CoverArticle
Intensive
Spiritual Care
A Case Study
Tiesha D. Johnson, RN, BSN
W hen faced with the tragedy
of a traumatic event or a serious ill-
ness, many people have strong reli-
gious beliefs, and they often display
more outward signs of devotion
than they did in everyday life. Beliefs
and behaviors affect their experi-
ences with healthcare—both posi-
tively and negatively. This pattern is
especially important in the critical
care setting, where time is often of
the essence and the experience may
mark the end of someone’s life.
As clinicians, we recognize the
needs of patients and their families.
In the critical care setting, the physi-
ological need for urgent action and
aggressive treatment often takes pri-
ority over other needs for healthcare
providers, depending on the circum-
stance. At the same time, patients’
family members need to know that
their emotional and spiritual needs
are held in high regard and that dig-
nity for their loved one will be pre-
served. It is important to prioritize
both sets of needs concurrently. By
doing so, we bridge the gap between
providers and patients by including
patients’ families as part of the health-
care team in a manner that is holistic
20 CRITICALCARENURSE Vol 25, No. 6, DECEMBER 2005
and supportive. The story of Edna, a
48-year-old Laotian woman, illus-
trates these points.
Case Report
I received a report from an anesthe-
siologist who was in the operating room
preparing for admission of a patient to
our intensive care unit; I was to receive
the patient within an hour of that
report. The anesthesiologist also pro-
vided a brief background. I learned that
the patient and her family were from
Laos and did not speak fluent English.
I accepted that information with little
further thought while making notes
about her physical condition and think-
ing ahead about what I would need to
prepare the room.
Edna had been traveling with her
husband and son from another state to
attend a Buddhist religious holiday
gathering. I learned of their destination
only much later. Edna had been in the
back seat of the car; her husband was
seated in front, and her son was driving.
They were involved in an accident in
which Edna was thrown from the back
window of the car. Her husband and
son sustained only minor injuries;
Edna had a severe head injury that
CE Continuing Education
* This article has been designated for CE credit.
A closed-book, multiple-choice examination fol-
lows this article, which tests your knowledge of
the following objectives:
1. Using the framework of Fitchett’s model,
describe dimensions of spiritual assessment
and their definitions
2. Recognize key components and appropriate
interventions for Edna and her family to sup-
port their spiritual case
3. Describe lessons learned in the care of Edna
and her family that positively affect future spir-
itual care provision of the Buddhist patient
Author
Tiesha D. Johnson is a nurse with 9
years of clinical experience in acute
care, critical care, adult emergency
medicine, and pediatric emergency
medicine. She recently founded a diver-
sified healthcare consulting company,
Lupine Creative Consulting, Inc, in
Rochester, NY.
To purchase electronic or print reprints, contact
The InnoVision Group, 101 Columbia, Aliso Viejo,
CA 92656. Phone, (800) 809-2273 or (949) 362-
2050 (ext 532); fax, (949) 362-2049; e-mail,
reprints@aacn.org.
required an emergent craniotomy after
a computed tomography scan showed a
large intracranial hematoma. Exten-
sive edema and widespread diffuse
axonal injury of the bulk of the sur-
rounding brain tissue were apparent.
Edna was in surgery for several
hours while her family waited anx-
iously. It was difficult to prepare the
family for what we knew would be a
shocking sight during their first encounter
with Edna postoperatively. Edna’s hus-
band spoke no English, and although
her son spoke some, the amount was
not nearly enough for an actual dia-
logue. Without a translator present, we
could not even know what language we
needed to translate, and in the intensity
of the moment, the hospital’s transla-
tion services were of no help.
In the operating room, the hematoma
had been evacuated, an external ven-
tricular drain had been placed, an
intracranial pressure monitor had been
placed, and a large piece of Edna’s skull
had been removed and left open to pre-
vent herniation. Although these steps were
successful, posttraumatic complica-
tions and irreversible tissue damage led
to a grave prognosis. When Edna’s family
was allowed to see her, she was receiving
mechanical ventilation, her head was
bandaged, and her eyes were swollen
shut. She had connections to monitors
and several intravenous catheters, was
not responding or moving except for
occasional seizures, and was surrounded
continuously by busy doctors, nurses,
respiratory therapists, and other health-
care workers who were trying to stabi-
lize her physical condition.
