Trauma 2010; 12: 183 192
Religion in trauma care: grand narratives and
sacred rituals
Tricia Scott
This article outlines major religious practices observed in the UK and discusses how
associated spiritual and religious custom and rites should be honoured by emergency
practitioners. The article does not intend to be an all encompassing text on religion but
to heighten awareness among emergency practitioners about various spiritual and
religious considerations affecting patients and families under their care during critical
and sometimes life-changing events in their life.
Key words: religion; spirituality; customs; rites; emergency; trauma care
responsive, sensitive trauma care. The following text
Introduction
introduces grand narratives associated with a range
of mainstream religions encountered by UK trauma
Globalisation has significantly impacted on the
health sector in recent years. European and inter- practitioners followed by an outline of various
national amendments to health legislation encour- associated sacred rituals.
The British Social Attitudes Survey (2006)
aged health professional migration to treat a wider
reported on the public response (3000 people) to
range of people with diverse religious needs.
the question  Do you regard yourself as belonging
Increased migration also impacts on the health
to any particular religion? A reduction in a sense of
sector as workers seek employment opportunities in
belonging to the Church of England was reported
other countries (Organisation for Economic Co-
(22.2% in 2006 compared to 29.3% in 1999). There
operation and Development, 2001; Castles and
has been an increase in the number of Muslims 
Miller, 2003). Increased global travel creates
3.3% (2006) compared to 1.8% (1999). There was
higher levels and a wider geographical spread of
an increase in reported belonging to the Hindu
health tourism than previously encountered.
religion  1.4% (2006) compared to 0.6% (1999). A
Finally, increasing numbers of individuals and
Jewish sense of belonging was reported as 0.5%
families adopt UK refugee status to escape the
(2006) compared to 0.3% (1999). Sikhism remained
conflict of war or civil unrest and practitioners work
static at 2.2% whilst there has been a reduction
on development programmes in remote foreign
in the sense of belonging to the Buddhist religion
regions and need to be well-informed regarding
at 0.2% (2006) compared to 0.5% (1999).
ethnicity, culture and religion providing develop-
Interestingly, there was a reported increase in
mental health services (Medicins san Frontiers,
people who declared their belonging to the category,
1997). The need for health professionals to be
 no religion at 45.8% (2006) compared to 42.6%
aware of a wider range of sacred religious rituals is
(1999).
greater than ever before in their quest to provide
Department of Academic Emergency Medicine, Academic
Centre, The James Cook University Hospital, Marton Road,
Background literature
Middlesbrough, UK.
A literature search was conducted using MeSH
Address for correspondence: Dr Tricia Scott, Department of
terms  religion and  spirituality identifying that
Academic Emergency Medicine, Academic Centre, The James
a dearth of published literature exists related
Cook University Hospital, Marton Road, Middlesbrough TS4
3BW, UK. Email: [e-mail] to emergency medicine. The term  religion is
ß The Author(s), 2010. Reprints and permissions:
http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/1460408610376708
184 T Scott
understood to be  A set of beliefs concerning the us tick is uncomfortable and it is also  . . .easier to do
nature, cause, and purpose of the universe, especially the  them and  us bit as otherwise it may be
when considered as the creation of a superhuman necessary to give up some positional power (p. 18).
agency. It usually involves devotional and ritual In a United States of America study Jang et al.
observances and often a moral code for the conduct (2004) assessed the religious spirituality of
of human affairs. (National Library of Medicine, Emergency Medical Services personnel and their
2010).  Spirituality is explained as the  Sensitivity or perception of the spiritual needs of ambulance
attachment to religious values, or to things of the patients. Emergency Medical Technicians (EMTs)
spirit as opposed to material or worldly interests. were asked to complete a three-part survey relating
(National Library of Medicine, 2010). Themes most to demographics, personal practice and perceived
associated with spirituality are charity, community patient needs. Responses were compared to ambu-
or connectedness, compassion, forgiveness, hope, lance patients declared needs from an earlier study
meaning and morality. So, religion and spirituality and 143 EMTs and 89 paramedics returned com-
are inextricably associated and enacted in every day pleted surveys. EMTs and paramedics did not
lives strengthening a sense of religious community. perceive spiritual concerns as often as reported by
 Religion was searched using the following ambulance patients, nor did they commonly inquire
databases for the period 1989-2009: AMED, BNI, about the religious/spiritual needs of patients.
