July 2004 Article of the Month
Arslanian-Engoren, C. and Scott, L. D. [University of Michigan, School of Nursing, Ann Arbor, MI]. "The lived experience of survivors of prolonged mechanical ventilation: a phenomenological study" Heart and Lung: Journal of Acute and Critical Care 32, no. 5 (September-October 2003): 328-334.
BACKGROUND: Considering how common mechanical ventilation has become, and how many people require a respirator either for extended periods of time following acute illness or on an ongoing basis as a result of a chromic condition, very little research has explored patients' experiences of this therapy and how they cope with it. Furthermore, of the few studies that touch upon patients' experiences, only one (prior to this month's featured study) appears even to mention the significance of religion/spirituality [see the article by Logan, J. and Jenny, J. in the Other Items of Interest section, below]. Yet chaplains who visit with patients receiving mechanical ventilation can easily attest to how many utilize pastoral support and draw deeply upon spirituality to contend with the anxiety, frustration (especially with communication), helplessness, and discomfort of having a machine in charge of one's breathing. The present study begins to open up the issue of the personal and clinical importance of spirituality for ventilator patients, and it suggests an area of research in which chaplains may play an important role.
SUMMARY AND COMMENT: This small qualitative study from two academic nurses explores the "lived experience" of seven people who had undergone prolonged mechanical ventilation (PMV). Subjects participated in semi-structured telephone interviews (ranging from 25 to 45 minutes) based on the research question, "What is it like to experience survival from prolonged mechanical ventilation?" They were "asked to identify important aspects that contributed to their successful liberation from PMV" and "encouraged to share all their thoughts and feelings that they could recall" [p. 330]. Analysis of the responses indicated six themes: 1) endures a traumatic experience, 2) relies on self-determination, 3) credits family support and devotion, 4) finds comfort through religion and prayer, 5) praises health care professionals, and 6) derives reassurance from angelic encounters. Of these themes, those concerning religion/prayer and angelic encounters are noted by the authors to be heretofore "not evident in the published literature" [p. 332].
Regarding the theme of finding comfort through religion and prayer, the authors elaborate:
According to the participants, they "prayed a lot every day," either in private or with family members, throughout the entire "ordeal." "Belief in God" and "belief in the power of prayer" provided comfort and support during "anxiety attacks" or episodes of fear. Moreover, the participants believed that "something more powerful than us" assisted in their recovery. [p. 332]And on the theme of deriving reassurance from angelic encounters:
Seeing visions of "angels" and receiving guidance and encouragement from "deceased relatives" provided participants with the reassurance that they were "going to make it through" this traumatic experience. One participant described conversing with her deceased mother who told her, "Baby, go back. It's not your time yet. God has something for you to do and you go back." Another participant recalled an incident where her grandfather, whom she referred to as her "guardian angel," appeared at the bedside. She believed that "he was there to help" her and insisted that he "pulled" her through this traumatic event.... [p. 332]
The authors report that all seven interviewees cited these two spiritual themes and held them as "vital to their ultimate liberation from PMV," providing "the psychological sustenance necessary to endure and persevere through the liberation experience" [p. 332]. The implication for health care professionals is said to be that patients should be afforded the "opportunity for religious and spiritual expressions," that "specific information concerning patient and family religious practices and preferences should be incorporated in the...plan of care," and that "as visions and apparitions are believed to be a source of patient comfort, concerted efforts should be made for open expression of these events" [p. 333]. The authors continue:
The challenge before critical care nurses will be to distinguish between religious and spiritual expressions and hallucinations. As such, pharmacological interventions to suppress these expressions must be judiciously considered and instituted only if patient safety is at risk. [p. 333]
In spite of the relatively weak sample of patients surveyed (i.e., only seven out of an original pool of 429 patients), this study is a good example of phenomenological research in that the authors do not seek to explain away patients' spiritual themes (e.g., as would be the case if they had merely labeled patients' memories of angelic encounters as hallucinations) but report these themes with a respect for the data as offered by those who have lived through the experience in question. Also, the article details well the methodological process used to discover patients' themes, according to the "Giorgi 4-step analytic method" [p. 330], each step being illustrated in a section on Data Analysis Procedure.
Arslanian-Engoren and Scott appear to have touched upon spiritual issues for patients on mechanical ventilation that have not been captured in previous research. The potential for further investigation is great. This reader, for instance, found himself wondering how the study's findings may be generalized to patients receiving prolonged intensive care or particularized to patients on respirators. Might there be sub-themes in these patients' experiences that closely connect spirituality with breathing issues? Might spirituality--a term, after all, from the Latin spiritus, meaning breathing/breath--have special connotations for respirator patients? Might clinical talk of "liberation" from mechanical ventilation resonate with religious themes of liberation? What are patients hearing, thinking, and feeling while their communication is typically quite restricted with this therapy, and might these things differ for patients who endure a ventilator for days, as opposed to weeks, as opposed to months or years (when the goal would seem to turn from liberation from the machine to adjustment to life on the machine)? And, what chaplaincy interventions may be most responsive and helpful to such patients?