Biomedical Factors
Severe head trauma caused by
rapid deceleration and extreme direct
force can lead to several serious com-
plications. Skull fractures often pro-
duce localized hemorrhage, and
shear forces applied to neuronal tis-
sue may cause acute swelling of the
brain itself. Signs associated with
intracranial bleeding and edema of
brain tissue include decorticate and
decerebrate posturing, coma, hemi-
plegia, dilated or unreactive pupils,
and respiratory irregularity. Com-
pression of intracranial tissue can
produce what is known as the Cush-
ing phenomenon, in which blood
pressure and pulse increase while
respiratory rate decreases.1 Edna had
all of these, both preoperatively and
postoperatively; her chance of long-
term functional survival was essen-
tially zero.
Edna’s Family and Loved Ones
Until some English-speaking fam-
ily members arrived at the hospital, it
was almost impossible to inform any-
one of Edna’s status and poor prog-
nosis. The English-speaking family
members who did arrive were not very
fluent in the language and did not
seem to entirely understand the infor-
mation we were presenting to them.
We attempted to obtain a translator,
but we were unsuccessful during the
3 days that Edna spent in the inten-
sive care unit: many of the staff had
little experience using the translator
service, so a very important interven-
tion was delayed from the beginning.
Eventually, several additional
members of Edna’s extended family
and the religious community to which
they were traveling arrived at the
hospital. Despite our hopes, few of
them spoke English with much flu-
ency either. It was never clear to us
which people were family members
and which were religious leaders—
or even if that distinction had the
same meaning to them as it did to us.
CRITICALCARENURSE Vol 25, No. 6, DECEMBER 2005 21
Cultural Differences
In addition to stabilizing Edna’s
physical condition, our focus was on
informing her family members
about her status and prognosis.
When she was no longer responding
to treatment and it was clear that she
most likely would die soon, our pri-
ority became to discover the family’s
wishes concerning her “code status.”
In some cultures, decisions about
the plan of care for an individual are
made by the community. Our hospi-
tal policy was to limit medical
decision-making authority to actual
family members if they were present
or to individuals with legal documen-
tation designating them a healthcare
proxy. This individualistic approach
to care is typical of our Western cul-
ture, and it created a potentially
challenging conflict regarding legal
distinctions between family, caretak-
ers, and decision makers for patients
from other cultural backgrounds.
From the medical perspective, we
needed to be clear about how aggres-
sive our interventions were to be.
The ongoing language barrier and
cultural differences created substan-
tial tension and only intensified our
need to handle the situation delicately
if we were to preserve any chance of
long-term emotional recovery for
Edna’s family. As this consideration
rose in priority, it became impera-
tive that we educate ourselves about
the family’s cultural background as
much as possible. Our hospital is
located in Rochester, NY, a city with
a population of 219773 people.2
Racially, the city is predominately
white and black; less than 3% of the
population are Asian.2,3 The majority
of the city’s residents observe a Judeo-
Christian faith, although the city
does have a Buddhist temple. The
surrounding county consists of
735 343 people, again with an Asian
population of less than 3%.3 Edna
and her family were a cultural chal-
lenge for all of us. I knew she was
going to die and that this death was
going to be handled differently from
any other that I had experienced in
my career as a nurse.
I knew she was going to die and that this
death was going to be handled differently
from any other that I had experienced in
my career as a nurse.