EMBASE, MEDLINE, PsycINFO and CINAHL, Johnson (2008) considered the impact of disaster
revealing 17,745 texts whilst  spirituality and  faith on individuals and communities and discussed the
revealed 11,350 and 8801, respectively. Other search importance of maintaining ritual, providing a place
terms included  accident and emergency ,  pre- to grieve and, tending to the needs of victims and
hospital and  trauma (including physical and their dependents. When emergency personnel and
psychological). Combined sets and duplicate elim- chaplaincy intervene, spiritual first aid does not
ination created 19 articles of significance. A search advocate any one faith or belief system for provid-
of evidence-based reviews, guidance documents and ing care and comfort for people during times of
specialist collections produced one systematic great need (Taylor, 2008). Taylor goes on to explain
review (Coruh et al., 2005) containing 15 studies how physical first aid stabilises an injury and this
concluding that religious activity may improve analogy is applicable to the provision of spiritual
health outcome though none of the cited studies care: stabilise, assess, provide care and comfort and,
were related to the context of accident and emer- refer as necessary.
gency or trauma. A Department of Health docu- From an injury prevention perspective, Falcone
ment (DH, 2009) offers guidance regarding equality et al. (2006) used pre-test, post-test methodology to
and diversity issues and practical responsive mea- implement a community participatory faith-based
sures to facilitate the expression of one s faith whilst youth injury prevention group to target motor-
a dedicated section contains specific considerations vehicle restraint use in the United States of
regarding emergency and disaster planning. America. Control and intervention churches were
A literature review by Spencer (2002) considered compared and the results demonstrated significant
child abuse as an event, which is likely to interfere improvements in restraint use compared to control
with normal social, cognitive and spiritual develop- churches. In particular, there was a 72% reduction
ment. In another study, Zhang et al. (2006) analysed in unrestrained children, a 25% increase in rear-seat
data from 74 suicide attempters and 92 accident child restraint and nearly 20% increase in driver
injured patients admitted to six emergency rooms in restraint use.
North eastern China. Compared with accident Redeker et al. (1995) interviewed 100 adolescent
victims, among other characteristics, the Chinese and young adult trauma victims in an urban trauma
suicide attempters were more likely to believe in a centre in the United States of America to define
religion/superstition. demographic, social, environmental, psychological
Gilbert (2009) explored cognitive blocks to spir- and developmental antecedents to risk-taking
itual care and asked why practitioners may find behaviours and to examine the types of trauma
difficulty in recognising the spiritual dimension and and rate of recidivism. Of the sample, 89% experi-
in  doing human . Looking inwards at what makes enced trauma related to interpersonal violence,
Trauma 2010; 12: 183 192
Religion in trauma care 185
including firearm injuries, stab wounds and blunt for policy-makers on how to integrate spiritual and
trauma. Male gender, unemployment, past arrest, mental health issues into the formal disaster
lower levels of spirituality and higher levels of response system. Gilbert (2002) presented an
anthology of the human predicament, the health
anger/aggression and thrill-seeking accounted for
care professionals story and the health care work
25% of the variance in the number of risk-taking
place within an overarching context of spirituality
behaviours. Hong et al. (2008) used interview
methods to explore the characteristics of 73 vio- and offered guidelines on spirituality for staff in
acute care services encouraging practitioners to
lently injured patients (VIPs) who were evaluated
listen to the patient s whole story and highlighting
and treated at an urban university medical emer-
the importance of spiritual awareness. Reese (2009)
gency room. Thirty-eight percent had previously
investigated the relationship between spirituality
been arrested for assault, for 52% it was their first
and compassion fatigue amongst emergency care
experience while 48% reported previous experience
providers in a Level 1 Trauma Centre in Vancouver.
with violence and desire for revenge featured
A convenience sample of registered nurses, flight
frequently (62%). This report discusses how spiri-
paramedics, chaplains and physicians (nź89) sug-
tuality and religion is used to cope with the
gest a trend towards significant spirituality and
aftermath of these attacks.
compassion fatigue; an inverse relationship between
Favazza (2009) discussed nonsuicidal self-injury
age and compassion fatigue; and a significant
(NSSI) explaining the importance of body modifi-
relationship between age, years of experience,
cation rituals as culturally sanctioned methods of
existential well-being and burnout.
achieving physical healing, spirituality and social
In conclusion, the search suggests that specific
stability. Knowledge of these factors may help
literature to guide practitioners on practical mea-
clinicians to engage with people who attend the
sures to uphold the religious and spiritual dimen-
emergency department after practising NSSI.
sion among emergency patients is limited.
Clinical insight may positively impact on the
approach of therapists who treat such individuals
whose behaviours typically illicit feelings of counter-
transference.