Suggestions for the Use of the Article for Discussion in CPE:
Students should find this relatively brief and quite readable article engaging for at least three reasons. First, it focuses on a patient population that is often both intriguing and intimidating to students: the combination of patients' rich emotional experiences with an impediment to communication can be a huge challenge for pastoral care providers. This study begins to bring to voice some patients' experiences that are not often heard, and it hints at how important pastoral visitation may be for ventilator patients. Second, it raises the question of distinguishing such experiences as "angelic encounters" from hallucinations--a question that often comes up during CPE (and that may be explored in discussion with psychiatric staff). Third, especially regarding research, the article offers a clear and concise explanation of its phenomenological method [see p. 330] and (briefly) its conceptual foundation in the philosophy of Edmund Husserl [see p. 329]. Even for non-research-minded students, however, this latter point speaks to the idea of understanding the "lived experience" of others, which may be a principal educational theme for many students in CPE.
Other Items of Interest:
Nowotny, M. L. [Baylor University School of Nursing, Dallas, TX]. "Life on a ventilator." Home Healthcare Nurse 17, no. 11 (November-December 1999): 691-694. [Though not a report of research, this is an interesting personal account of life on a mechanical ventilator, by a well-known nursing educator and practitioner. She several times makes brief references to her faith life.]
Logan, J. and Jenny, J. [Nursing Research and Professional Development, Ottawa Civic Hospital, University of Ottawa School of Nursing, Ontario, Canada]. "Qualitative analysis of patients' work during mechanical ventilation and weaning." Heart and Lung: Journal of Acute & Critical Care 26, no. 2 (March-April 1997): 140-147. [This qualitative analysis of interviews with 20 patients who had recently undergone mechanical ventilation makes slight mention of spirituality--see under Controlling Responses on p. 345 and in table III on p. 343. This is a second write-up of the study which was conducted in 1992-1993 and originally reported in Jenny, J. and Logan J., "Caring and comfort metaphors used by patients in critical care," Image--The Journal of Nursing Scholarship 28, no. 4 (Winter 1996): 349-352; which makes no mention of spirituality. It is worth remembering that spirituality was not a very salient topic in health care research prior to 1993, and that may have contributed to the silence on the subject here.]
Menzel, L. K. [University of Wisconsin-Milwaukee, WI]. "Factors related to the emotional responses of intubated patients to being unable to speak." Heart and Lung: Journal of Acute & Critical Care 27, no. 4 (July-August 1998): 245-252. [This qualitative study may be interesting to pastoral researchers even though spirituality is not considered, because it essentially pilots measures of emotional responses, including anger, with a ventilator patient population; and such measures may be useful as part of a battery of measures for investigations of spirituality & health. The topic of emotional responses to communication barriers is also one which may be of interest to chaplains.]
Papathanassoglou, E. D. and Patiraki, E. I. [University of Athens, School of Nursing, Greece]. "Transformations of self: a phenomenological investigation into the lived experience of survivors of critical illness.." Nursing in Critical Care 8, no. 1 (January-February 2003): 13-21. [Of possible--ableit tangential interest--is this phenomenological study of eight ICU patients which reveales a theme of critical illness as a "cocooning phase" leading to transformation of self, spiritual arousal and personal growth. One might imagine that such a theme could be explored in future research with ventilator patients as well as ICU patients in general. A distinct and intriguing aspect of the study is that patients were asked to talk about their dreams.]
Rotondi, A., Chelluri, L., Sirio, C. A., Mendelsohn, A., Schulz, R., Belle, S., Im, K., Donahoe, M. and Pinsky, M. R. [University of Pittsburgh, PA]. "Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit." Critical Care Medicine 30, no. 4 (April 2002): 746-752. [Another background piece that may be valuable to chaplains, this relatively recent quantitative study touches upon an array of emotional responses to prolonged mechanical ventilation, including spells of terror and nervous feelings when alone.]
Stein-Parbury, J. and McKinley, S. [Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Australia]. "Patients' experiences of being in an intensive care unit: a select literature review." American Journal of Critical Care 9, no. 1 (January 2000): 20-27. [The scope of this review extends beyond studies regarding mechanical ventilation, and it does not consider spirituality, but is an important background piece with many methodological insights for anyone pursuing research into the experiences of ventilator patients. A table on pp. 22-23 gives basic information about 26 studies published between 1981 and 1997.]
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