A Difficult Process and
an Impossible Decision
Under the circumstances, it was
impossible for Edna’s family to make
any decision about whether car-
diopulmonary resuscitation should
be performed on Edna if her heart
stopped beating. Many people of
Asian cultures typically resist even
talking about death.4-6 Edna’s family
was aware of her poor condition in
general, but we were not certain that
they recognized the looming critical
decision. We tried to explain the
options to her husband with the
help of family members, whose Eng-
lish was quite limited. When we
asked family members to repeat to
us in English what they had told
Edna’s husband in Laotian, the infor-
mation was often incorrect. The
process was painstaking, frustrating,
and frightening for everyone. Edna’s
husband appeared resistant to the
prospect of a do-not-resuscitate
order, but it was difficult for us to
know if he had a full understanding
of the situation or of what such an
22 CRITICALCARENURSE Vol 25, No. 6, DECEMBER 2005
order actually meant. I noticed that
some family members had left and
had returned to the hospital with a
dress that Edna was to wear in case she
died. One family member explained to
me, “She should not ‘travel’ without
clothing.” I learned that modesty in
Asian cultures, especially for women,
is extremely important.4-6 I could not
dress her then, but I did place the
dress over her weakening body, under
the bed sheet that was covering her.
It became clear that Edna’s grave
prognosis was apparent to some
people in the group, whether or not
we could explain the details.
Changing Priorities
Once I learned of the family’s Bud-
dhist faith, I gathered as much general
information as I could through short
conversations with English-speaking
family members and through a brief
Internet search. On the basis of what
I had learned, I tried, especially in the
last moments of her life, to refrain
from much physical contact with
her, especially her head and shoul-
ders, where, according to the Bud-
dhist tradition and within Laotian
culture, the spirit resides. One should
not touch another’s head or shoul-
ders, if possible.4,5 I also strove to
create a quiet and peaceful environ-
ment by closing the doors to the
room and encouraging the various
healthcare providers to leave the
room immediately after physical
examinations and to converse about
the case elsewhere. Creating a peace-
ful environment was something I
tried to do for all my patients. This
intervention was the one thing I was
familiar with and could offer Edna’s
family with confidence. Addition-
ally, I tried to provide space for the
family to place Buddhist statues and
other important materials that they
had brought to the hospital. In my
experience, many family members
bring in pictures and items that are
important to either them or the
patient and place the material around
the room when the patient’s condi-
tion is serious. It occurred to me that
this family was probably no different
in that respect. Some family members
seemed to know that Edna would not
survive; others were clearly hoping,
almost insisting, that she would.
Either way, my job was to facilitate
whatever they needed to do.
The time came when Edna’s condi-
tion deteriorated irreversibly despite
all of our interventions. The cart for
resuscitation was in the room, and
the doctor checked to make sure the
defibrillator was charged, drugs were
prepared, and syringes were placed
near the central intravenous catheter
in Edna’s chest. Within minutes, Edna
was going to require resuscitation,
and we still had no do-not-resusci-
tate order. The family stood near
Edna’s bed, and we surrounded her,
ready to act. As her monitor showed
evidence of premorbid bradycardia
and we began to administer the first
round of drugs, someone abruptly
said, “Stop.” I never knew who said
it. Edna’s husband tearfully nodded
in agreement. We paused and stepped
away from the bed. Sighs of relief
could be heard from a few of us. A
few tears escaped my eyes; I was sad
that this marked the end for Edna,
yet relieved that we would not proceed
with futile resuscitation because of a
lack of understanding.
The end of our interventions
marked the beginning of a new phase
for Edna’s family. A young woman,
speaking broken English and crying,
approached me frantically and
somehow conveyed her wish for
white candles, some ribbon, and yel-
low flowers. I did not understand
the meaning behind this request—
but I did not question it. The expres-
sion on her face, the tone of her voice,
and her overall sense of urgency
made her plea my priority. I never
learned the specific significance of
these items. In many Laotian cultures,
strings and amulets have important
connections to the spirit. Perhaps
the requested items were needed for
a variation of such traditions.5,7
We scoured the unit for those 3
items. Finding artificial yellow
daisies in another patient’s flower
arrangement, we asked if we could
cut 3 of them out. She agreed with-
out question—our demeanor must
have spoken to her (we later told her
why we had needed them). We found
some small candles in the break
room, left over from a staff mem-
ber’s birthday celebration. We tied
birthday candles and plastic flowers
together with a piece of twill tape
normally used to secure endotra-
cheal tubes, and we handed the collec-
tion to the young woman. Meanwhile,
Edna’s family had pulled back her
covering sheet, revealing the dress
that I had placed over her body ear-
lier. They were moving quickly,
some crying and some chanting.