Grand narratives and sacred rituals
Thompson et al. (1999) used an observational
When a trauma patient enters the emergency
design incorporating semi-structured interviews
department they may be in physical and/or spiritual
with 79 family members of burns patients 1 3
pain and once physically stabilised may derive
days after injury. Content analysis established
comfort from an emergency practitioner who com-
thematic data. Amongst other support structures,
municates in a caring way. The following section
spirituality was considered to be a major source of
offers a short philosophical summary of a range of
support.
religions and is followed by a series of discussions
Digieri et al. (2006) described the management of
outlining specific sacred rituals and aspects of life
a child multiple trauma victim with severe anaemia
which the respective religion sanctifies. Emergency
due to hypovolaemia whose family would not
practitioners may find it necessary to accommodate
authorise blood transfusion because of their
strict requirements of religious orthodoxy as com-
Jehovah s Witness faith. Dipasquale et al. (2005)
pared to the more flexible practises of non-orthodox
provided a case report documenting the successful
followers, as a person is a unique blend of their
use of temporary balloon occlusion (internal
culture, religiosity and spirituality.
tourniquet) to minimise blood loss during an
open-reduction internal fixation of an acetabulum
fracture in a Jehovahs Witness. The religious tenets
of this faith preclude the use of blood transfusions
Buddhism
and certain other blood products, based on the
interpretation of Acts 15: 20, 28-29. Buddhism focuses on the liberation of the human
Koenig (2006) offered guidelines to faith com- mind from anguish, the word  Buddha literally
munities and organisations on how to provide meaning  Enlightened One . A state of being
effective services in times of crisis and an argument insightful or  dharma (Gill, 2003). The main aim
Trauma 2010; 12: 183 192
186 T Scott
of Buddhism is to achieve Nirvana, the ultimate and Unitarian. The Christian message is to love
refuge, releasing the person from the material one s neighbour whilst central Christian themes
world.  Karma is a negative energy generated concern the Trinity: God the Father (creator),
from evil acts, which locks a person into a cycle of God the Son (Jesus Christ) and, God the Holy
death and rebirth to be reincarnated into new lives Spirit which promise eternal life and pardon from
and suffering the consequences of their behaviour in sin (Gill, 2003). Followers declare faith in Jesus
their old life (dukkha). Four noble  truths focus on:
Christ, engaging in prayer and contemplation
the universality of suffering (dukkha), the origin of
within a shared Church community (the body of
suffering due to human desire (tanha), elimination
Christ). Resisting temptation is a feature of the daily
of suffering (samsara) or  endless wandering
struggle of believers and repenting sin is considered
(Keene, 2002) and, finding the  Middle Way , a
to lead to forgiveness and salvation. It is believed that
balanced, measured existence which denounces
Jesus Christ guides followers and enables them to
hedonism (ASA, 2005). The Noble Eightfold Path
share in victory over death and sin. Christians are
to enlightenment concerns personal development in
encouraged to live well, to accept suffering gra-
the understanding of the Noble Truths  speech,
ciously, and to follow Jesus in the   . . .way of the
actions, livelihood, effort, mindfulness and concen-
cross. . .  (Langley, 2002, p. 50) leading to resurrec-
tration. A huge range of sacred texts exist of which
tion and eternal life with God. The sacred text is
one is the Pali Canon  there is no God to worship
The Bible (Old and New Testaments) and teaching is
and meditation provides a path to practise their
through sermon and parables taken from everyday
ideal (Keene, 2002; Gill, 2003).
life.
As most Buddhists are vegetarian there may be an
Modesty should be preserved at all times and
objection to bovine-based products. However, there
females may request the presence of a female
is no religious objection to blood transfusion or
practitioner if they are to undress. The Roman
organ donation. It should be taken into consider-
Catholic Church does not support contraception,
ation that Buddhism condemns abortion and active
abortion or homosexuality. In particular, Jehovah s
euthanasia. Providing peace through silence in the
Witnesses do not accept blood transfusions and do
emergency room is difficult; however, chanting may
not allow the storage of their own blood because it
calm the follower s mind as death approaches and
is perceived to represent the essence of life itself.
the follower should be facilitated to receive support
Some Jehovah s Witnesses may consent to auto-
from a fellow Buddhist (Green, 1993; ASA, 2005).
transfusion during surgery as there is a continuous
There are no special ritualistic requirements for the
cycle of the patient s own blood.
cadaver after a death though the visiting Buddhist
minister or monk should be of the same school of
The prohibition on blood transfusions includes
Buddhism (Hinayana, Mahayana and Vajrayana)
whole blood, red cells, white cells, platelets and
as the deceased (Green, 1993). There is no objection
plasma. Blood fractions such as Factor VIII, anti-
to post-mortem examination and cremation rather
D and globulins are considered to be substantially
than burial is preferred.
different from whole blood and from the basic
constituents that nourish and sustain the body
(Henley and Schott, 1999, p. 541).
