and faith – and the healing power of prayer.

Modern scientific medicine has made such dramatic progress in treating and even eliminating disease that we tend to see treatment solely in terms of physical interventions: drugs, surgery, radiation, manipulation. The science of medicine dominates the field today; the art of medicine is seldom mentioned. This is a story about the subjective aspects of healing and the importance of mental, emotional and spiritual factors in illness. But being subjective does not put it beyond the scope of science. I approached this as a medical scientist and looked for empirical evidence for benefits. I found much more than I had expected.

First, a word of caution, please do not confuse the use of spiritual in this context with ‘spiritual healing’ cults. The world is awash with such cults; just Google ‘spiritual healer’ and you will be flooded. One cult, the Aetherius Society, claims that its founder, Dr. George King, was taught the arts of psychic healing by extraterrestrial beings. Aetherians and similar cults often claim to manipulate some sort of ubiquitous ‘spiritual energy’ by ‘contact healing’. A recent expose in the Toronto Star warned of the fraudulent nature of purported ‘healers’ (Mendleson 2015). Harold and I use spiritual in a very different sense – not as a substance or force to be manipulated – but as a personal conviction that there is a being, greater than us, who loves us and asks only for our love in return. Harold never expected to be healed by prayer; he prayed for the strength to endure his illness.

Prayer for health is more common than we suspect. A national survey in the U.S. in 1998 found that 35% prayed for some aspect of their health and two-thirds of those found prayer to be helpful (McCaffrey, Eisenberg et al. 2004). Most did not discuss prayer with their physicians. This suggests an interesting dichotomy in health care: patients consult their physicians for the medical aspects of care but not for their spiritual, emotional and mental needs.

The use of prayer as therapy is a very private and largely ignored practice. Prayer can be for the benefit of others or for self. The first is called intercessory prayer, prayer by an individual or group for the benefit of another. The second is petitionary prayer, prayer for oneself. Harold was the beneficiary of both. His church community prayed for him; and his sometimes anguished personal prayers are well described in his story.

Intercessory prayer has been studied empirically by several groups, probably because it lends itself to the rigidly controlled studies necessary to ensure scientific validity. Leanne Roberts (Hertford College, Oxford, UK) has published three Cochrane Reviews (latest 2009, Intercessory Prayer for the Alleviation of Ill Health) which have summarized by meta-analysis the Randomized Control Trials (RCTs) completed up to that date. Now this is a heavy dose of academic shop-talk so let me clarify the terminology. The Cochrane Database is a gold standard for evidence based medicine; Cochrane reviews are carefully edited and scientifically vetted. Meta-analysis is a statistical technique for combining the results of several studies. RCTs are the gold standard for medical research and are designed to measure the effect of one treatment, and one only, on a target outcome. In their latest review Roberts and Company combined ten RCTs by meta-analysis (7,646 patients). First, you might be surprised to hear that there have been ten scientifically valid studies of this subject. Second, you might not be too surprised to learn that the results were equivocal. What does that mean exactly? Well, some studies showed beneficial results, some did not, but the combined analysis did not reveal a statistically significant benefit. Not surprised?

Does that mean there is no value whatsoever to intercessory prayer? No one has yet considered that the main, and perhaps intended, benefit may be to the prayer group. Group prayer fosters group cohesion, common purpose, shared values and reinforces faith. It enfolds the object of the prayer into the nurturing bosom of the community and reinforces group identity for all. Group benefit and individual benefit are difficult to separate.

However, before reaching a final conclusion, consider this. An RCT performed by Olver and Dutney from the Royal Adelaide Hospital in Australia with 1000 patients, published in 2012, showed small but statistically significant benefits in spiritual, emotional and functional well-being in patients who were prayed for (Olver and Dutney 2012). Now are you surprised? I am amazed! The design of their RCT was technically called ‘double-blinded’, that is the patients were randomized to treatment (prayer) and control groups but were not told which group they were assigned to. The group who prayed, an external prayer group, was given details about the patients but not their identity. In other words, the prayer group was praying for someone, they didn’t know exactly who, who in turn didn’t know if they were or were not being prayed for. Sound ridiculous? Well, that’s what you have to do to meet the scientific rigor of an RCT. There must be something about intercessory prayer that works at some level to survive that amount of obfuscation. Perhaps this issue is just too complex for science and we should abandon scientific efforts to prove or disprove religion.