They placed our little bundle on top
of her, along with money, jewelry,
and other items. The doctor and I
stood quietly in the background.
Edna died as her family cared for
her. They asked if I would dress her
before her body was transported. I
was grateful for this chance to par-
ticipate one last time in Edna’s care.
The Heart of Nursing
The last moments of Edna’s life
and the first moments of her death
moved me. I felt a deep responsibil-
ity to continue the tone of ritual that
her family had started. I did not com-
pletely understand it, but I knew that
my job, dressing her, was extremely
important. Normally, postmortem
care is something that we want to
get done quickly. It is not unusual
for a few of us to work as a team.
This time was different for me. Still
wanting to preserve Edna’s dignity
and privacy (I could not help but
wonder if her spirit would still some-
how be present until her body had
been prepared), I tackled this task
on my own. It just seemed right to
me for this to stay just between Edna
and me. I closed the door, bathed
her, and dressed her before covering
her for the last time. I hoped that I
had prepared her for the journey in
the ways that her family would wish.
In retrospect, the story of Edna
and her family is rich with spiritual
significance, and it provided oppor-
tunities for careful assessment and
action. Without specific guidelines
to follow, we had to improvise in
order to meet the family’s spiritual
needs. I realized that we might have
better served Edna and her family if
we had had some established guide-
lines. Later, after our 3-day experi-
ence, I further explored elements of
Buddhism as well as some of the lit-
erature about spiritual nursing care.
CRITICALCARENURSE Vol 25, No. 6, DECEMBER 2005 23
I am now better prepared for an
encounter such as this one.
Buddhism and Laotian Culture
Although practiced by several
billion people worldwide, Buddhism
is a minority religion in the United
States.8 It entails many beliefs, prac-
tices, and customs that my colleagues
and I did not immediately recognize
or understand. Many Laotians are of
Hmong ethnicity. This ethnic group
typically practices Theravada Bud-
dhism, although the particular type
of Buddhism practiced varies depend-
ing on the region of Laos from which
the person originates. In this culture,
illness and injuries may be attributed
to the loss of 1 of the 32 spirits that
inhabit the body and maintain
health. The loss of a spirit may also
be the result of traveling, having an
accident, or even being startled when
walking alone.4-6
The language barrier further com-
plicated the ability of Edna’s health-
care providers to participate in any
genuinely active or expressive fash-
ion. Language barriers are often an
issue for older Laotians. Because
healthcare situations present unique
challenges in understanding and in
decision making, even the presence
of a family member who speaks both
English and Laotian may not be suf-
ficient for circumstances such as
those in Edna’s case.5
Because of the language barrier,
Edna’s poor prognosis and unstable
condition must have been even more
frightening to her family. Edna’s hus-
band showed little emotion initially
other than occasional tears. His affect,
for the most part, was flat. I wondered
if he was in shock or if this behavior
was typical for his culture. I later
learned that Laotians tend to be
reserved in most interactions, espe-
cially in healthcare settings. Effu-
siveness and expression of strong
feelings are not valued in Laotian
culture.4,5 Although Edna’s family
did have support from others within
their own culture, we could not
explain the situation in terms that
were culturally and spiritually under-
standable to them. Edna’s son may
have been experiencing a great deal
of guilt related to the fact that he was
driving the car. He was obviously
distraught for the entire time, and I
wondered if he was receiving indi-
vidualized support from Edna’s
other family members. In retrospect,
his visibly expressed emotion may
have conflicted with the reserve that
is the cultural norm. I had detected
some tension between father and
son and wondered then if it was cen-
tered on guilt and resentment. It
seemed to me most likely that the
son’s emotional expressions disturbed
older family members rather than
inviting their support and comfort.