It should be acceptable to administer human anti-
Christianity
tetanus immunoglobulin. However, it is advised
to consult the patient and/or family first and
There are two main Christian groups: the
guidance on the management of resuscitation for
Episcopalians (Roman Catholic, Eastern Orthodox,
Lutheran, Anglican) and the non-Episcopalians the Jehovah s Witness is available from The
(Baptist, Congregationalist, Methodist, Reformed, Association of Anaesthetists of Great Britain and
Pentocostal). Various Christian fringe movements Ireland (2005). Consideration should also be given
have Christian origins but modify their practice, to the beliefs of 7th Day Adventists who perceive the
for example, Jehovah s Witness, Christian Scientist, body to be the  Temple of God . Many followers are
Jesus Christ and Latter Day Saints, Unification vegetarian or vegan and avoid in particular, pork,
Trauma 2010; 12: 183 192
Religion in trauma care 187
offal and shellfish which are considered unclean, Orthodox Christians may wish to confess specifi-
therefore, porcine derived insulin and capsules cally to a Priest or Minister and emergency practi-
containing gelatine may be refused (Henley and tioners should contact the relevant member of the
Schott, 1999). Followers may also avoid tea and clergy with request to attend. Last rites should be
facilitated, wherever possible, preferably when
coffee, which should be considered when offering
death is imminent rather than after the death.
refreshments.
Following death Christians hold no religious objec-
The Church of the Latter Day Saints (also known
tion to post-mortem or organ retrieval though
as Mormon) emphasise sexual purity, doctrinal
Jehovah s Witnesses prohibit the receiving of an
orthodoxy and dietary laws. The  Word of
Wisdom outlines the Mormon health code involv- organ.
ing abstinence from alcohol, tobacco and hot
drinks, for example, tea and coffee, though herbal
tea is permitted. Meat is also permitted if eaten
Judaism
sparingly though eating fruit, vegetables and grain
is encouraged (Mormon Church, 2010). On receiv-
Judaism, a monotheistic faith is based on the Old
ing  endowment the follower enters into a covenant
Testament and is concerned with the inner struggle
to spread the faith. Special white undergarments are
to find a higher self. There are five types: Orthodox,
worn day and night for the remainder of the
Conservative, Reconstructionist, Hasidic and
follower s life which should not be removed in the
Reformist. Jews perceive God as an all-powerful
emergency department as they provide a reminder
and all-loving protector of his  chosen people , the
of the sacred covenants and are believed to provide
descendants of Abraham (Langley, 2002). As such,
protection from evil and temptation (Patheos Seek
Jews must take responsibility to uphold God s
Understand, 2010).
commandments (ASA, 2005) through rules of
The seriously ill Christian patient may request
behaviour. Reading the Torah comprising the first
baptism, a ceremony symbolising the spiritual
five books of the Old Testament provides the  Law ,
cleansing of the believer s soul permitting the rite
instruction on moral, physical and religious com-
of entry into the church (Langley, 2002). It is usual
pliance with rules governing purity and social
for a religious minister to perform this ceremony;
justice. During  kaddish (morning prayer) followers
however, in real emergencies, it is accepted that a
wear the  tallit (blue and white robe), the  tefillin
believer who is also a baptised Christian, may
(cube-shaped leather box containing four passages
baptise another by sprinkling water on the forehead
from the Torah) and the yamulke (skull cap).
whilst saying,  . . .I baptise you in the name of the
Sabbath is the day of rest from sunset on Friday
Father, the Son and the Holy Spirit. Prayers may be
evening to the sighting of three stars on the
said and the sign of the cross may be made over the
Saturday evening, a time when Jewish people
person. (Henley and Schott, 1999, p. 468). A record
observe strict religious practice regarding abstinence
of the given Christian names must be made.
from all forms of labour preferring, for example,
Prayer should be facilitated during the patients
not to write, travel or switch on electrical appliances
and families spiritual quest for courage in adver-
(Green, 1993).
sity, forgiveness for sins and either restoration of
When undressing for examination modesty must
health or the receiving of the soul following death.
be upheld as women will prefer to keep their arms
Privacy in prayer should be provided because some
and legs covered and Orthodox Jewish women may
denominations, for example, Pentecostalism may
cover their hair with a headscarf. Additionally they
express loud and sometimes quite emotional prayers
may be reluctant to discuss gynaecology problems
which may also involve  speaking in tongues . In
with their husband and this may also extend to the
contrast, members of the Friends Society (Quaker)
non-Jewish male emergency practitioner. Jewish law
may prefer to sit in devout silence and contempla- forbids any physical contact between man and wife
tion (Freke and Gandy, 1997). When death is when there is any uterine blood loss (Henley and
imminent some followers may request the Schott, 1999).