Petitionary prayer has not been as well studied. In large part this is because it is so subjective and private. Since belief in the efficacy of the prayer is integral to the effect, it is difficult to conceive a study design where subjects could be randomly assigned to treatment (prayer) and non-treatment groups. However, there is a huge literature on religion and health outcomes and most studies used a general classification of religion/spirituality (R/S) to cover all aspects of belief, ritual and prayer. The specific contribution of petitionary prayer is hidden in the whole. Two major reviews were published in 2015 with meta-analysis of literally hundreds of studies (Jim, Pustejovsky et al. 2015, Salsman, Pustejovsky et al. 2015). Overall they concluded that there was a positive benefit of R/S on several measures of patients’ physical and functional well-being, including their symptoms and mental health. Several studies reported increased tolerance to pain and improved function, even when intensity of pain was unchanged.

It is also interesting that there is a trend in the recent palliative care and oncology literature to separate spirituality from religion. Medical providers are appropriating spirituality and relocating it into the bio-medical and psycho-social fields of research. Spirituality is being reshaped to encompass considerations of self and relationships while shedding the dependency on religious beliefs. A brief quotation from a recent review may give you a flavor of this change: “A ‘spirit to spirit’ framework for spiritual care-giving respects individual personhood.” (Edwards, Pang et al. 2010) If you understand that please enlighten me by writing a commentary to this article.

Medical science has identified that the benefits of prayer are mainly on subjective outcomes and coping behaviours. Please note that, in all of the literature documenting the benefits of prayer, there are no scientifically valid studies that demonstrate prayer to be an effective substitute for medical treatment. The main reason that prayer is held in disdain by scientists and medical doctors is the exaggerated claims made by some, Christian Science foremost, that prayer can replace medical treatment. There is no credible evidence whatsoever for these claims. Prayer can be complementary to medical treatment but it is not a substitute. If you read Harold’s story you will see that replacing medical treatment with prayer never occurred to him, not even when his treatment was causing him more distress than his disease.

The physical benefits of prayer may be attributed to a phenomenon well known to medicine, the placebo effect. Henry K. Beecher, Professor of Anesthesiology at Harvard brought the placebo effect to public attention in 1955. Its most important application since has been as a sham treatment administered to the control group in placebo-controlled clinical studies. However, there is new interest in placebos as a therapeutic tool in their own right. This is summarized in a recent feature article in the National Geographic magazine (Vance 2016). A more scholarly review published in the NEJM in 2010 combined studies (again by meta-analysis) in which placebo-treated groups were compared to no-treatment groups. They concluded that placebo treatment had a significant benefit when the measured outcomes were subjective and patient-reported, such as pain and nausea (Hróbjartsson and Gøtzsche 2010). These articles support the hypothesis that placebos act by psychological mechanisms, perception and expectancy effects, and by triggering the release of endogenous hormones in the brain (endorphins and cannabinoids). The magnitude of the effects are still controversial but estimates range from 7-35%. Evidence is mounting that the placebo effect is part of a natural defence mechanism. Are the medical benefits of prayer a placebo effect? They have similarities, and may depend on the same mechanisms, but we wait confirmation from appropriately designed studies.

This brings us to our last consideration; is prayer a psychotherapeutic or spiritual exercise?  It may be both since those who pray with conviction experience both spiritual and physical benefits. Although the spiritual side is opaque to empiric methods of study, bits of the enigma, the physiological and psychological bits that can be measured, are emerging. Hans Lou and colleagues at Aarhus University, Denmark, have observed that meditation exercises (they studied Yoga Nidra meditation) were associated with activation patterns in specific areas of the brain that modulate self-awareness (Lou, Kjaer et al. 1999). The same may be true for prayer. This is a start in understanding the complex cognitive processes associated with prayer and meditation. But the spiritual realm remains impenetrable to our methods, though spiritual needs are still a reality in our lives. Fear, grief and despair are the constant companions of disease and are not comforted by tranquilizers. Prayer is not just the bridge to the spiritual domain, it links the physical and spiritual domains so that its benefits are experienced in both.