Spiritual Assessment
Just as the nursing process and
certain protocols are often helpful in
guiding interventions, a model of
spiritual care is valuable, especially
in circumstances that are not ordi-
nary to routine care. Fitchett’s model
of spiritual assessment9 would have
been applicable in this case. Although
it was impossible to interview Edna
directly and difficult for us to inter-
act with her family, our team might
have been better able to provide
spiritual care in this situation if we
had had a deeper understanding of
Buddhism as assessed through the 7
dimensions of Fitchett’s model9 (see
Table). This model is a useful guide
to spiritual assessment and helps in
24 CRITICALCARENURSE Vol 25, No. 6, DECEMBER 2005
Fitchett’s model of spiritual assessment: 7 dimensions9
Dimension
1. Beliefs and meaning
2. Authority and guidance
3. Experience and emotion
4. Fellowship
5. Ritual and practice
6. Courage and growth
7. Vocation and consequences
categorizing important data in order
to implement the nursing process
more efficiently in a plan of care.
As it became apparent that
beliefs and spiritual traditions were
an important component of the lives
of Edna and her family, it was
important to allow ample time and
opportunity for the family to partici-
pate in activities that had meaning
in Buddhism. As moments passed
bringing Edna closer to the end of
her life, her family worked to create
a peaceful atmosphere and prepare
her spirit to leave her body with seren-
ity. “All Buddhists have faith in (1)
Buddha; (2) his teachings, called the
dharma; and (3) the religious com-
munity he founded, called the sangha.
Buddhists call Buddha, the dharma,
and the sangha the Three Refuges or
Three Jewels.”8 “Buddha preached
that existence was a continuing cycle
of death and rebirth. Each person’s
position and well-being in life was
determined by his or her behavior in
previous lives.”7 Buddhism also places
much emphasis on the concept of giv-
ing. Any act of giving is considered
Description
Personal or religious mission, purpose of
events or circumstances, perception of
meaning of life
Individual or group in which individual or
family places trust and seeks guidance;
resources (religious writings or texts) to
which patients or their families may refer
Perception of event or circumstance;
emotional tone emerging from experience
Formal or informal community that shares
beliefs or common practices
Meaningful activities and specific traditions
Encountering doubt, change, and challenges
Expressions based on moral and ethical
decisions, realizing a calling toward beliefs
auspicious and promotes a peaceful
death and rebirth.7
Guidance may or may not have
a spiritual basis. It is important to
establish a rapport and gain the trust
of patients and their families and/
or explore their existing resources
while encouraging the use of those
resources. It is essential to allow
patients and their families to be
their own authority on the type of
care they most need, and it is imper-
ative that we do our best as health-
care providers to meet those needs.
Edna’s family seemed to seek guid-
ance through each other and some
of the traditions of Buddhism itself.
It was apparent that Edna’s family
had great confidence in the purposes
of the ritual actions they performed.
Our responsibility was to facilitate
those rituals and practices.
The experiences surrounding the
death of a loved one can establish a
spiritual connection when family
members are confident in their
beliefs and the results of ritual. The
entire experience became mission
driven for Edna’s family in the last
moments of her life. Edna’s family
openly displayed much sadness. Once
the decision was made not to resus-
citate her, I watched the emotional
tone change from sadness and fear to
urgency. The urgency was mostly
around preparation for a peaceful
environment and necessary rituals to
be performed near the time of death.
Buddhists believe that friends
and relatives have a responsibility to
help loved ones have a peaceful death.
This belief promotes the best possi-
ble rebirth, according to the teach-
ings of Buddhism.7 The presence of
others during times of crisis and
stress is often more of an individual
preference than a religious prefer-
ence. The presence of people other
than Edna’s family members sig-
naled the likelihood of an ongoing
support system. Several extended
family members and friends within
their Buddhist community were pres-
ent during the last hours of Edna’s
life. This fellowship was extremely
important to the group and pro-
moted a more healing environment
for them.
Actions such as placing the dress
over Edna’s body and the candles,
ribbon, and flowers have great mean-
ing. Buddhist images are often sur-
rounded by flowers as a symbol of
protection from the gods. Candles
are sometimes lit to welcome ances-
tral spirits.7 Personal items left with
Edna for her “journey” were also part
of Buddhist ritual and tradition.
These rituals were a means of caring
for Edna and giving her survivors
some control within the situation.
These practices were extremely impor-
tant to the outcome of Edna’s spiri-
tual journey.
The intensive care unit can be a
frightening environment for anyone.
