Doctors tend to ignore spiritual care or back away from it out of fear of inadequacy or invading patients’ privacy, Dr. Sulmasy said. Often they think they are helping, but underserve patients by turning spiritual questions into technical problems, he said.

For dying patients, the impulse is the reverse, he said: the terminal patient whose spiritual life is outstanding despite great physical distress reports having an outstanding quality of life.

The split is so large that a new model for medical education may be needed, he said. The model would integrate biological, social and spiritual issues in training doctors.

In the short run, doctors must be alert to ways to engage patients spiritually while still letting the medical facts decide the course of care, Dr. Sulmasy said. They should be mindful that patients’ spiritual questions are fundamental — deeper than the biological, moral and ethical issues that concern clinicians and hospital ethics advisory boards, said Dr. Sulmasy, who holds the Sisters of Charity Chair in Ethics at St. Vincent’s Hospital in Manhattan.

“Spirituality is incredibly important in the care of patients and it’s shocking how we do wind up ignoring so much of it,” he said.

When ‘spiritual care’ falls short

The author of four books and an advisor to former New York Gov. George Pataki, Dr. Sulmasy wrote an eye-opening article on spiritual issues in the care of dying patients for a Journal of the American Medical Association series called “Perspectives on Care at the End of Life.” He gave talks at the University of California at San Francisco, which produced the series, and at USF to elaborate on the paper for medical professionals and students.

Dr. Sulmasy opened his USF talk with the case of a 54-year-old man, Mr. “W.” Dying of cancer, the patient was Christian and believed in the possibility of miracles, but also accepted that God might not grant one in his case. In reviewing the transcripts of interviews with the patient’s caregivers, Dr. Sulmasy found that despite the patient’s outspoken spirituality, his spiritual care fell short.

He paraphrased the patient’s primary doctor: “I had deep conversations with him but we never spoke explicitly. I didn’t feel that opening. We tread the line between being disrespectful and probing. I wonder now why I didn’t ask the patient these questions.”‘

Mr. W’s belief in miracles caused some confusion for the medical team. As a result he was transferred to a nursing home rather than to hospice care, where he would have received better treatment for his pain.

“It was stunning the way this man was treated,” Dr. Sulmasy said. “There’s nothing that says the patient who believes in miracles is ineligible for hospice, but somehow the hospice care team felt that belief was an issue.”

A chaplain, though, had correctly diagnosed the underlying problem. As Dr. Sulmasy paraphrased the chaplain: “When I look at a patient I look at the primary, core spiritual need. Is it a request for meaning to try to determine what their life meant? Or are they looking validation of their life? Or trying to reconcile broken relationships?”‘

Meaning, value, relationship

Meaning, value and relationship are the ingredients of spiritual health and become urgent in the last months of life as patients strive for dignity and hope despite losing their productivity and appearance, Dr. Sulmasy said.

“People who were able to find meaning in their illness, meaning in their dying, are people who understand what it is to hope in a deep way,” Dr. Sulmasy said.

Dr. Sulmasy stressed how important it is for dying patients to reconcile relationships with family, friends and God. “The brokenness of their bodies reminds patients in a deep way about the brokenness of their relationships,” he said. “They’re looking perhaps to express their own forgiveness of someone who had hurt them or to try to be reconcile to those they had hurt, to try to bring families and friends together in ways that arise as they’re dying in a very salient way.”

Dr. Sulmasy said patients want their doctors to ask these questions. “We commit ourselves to treating whole persons,” he said. “In fact we have a moral commitment to at least address these questions in a practical way.”

Dr. Sulmasy displayed a detail from a Giotto painting of the dying St. Francis of Assisi. The detail shows a monk kissing the saint’s stigmatic wounds. It is a part of a scene in which St. Francis is dying at home surrounding by his friends and watched over by God. The scene embodies the three ingredients of spiritual health for the dying person — meaning, value and relationship.

“You see a picture of somebody who is surrounded by people who love him, who are supremely present to him, who care about him, care about him as a whole person,” he said. “They are praying with him, engaged with him as a whole person in this experience.

“I think this is death with dignity,” Dr. Sulmasy said. “If it was possible in the 14th century, why isn’t it possible for us in the 21st?”