Sacrament of the Sick to enable confession, pen- The dying Jew may wish to hear or recite special
ance, reconciliation and absolution. Catholic and psalms, for example, Number 23 (The Lord is
Trauma 2010; 12: 183 192
188 T Scott
my Shepherd) and the special prayer (The Shema). the Ramayana, the Upanishads and the
If possible an opportunity should be provided to Mahabharata. Individual prayer may take place
hold the page on which the prayer is written (Green, three times a day (sunrise, noon and before sunset),
1993). After death the body should be minimally using a string of sandalwood beads and offering
handled (and not at all if an Orthodox Jew), covered
fruit or milk to their god or goddess. Spiritual
with a plain white sheet and the Chevra Kaddisha
cleanliness is important, so emergency practitioners
(Holy Jewish Society) should be contacted who will
may need to provide facilities for the patient to
attend to wash and prepare the corpse. It is
wash and rinse their mouth (Henley and Schott,
considered disrespectful to leave the body alone,
1999).
so wherever possible a practitioner should remain
Most Hindu women will need their modesty
until relatives or the Holy Jewish Society arrive. The
protecting, with a sheet covering their body when
eyes of the deceased should be closed ideally by one
undressing and only a female practitioner should
of the deceased s children. Burial rather than
attend them. The cow is considered a sacred animal,
cremation should take place within 24 h of the
therefore many Hindus are vegetarian, so eating
death. When a death occurs on the Sabbath the
eggs, symbolic of life, is to be avoided. Some Hindus
body should not be moved, so it is necessary for
may prefer not to ingest medicines derived from
emergency practitioners to sensitively handle this
alcohol or animal products.
dilemma. The Coroner s Officer should be made
Death in hospital is to be avoided at all costs for
aware that the body is that of a Jew in order to
Hindus as they prefer to die at home. Where this is
respond to the 24 h timeframe for autopsy and
impossible, the dying Hindu patient may be com-
burial. The principle of preservation of life enables
forted by reading one of the Hindu prayer books
the use of organs to help another, so there should be
and may ask to lie on the floor to be nearer Mother
no religious objection to organ donation.
Earth. Hindu boys may wear sacred threads, which
wrap around the torso and permission should be
sought from the patient or next of kin to remove
them. In emergencies, where it may be necessary to
Hinduism
cut the thread, it should be returned to the patient.
Following death, jewellery, sacred threads or reli-
The central tenet of Hinduism concerns belief in one
gious objects should remain on the body (ASA,
ultimate reality, authority of the Veda (holy books)
2005). Emergency practitioners should wear gloves
and that karma and samsara lead to moksha
when handling the cadaver, avoid body washing
(liberation from rebirth) (Kanitar and Cole, 2003).
and cover the body with a plain sheet. Prior to
Hinduism is polytheistic recognising many gods and
placing the sheet over the body, the palms should be
goddesses though Brahma is recognised as the
brought together and the fingertips placed under-
ultimate divinity which is  . . . indescribable, imper-
neath the chin (Henley and Schott, 1999). At death,
sonal and abstract. . . embodied in a range of gods
where possible, a Hindu priest or the family may
and goddesses. Multiple deities have many faces
attend the deceased to perform holy rites involving
permitting each follower to ascribe personal mean-
tying a thread around the neck or wrist, sprinkling
ings to their religious conviction (Freke and Gandy,
holy Ganges water over the dying person or placing
1998). Three spiritual images exist: Brahma the
a sacred  tulsi leaf in the patient s mouth. The
creator, Vishnu the Preserver and Shiva the
family may prefer not to eat or drink anything
Destroyer. There are four paths to salvation:
between the death and the funeral and there may
 Bhakti , devotion to one of the gods,  Karma
also be a request to ask the dying patient to touch
which suggests that good deeds generate good
his/her clothes before distribution to the needy
results whereas bad deeds generate bad results,
(Green, 1993). Though abhorred, there is no real
 Jnana requiring complete understanding of Hindu
objection to post-mortem; however, strong concerns
scripture in order to find liberation from worldliness
and  Yoga which is a spiritual and physical may be expressed particularly where it delays the
discipline enabling worldly detachment and con- funeral. In addition, some families may request that
nectedness with Brahman (Keene, 2002). Four the organs be returned to the body following
sacred books (Vedas) exist: the Bhagavad Gita, examination to enable the deceased to be cremated
Trauma 2010; 12: 183 192
Religion in trauma care 189
with all body parts intact (Henley and Schott, 1999). Time of death is considered to be determined by
No religious objection to organ donation exists Allah alone, so a sense of fate is a feature of this
within the Hindu faith though again, some followers religion and to avoid death through aggressive
may object because the body is not cremated whole. resuscitation is paramount to challenging Allah s
will. Similarly, suicide is considered particularly
sinful. Some may request the trolley be moved or
the patient helped to lay on their right side facing
Mecca. The Imam or a family member may wish to
Islam
recite from the Qur an giving the dying Muslim
patient an opportunity to respond (kalima). The
Islam, translated from Arabic, means  to submit
soul is considered to linger above the body for some
providing a total way of life in both secular and
time after death. Following death the body is
spiritual terms (Keene, 2002). The Five Pillars of
considered to belong to God, therefore no part
Islam provide an obligatory way of life for muslims
should be cut out, harmed or donated (Green,
specifically, the  shahadah declares Allah as the
1993). So the family may be highly offended, were
supreme being (tawhid), prayers  salah occur five
the emergency practitioner to raise the issue of post-
times a day,  zakah concerns the giving of alms,
mortem or organ donation. Organ donation is now
 sawm is the fasting during Ramadan and the  haji
permitted (Lamb, 1993, pp. 133 4) and the diagno-
is the pilgrimage to Mecca generally once in a
sis of brain stem death supported by Sharia Law in
lifetime. Islamic virtues concern purity of speech,
Britain (Henley and Schott, 1999). Some families
charity, patience and beneficence whilst sacred
may wish to perform last offices themselves though
virtues concern faith, hope and trust in God and
it is acceptable for a non-muslim emergency prac-
his benevolent government of the universe. Of
titioner to straighten the limbs, close the eyes and
significance to ill-health, Muslims believe in exercis-
mouth, take any tubes and drains out and seal any
ing patience and constancy in suffering. Restrictions
wounds that may seep bodily fluids.