Fear is intensified by the feeling of
isolation one has when surrounded
by people who do not speak the same
language and a culture that may be
very different from one’s own. The
young woman’s request for candles
and flowers and for an assurance that
Edna would be dressed showed
tremendous courage and commit-
ment to the woman’s beliefs. Recog-
nition of her courage empowered
the young woman to participate in
Edna’s care in a significant way.
It was apparent that Edna’s imme-
diate family was unsure of what they
should do about whether or not to
resuscitate her if her heart stopped
beating. They did, however, exhibit
a great sense of devotion to the nec-
essary rituals once the decision was
made.
The process of Edna’s dying
shifted the priority from Edna herself
to her family and their spiritual
needs. Spirituality provides coping
resources.9 The spiritual well-being
of the family members was of
utmost importance. What happened
in the hospital would affect their
coping and healing in the future.
Moving Forward
and Looking Back
“Although verbal conversation is
integral to a typical spiritual assess-
ment, some clients may not be able
to speak, hear or cognitively under-
stand a verbal assessment.”9 Specific
guidelines that address the needs of
a nonverbal patient and/or a non–
English-speaking family can help to
eliminate oversights that could result
in long-term adverse outcomes. It is
important for nurses to remember
that the experiences of patients’ fam-
ilies in the intensive care setting in a
tragedy such as Edna’s is one that
CRITICALCARENURSE Vol 25, No. 6, DECEMBER 2005 25
leaves a lasting impression, often
centered on interactions with health-
care providers.
The lack of time in this case was
another barrier to comprehensive
spiritual care. Even simple commu-
nication was time-consuming because
of the language barrier. We never
located a Laotian translator during
the 3 days of Edna’s admission. Since
then, the hospital has contracted
with a different service. Staff mem-
bers were instructed about the use of
the service, and quick reference guides
were placed in several locations
throughout the unit. As the primary
care nurse for Edna, I was deter-
mined to learn about the Buddhist
faith in order to understand some of
her family’s needs and to provide the
family with some comfort.
Unfortunately, as much as I
would like to, I could never go to
such lengths for every patient in my
care. Perhaps it would not seem so
difficult if protocols for assessing
spiritual needs became as routine as
protocols for assessing vital signs. A
unit-based cultural awareness com-
mittee would be an ideal and effec-
tive way to prepare for the challenges
we faced. As we try to learn about pop-
ulations within our own community,
no matter how much of a minority, a
reference could be created and used
in situations such as this case. Cre-
ating such a reference would fur-
ther the concept of holistic care for
patients and their families.
Under ideal circumstances, we
could have implemented several
effective and spiritually appropriate
interventions. In the critical care
context of Edna’s situation, and under
the time constraints imposed by her
unstable and deteriorating condi-
tion, comprehensive spiritual sup-
port was impossible. Nevertheless, we did not entirely
neglect spiritual nursing care for Edna and her family,
and with understanding and flexibility on the part of
both the family and the staff, at least we provided some
of the core elements of important rites.
A Buddhist representative as part of the healthcare
team or at least a Laotian-speaking translator would have
been helpful. Despite the minimal spiritual resources that
were available, I have always thought that we provided
the best care we could as Edna “left for her journey.” Care
of the spirit requires care by the spirit. The spirit resides
in the soul and is manifested by the actions of the heart. I
think that Edna’s family recognized that our actions
expressed our caring for her spirit and that, ultimately,
we did not fail them.

Acknowledgment
I thank Julius G. Goepp, MD, for extensive review and criticism of this manuscript.

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 CE Test Test ID C0562: Intensive Spiritual Care: A Case Study
Learning objectives: 1. Using the framework of Fitchett’s model of spiritual assessment, describe dimensions of spiritual assessment and their definitions
2. Recognize key components and appropriate interventions for Edna and her family to support their spiritual care 3. Describe lessons learned in the care of
Edna and her family that positively affect future spiritual care provision of the Buddhist patient
1. Which of the following factors most affected the interactions with Edna’s family 7. Edna’s son visibly expressed emotion for her entire stay in the intensive care
during the initial hours of her time in the intensive care unit? unit. How was this likely interpreted by the other family members?
a. Lack of ability to effectively communicate a. Edna’s husband was actively supportive and understanding of his son’s grief.
b. Edna’s fear and anxiety about medical procedures b. The son’s emotional expressions disturbed older family members.
c. Disagreement between the medical and nursing staff as to futility of care c. Edna’s son’s active expression of grief invited support and comfort.
d. Guilt and remorse of Edna’s husband for causing the motor vehicle collision d. The family expected such expressions of grief.