Spiritual needs are traditionally met within a religious framework and Harold’s story describes how he found spiritual comfort in prayer and scripture, within his Christian faith. Some recent literature suggests that spiritual needs can also be addressed outside of a religious context. This at least recognizes the existence of spiritual needs, especially for the elderly, sick and dying, but we wait to see how these alternative approaches will evolve. Spiritual needs aside, my reading has convinced me that prayer is a powerful adjunct to medical treatment and is probably underutilized. The medical literature confirms that prayer, when offered with conviction, improves patients’ outcomes. Since most patients do not discuss their religion with their doctors the medical profession’s indifference to prayer is understandable. This is the business of hospital chaplains, but doctors rarely speak to them either. Instead of “Integrative” health care we have partitioned health care. If prayer were offered as part of the treatment plan would patients feel better, recover faster, and use less fentanyl? This is a challenge that our modern “patients first” policy makers might consider.

Postscript:

Before closing this story I want to add a personal postscript. I wanted to write about Harold’s experience for several reasons. I knew that Harold was articulate and insightful and could help us, as sympathetic spectators, share his experience and better understand the physical and mental agony of life-threatening disease. Harold and I are medical school classmates and have been friends for more than fifty years. We share the same medical education and the same scientific view of medicine and disease. Harold is also deeply and sincerely religious, as his story proves. What we see clearly in this story, and others of similar genre, is that his religious and his medical responses to his illness were never in conflict. There is never a suggestion that his medical treatment was threatened by his religion nor that his religion was threatened by medical science. His spiritual needs and medical needs were in different spheres and required different therapy. Medicine and prayer were certainly compatible and may have been complimentary. Those who claim that science has conquered religion, or that religion denies science have a very shallow understanding of both. Harold’s story shows that science and religion are not at odds; they serve different needs towards the same end.

 

 

. “The Aetherius Society.” from http://www.aetherius.org/dr-george-king/.

Edwards, A., N. Pang, V. Shiu and C. Chan (2010). “The understanding of spirituality and the potential role of spiritual care in end-of-life and palliative care: a meta-study of qualitative research.” Palliat Med 24(8): 753-770.

Hróbjartsson, A. and P. C. Gøtzsche (2010). “Placebo interventions for all clinical conditions.” Cochrane Database of Systematic Reviews(1).

Jim, H. S., J. E. Pustejovsky, C. L. Park, S. C. Danhauer, A. C. Sherman, G. Fitchett, T. V. Merluzzi, A. R. Munoz, L. George, M. A. Snyder and J. M. Salsman (2015). “Religion, spirituality, and physical health in cancer patients: A meta-analysis.” Cancer 121(21): 3760-3768.

Lou, H. C., T. W. Kjaer, L. Friberg, G. Wildschiodtz, S. Holm and M. Nowak (1999). “A 15O-H2O PET study of meditation and the resting state of normal consciousness.” Hum Brain Mapp 7(2): 98-105.

McCaffrey, A. M., D. M. Eisenberg, A. T. Legedza, R. B. Davis and R. S. Phillips (2004). “Prayer for health concerns: results of a national survey on prevalence and patterns of use.” Arch Intern Med 164(8): 858-862.

Mendleson, R. (2015). Purported spiritual healers a wideapread problem. Toronto Star. Toronto.

Olver, I. N. and A. Dutney (2012). “A randomized, blinded study of the impact of intercessory prayer on spiritual well-being in patients with cancer.” Altern Ther Health Med 18(5): 18-27.

Salsman, J. M., J. E. Pustejovsky, H. S. Jim, A. R. Munoz, T. V. Merluzzi, L. George, C. L. Park, S. C. Danhauer, A. C. Sherman, M. A. Snyder and G. Fitchett (2015). “A meta-analytic approach to examining the correlation between religion/spirituality and mental health in cancer.” Cancer 121(21): 3769-3778.

Vance, E. (2016). “Mind Over Matter.” National Geographic 230(6): 30-55.