exist regarding specific animals and food especially
in the daylight hours of Ramadan, and generally in
all bad appetites and desires including sexuality,
supporting purity in motive, thought, word and
Sikhism
deed. Constant attention to God s Message and
cultivation of the desire to get nearer to God is
Sikhism offers a doctrine of salvation through the
prescribed (Shaik Kadir, 2006).
restoration of the human soul to unity with a single
The sacred text is the Qur an, which guides the
all-powerful, ubiquitous and compassionate God
follower to wash five times a day before praying on
who is present in the human soul though,
a prayer mat with the head facing Mecca (south east
  . . .unknowable , without form, without qualities
from the UK). Mibeha prayer beads help a Muslim
and beyond description. . . (Keene, 2002, p. 154).
to recite the 99 beautiful names of Allah. If possible
Sikhism concerns an awakening through the Divine
the emergency practitioner should avoid eye contact
Guru and individual prayer consists of repeating
as it is considered disrespectful. Some Muslims wear
God s name (Guru Nanak or Sat Guru) morning
jewellery containing scripture considered to protect
and night. There are no priests as it is considered
them whilst ill which should remain intact. Many
that all humans have a direct line to God and Sikh
Muslim women keep their bodies covered with a
doctrine recognises other religions as alternative
burqa or chador whilst some wear a headscarf
routes to God. The Sikh cycle of reincarnation
(hijab). Any form of nudity is considered humiliat- supports the view that good karma leads to rebirth
ing and it is prohibited for a woman to have
as a human being whereas bad karma leads to
physical contact with a man who is not her husband
rebirth as an animal. The sacred text is the Guru
unless it is an emergency. During Ramadan women
Granth Sahib and prayer takes the form of reciting
may refuse to be vaginally examined (Henley and five hymns each day and service to others.
Scott, 1999). The giving of blood during Ramadan The Five K s of the Khalsa community should
may be refused as it is considered to further drain remain undisturbed: the kirpan (sword) represents
the body of essential nutrients. readiness to fight oppression, the kangha (comb)
Trauma 2010; 12: 183 192
190 T Scott
represents purity, the kara (bangle) represents each element to enable meaning to be associated
unbreakable oneness with God, kesh or keshas with their emergency department experience.
(uncut hair) including the beard symbolises holiness Culture, as distinct from religion, refers to those
and the kacha or kacchera (shorts worn as under- activities and norms of daily life that add to the
garments) symbolise modesty (Langley, 2002).
sense of community. However, community is often
Many Sikh women wear a headscarf (dupattah or
based on religiosity and perpetuated by the customs
chooni), particularly in public in the presence of
associated with religious observance though it
men. For men, the turban is a sacred symbol and
should be borne in mind that, whilst there are
should be handled with care should it be necessary
varying levels of personal compliance with doctrine,
to remove it for examination following, for exam-
according to how orthodox a follower is,  . . .many
ple, head injury or stroke. A request for removal of
people hold strong views about not having personal
turban and/or breeches may cause embarrassment
religious belief  (DH, 2009).
