Background: “We are praying for a miracle.” “It’s in God’s hands.” “Only God knows.” These statements likely sound familiar to any clinician who has cared for a patient with a serious illness. Yet even the most experienced clinicians may feel caught off-guard when patients and families use religious- or spiritual-based coping to guide healthcare decisions. This Fast Fact assimilates published evidence and expert opinion to offer a paradigm for responding to patients or families who express hope for a miracle.

Recognize that spiritual beliefs commonly affect decision-making in a variety of ways:  Spiritual and religious practices often impact decision-making, goals, and values (1). Even within the same faith or belief community, the implications of a given religious belief vary substantially (1). Hence, patients can imply vastly different meanings when they use spiritually based language. For example, when a patient states that they do not wish to “give up hope for a miracle,” that patient may be requesting that the clinician “do everything” possible to help them live longer no matter the medical burden. For others, such words convey a wish to delay or discontinue standard treatment in favor of holistic or spiritual healing. 

Begin with curiosity and seek clarity: Clinicians should take the stance of a curious explorer who seeks to know more about a patient’s belief. A statement such as, “This is in God’s hands,” can be an opportunity for clinicians to understand the patient and their illness perspective better. It is essential to remain non-judgmental and use open-ended responses such as: “Tell me more about what that looks like for you.” The same exploratory framework applies to statements about hope and miracles: “Can you tell me more about what you are hoping for?” or “What does a miracle look like for you?” This acknowledges the patient’s spirituality as a source of strength and peace, while helping the clinician to offer more individualized guidance.

Align with their hopes for a miracle:  Aligning with the patient involves naming your willingness to hope alongside them (2): “I hope for a miraculous cure for your cancer as well.” Use “and” instead of “but” when holding two contrasting ideas together, to avoid negating hope: “I know these goals are important to you, and I also worry that time may be short.” Clinicians can validate the desire for a miraculous outcome, while inviting discussion of additional hopes if their illness is not cured (e.g., family reconciliation, a deeper faith practice, participating in an important life-cycle event, choosing the location of dying). 

Explore how miracles impact their point of view:  If a patient feels that God has healed their disease in the past, they may hope for God’s healing again and request medical treatment accordingly (3). Clinicians should acknowledge past experiences, while exploring how the current situation may be different: “I think it’s wonderful that your mom has lived so long with this disease, despite many hospitalizations. I also worry if her situation is changing, and we may be in a different place now.” Clinicians often worry that patients who are hoping for a miracle lack insight into the seriousness of their underlying illness. However, hoping for a medical miracle can be a proportionate coping mechanism that implies a certain level of clinical insight; otherwise, that patient likely would not feel the need to hope for one. To preserve hope, while acknowledging the clinical situation, language such as “hoping for the best, preparing for the worst” has been recommended (4).

Enlist the expertise of a clinical chaplain: Board certified chaplains (see Fast Fact #347) explore spiritual distress, anticipatory grief, and sources of meaning for patients and families of all belief systems, including agnostic or non-religious patients (5). Evidence suggests chaplaincy involvement leads to better communication and a more nuanced understanding of how spirituality and faith affects care decisions (6). Religiously observant patients who receive spiritual support from an IDT that includes a chaplain are less likely to seek intensive end-of-life interventions and die in the ICU than religious patients who receive spiritual support only from their faith communities (6).

The AMEN Protocol:  A group of experts published this acronym to help clinicians navigate expressions of hope for a miracle within their scope of practice, while respecting faith and culture (7).      

• Affirm the patient’s belief and validate his or her position: “Ms. X, I am hopeful that your spouse makes a full medical recovery, too.”
• Meet the patient or family member where they are: “I join you in hoping for a miracle.”
• Educate from your role as a clinician: “And I want to speak to you about some medical issues.”
• “No matter what”: This is an affirmatory statement of non-abandonment to assure the patient and family you are committed to them regardless of how their illness evolves: “No matter what happens, we will be with you every step of the way.”

Author’s Affiliations: Massachusetts General Hospital, Division of Palliative Care and Geriatric Medicine

Conflicts of Interest: None to report

Version History: First electronically published in November 2021; originally edited by Sean Marks MD

References

1. Blackler L. Hope for a miracle: treatment requests at the end of life. J Hospice Palliat Nurs. 2017;19(2):115-119.
2.  Paladino J, Koritsanszky L, Neal B, et al. Effect of the serious illness care program on health care utilization at the end of life for patients with cancer. J Palliat Med. 2020;23(10):1365-9.  
3. Shinall Jr M, Stahl D, Bibler T. Addressing a patient’s hope for a miracle. J Pain Symptom Manage. 2018;55(2):535-539.
4. Back A, Arnold R, Quill T. Hope for the best, and prepare for the worst. Ann Intern Med. 2003;138(5): 439-443.
5. Fitchett G, Hisey Pierson AL, Hoffmeyer C, et al. Development of the PC-7, a quantifiable assessment of spiritual concerns of patients receiving palliative care near the end of life. J Palliat Med. 2020;23(2):248-53.
6. Balboni T, Balboni M, Enzinger A, et al. Provision of spiritual support to patients with advanced cancer by religious communities and associations with medical care at the end of life. JAMA Intern Med. 2013;173(12):1109-1117.
7. Cooper R, Ferguson A, Bodurtha J, Smith T. AMEN in challenging conversations: Bridging the gaps between faith, hope, and medicine. JCO Oncol Pract. 2014;10(4):e191-e195.