2. Which of the following best describes the dimension of authority and
guidance as described in Fitchett’s model of spiritual assessment?
a. Meaningful activities and specific traditions
b. Encountering doubt, change, and challenges
c. Individual, group, or resources (written) in which the individual or family places
trust and seeks guidance
d. Perception of event or circumstance
3. On the basis of Laotian culture, why is it important to avoid touching Edna’s head
or shoulders if at all possible?
a. Touching the head or shoulders prevents the individual from moving into the other
realms after death.
b. This is the area of the body in which the spirit resides.
c. According to Oriental medicine, this can interrupt the flow of Chi.
d. Touching this area of the body is against the patient’s religion.
4. What is the probably the best rationale for providing a dress for Edna as she
approached death?
a. To keep her body warm as she approaches death
b. To respect both cultural importance of modesty and family desire for her to be dressed
appropriately for travels at the end of life
c. To remind the nurses and physicians to provide individualized, holistic care
d. To cover any intravenous catheters and wounds that occurred during her accident
5. Which of the following is true regarding the Buddhist tradition globally?
a. Buddhism is a minority religion worldwide with approximately 1 million followers.
b. Few Laotians follow Buddhist teachings.
c. Many Laotians are of the Hmong ethnicity and generally practice Theravada Buddhism.
d. Buddhists do not believe in rebirth or reincarnation.
6. Which of the following is true regarding expression of emotions in Laotian
culture?
a. Female family members frequently verbally and nonverbally express strong
emotions within the Laotian culture.
b. Being a patriarchal culture, the male family members are expected to verbally
express strong emotions.
c. Laotian children are encouraged to express strong emotions through emotional
outbursts.
d. Effusiveness and expression of strong feelings are not valued in the Laotian culture.
8. Which of the following is not a common component of all Buddhist faiths?
a. Belief in Buddha
b. Dharma
c. The Five Jewels
d. Sangha
9. Who should be the authority on the end-of-life care the individual
ultimately needs?
a. Religious leaders
b. Physicians
c. Religious texts and Holy Writings
d. Patient and family
10. Once the decision was made by the family to not resuscitate Edna, what led
the emotional tone to change from sadness to one of urgency?
a. Urgency to slow down the death process
b. Urgency to remove the husband and son from the immediate surroundings
c. Urgency to create a peaceful environment and prepare for necessary rituals
d. Urgency to call a Buddhist religious leader to preside over her death
11. What do flowers and candles represent in the Buddhist tradition to the
dying?
a. Flowers represent eternal life; candles provide light for the journey to heaven.
b. Flowers represent protection from the gods; candles welcome ancestral spirits.
c. Flowers represent opening and renewal; candles represent rebirth.
d. Flowers represent dharma; candles represent Buddha.
12. Which of the following changes occurred as the result of caring for Edna and
her family?
a. The hospital contracted with a different translator service, and quick reference
guides were provided to educate staff.
b. Intensive courses in spiritual care at the end of life were offered.
c. Buddhist leaders came in to lead group discussions with staff.
d. The hospital translator who provided services during Edna’s last few days pro-
vided feedback and support to staff.

Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. K a 2. K a 3. K a 4. K a 5. K a 6. K a 7. K a 8. K a 9. K a 10. K a 11. K a 12. K a
Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb
Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc
Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd
Test ID: C0562 Form expires: December 1, 2007 Contact hours: 1.5 Fee: $11 Passing score: 9 correct (75%) Category: A Test writer: Kimberly Brown, RN, MSN, CS-FNP
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CRITICALCARENURSE Vol 25, No. 6, DECEMBER 2005 27