(Henley and Schott, 1999). Many Sikhs are vege-
Caution is advised in misplaced concreteness of
tarian and may also refrain from eating fish and
the use of the term  religious or  spiritual and in
eggs. Whilst a Sikh may eat meat they may exclude
how these concepts are enacted during emergency
beef and sometimes pork from their diet. Alcohol
encounters. Rather, it is suggested that practitioners
may be acceptable if it is a constituent part of a
try to engage on a spiritual level with the real pain
medicine though animal products may be best
and suffering the emergency patient and their family
avoided.
is experiencing. Emergency practitioners should be
The dying Sikh may derive comfort from reciting
aware that some religions require strict adherence to
hymns from the Guru Granth Sahib or if they are
specific traditions and rituals whereas others, for
too ill a representative of the Sikh Gurdwara
example, Buddhism, may not be so prescriptive. For
(Temple) may offer to do so. In their absence any
some, it is the daily enactment of religious rites
practising Sikh may offer to provide spiritual
which provide spiritual comfort, so followers should
support should the patient request. There is no
be provided with the facilities and time to enact
religious objection to post-mortem examination and
their belief through sacred rituals. So, for example,
the principle of life preservation enables the use of
patients who are waiting may be able to pray if the
organs and blood to help another. In addition, it is
emergency practitioner finds a quiet, private place
acceptable for non-Sikhs to prepare the body after a
in the department. Cleanliness features strongly for
Sikh death but preferably the family should be
some followers, therefore practitioners should pro-
offered an opportunity for ceremonial body wash-
vide soap and water, for example, after toileting and
ing, positioning and covering the body with a plain
before prayer. Where reading of a sacred script is
white sheet. A practical dilemma exists whereby
part of the spiritual journey, particularly towards
when a Sikh dies in the UK the requirement to
death, consideration should be given to whether
cremate the body within 24 h becomes problematic
emergency departments should stock a copy of a
and great care should be taken in explaining this to
range of sacred texts.
the relatives.
Understanding the depth of distress and humil-
iation which individuals feel is of particular concern
should the patient require, for example, vaginal or
rectal examination. Ensure doors, windows, cur-
Discussion
tains and screens are appropriately placed to facil-
itate privacy, minimising risk of exposure by, for
The above text offers a non-prescriptive approach
example, covering the body with a sheet or blanket
for emergency practitioners to heighten awareness
to expose only the part to be examined. Emergency
of sacred rituals to enhance the spiritual care. It
practitioners should seek the patient s opinion as
does not intend to be all-encompassing and only six
religions encountered in UK emergency depart- they may prefer a same sex practitioner to perform
ments are presented. Spiritual care is juxtaposition intimate examination. It is important not to show
to hope, vulnerability, suffering, shame, loneliness, surprise should a woman cover her face with a sheet
coping, empowerment and comfort. Emergency or sari during intimate examination to hide their
practitioners should uphold the central tenets of embarrassment and also to request that their family
Trauma 2010; 12: 183 192
Religion in trauma care 191
Dipasquale T, Michael GR, Simmons P, Zweibel B,
do not learn of the nature of the examination
Bernasek T, Steinberg J, Mangar D. 2005.
(Henley and Schott, 1999).
Temporary partial intra-iliac balloon occlusion for
the treatment of acetabulum fracture in a Jehovahs
Witness: a case report. J Orthop Trauma 19: 415 19.
Falcone Jnr RA, Brentley AL, Ricketts CD, Allen SE,
Conclusion
Garcia VF. 2006. Development, implementation and
evaluation of a unique African-American faith-
It is essential to be patient, attentive and enquiring
based approach to increase automobile restraint
to the religious and spiritual needs of patients
use. J Natl Med Assoc 98: 1335 41.
entering the emergency department and to prevent
Favazza AR. 2009. A cultural understanding of non-
violation, albeit unknowingly, of deeply held spir-
suicidal self-injury. In: Nock MK ed. Understanding
itual tenets. Not only is it necessary to be aware of
nonsuicidal self-injury: origins, assessment and treat-
the various religions and spiritual dimensions to
ment, Washington, USA: American Psychological
care but also towards the need to develop cultural
Association, 19 35.
competence among practitioners. This can best be Freke T, Gandy P. 1997. The complete guide to world
mysticism. London: Piatkus.
achieved by appreciating the differences between the
Gilbert P. 2009. Guidelines on spirituality for staff in
patient s and family s emergency experiences and
acute care services.
those held personally by the emergency practitioner.
Gilbert RB. ed. 2002. Health care and spirituality:
In essence, it is advised to treat people as they would
listening, assessing, caring. New York: Baywood
like to be treated which may not be the same as the
Publishing.
way the practitioner would like to be treated. When
Gill D. 2003. World religions: the essential reference
in doubt, assumptions should be avoided and the
guide to the world s major faiths. London: Collins.
patient asked to clarify exactly how they would
Green J. 1993. Death with dignity: meeting the needs of
prefer their religious and spiritual needs to be met.
patients in a multi-cultural society. London:
Where necessary, translation services must be Macmillan.
Henley A, Schott J. 1999. Culture, religion and patient
accessible and a list of telephone contact numbers
Care in a multi-ethnic society: a handbook for
should be available in the department.
professionals. London: Age Concern.
Hong BA, Olatunde L, McGill KLS, Ridenour TA,
Lucas A, North CS. 2008. Violently injured patients
seen in the emergency department of Barnes-Jewish
References
Hospital: a descriptive study of context, future views
Ambulance Service Association. 2005. Community hand- and spirituality. Mo Med 105: 86 9.
book: a guide to understanding the diverse faith and Jang T, Kryder GD, Char D, Howell R, Primrose J,
ethnic communities in the UK. London: ASA. Tan D. 2004. Spirituality in the emergency depart-
British Social Attitudes Survey. 2006. Available at: ment: the difference between Ambulance patients
www.statistics.gov.uk/CCI/nugget.asp?IDź and Clinicians. Research abstract. Acad Emerg Med
1086&Posź2&ColRankź1&Rank=326 (accessed 11: 451 2.
13 November 2009). Johnson EE. 2008. Memorial services, site visits, and
Castles S, Miller MJ. 2003. The age of migration: other rituals. In: Roberts BC, Ashley WWC eds.
international population movements in the modern Disaster spiritual care: practical clergy responses to
world. Hampshire: Palgrave Macmillan. community, regional and national tragedy.
Coruh B, Ayele H, Pugh M, Mulligan T. 2005. Woodstock, USA: Longhill Partners Inc, 196 205.
Does religious activity improve health outcomes: a Kanitar VPH, Cole WO. 2003. Hinduism. London:
critical review of the recent literature? Explore-NY 1: Hodder.
186 91. Keene D. 2002. World religions. Oxford: Lion Hudson plc.
Department of Health. 2009. Religion or belief: a Koenig HG. 2006. In the wake of disaster: religious
practical guide for the NHS. Available at: responses to terrorism and catastrophe. Philadelphia:
www.dh.gov.uk/en/Publicationsandstatistics/ Templeton Foundation Press.
Publications/PublicationsPolicyAndGuidance/ Lamb D. 1993. Organ transplants. In: Dickenson D,
DH_093133 (accessed 12 November 2009). Johnson M eds. Death, dying and bereavement.
Digieri LA, Pistelli IP, Carvalho CE. 2006. The care of a London: Sage, 133 4.
child with multiple trauma and severe anemia who Langley M. 2002. Eyewitness: religion. London: Dorling
was a Jehovah s witness. Hematology 11: 187 91. Kindersley.
Trauma 2010; 12: 183 192
192 T Scott
Medicins san Frontiers. 1997. Refugee health: an approach Shaik Kadir. 2006. Qur an 33:35. In: Islam explained,
to emergency situations. Oxford: Macmillan. Marshall Cavendish: Singapore, 68 9.
Mormon Church. 2010. Are Mormon dietary laws Spencer D. 2002. Paediatric trauma: when it is not an
similar to Kosher? Available at: http://www. accident. Accid Emerg Nurs 10: 143 8.
mormonchurch.com/680/are-mormon-dietary-laws- Taylor J. 2008. Spiritual first aid. In: Roberts BS,
similar-to-kosher (accessed 5 April 2010).
Ashley WWC eds. Disaster spiritual care: practical
National Library of Medicine. 2010. Available at: http://
clergy responses to community, regional and national
www.nlm.nih.gov/cgi/mesh/2010/MB_cgi (accessed
tragedy. Woodstock USA: Longhill Partners Inc.,
25 January 2010).
106 18.
Organisation for Economic Co-operation and
The Association of Anaesthetists of Great Britain and
Development. 2001. 13 Trends in international migra-
Ireland. 2005. Management of anaesthesia for
tion: annual report  2000. Paris: OECD.
Jehovah s witnesses. Hampshire: Association of
Patheos Seek Understand. 2010. Mormonism worship
Anaesthetists of Great Britain and Ireland.
and devotion in daily life. Available at: http://
Thompson E, Boyle D, Teel C, Wambach K, Cramer A.
www.patheos.com/Library/Mormonism/Ritual-
1999. A qualitative analysis of family member needs
Worship-Devotion-Symbolism/Worship-and-
and concerns in the population of patients with
Devotion-in-Daily-Life.html (accessed 5 April 2010).
burns. J Burn Care Rehabil 20: 487 96.
Redeker NS, Smelter SC, Kirkpatrick J, Parchment S.
Zhang J, Jia S, Jiang C, Sun J. 2006. Characteristics of
1995. Risk factors of adolescents and young adult
Chinese suicide attempters: an emergency room
trauma victims. Am J Crit Care. 4: 370 78.
study. Death Stud 30: 259 68.
Reese MT. 2009. Compassion fatigue and spirituality
with emergency health care providers. Diss Abstr Int
B: Sci Eng 69: 419 27.
Trauma 2010; 12: 183 192
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