The spiritual experiences of patients with diabetes- related limb amputation

Abstract

Background:

Confrontation with the consequences of diabetes causes a crisis in physical, mental, and spiritual dimensions. Sometimes the spiritual crisis can be tremendous. Since spiritual health coordinates different aspects of human life, this study aimed to identify the spiritual health of patients with defects caused by diabetes.

Materials and Methods:

This was a qualitative-phenomenological and descriptive study and the participants were selected from rehabilitation centers in Isfahan and Valiasr Hospital in Zanjan. A purposive sample of 15 participants underwent deep interviews. Colaizzi’s method of analysis was used to analyze the data.

Findings:

outcome of this phase of the study was 173 codes and 2 groups that included hindering factors in spiritual health and the promotion of the relation with God. The concepts that patients had experienced as hindering factors of the treatment process were disappointment and hopelessness, guilt, feeling distant from God, quitting obligatory acts and knowing God as cruel. The concepts that patients had experienced as contributing factors to the healing process were resorting to Imams, God’s ordering the disease as a reward, fear of God’s punishment, believing in miracles, being closer to God, believing in the mercy of God, returning to religious practice, feeling of enjoying life and knowing that the disease is the atonement of sins.

Conclusions:

With regard to the importance of spiritual and religious care as one of the tasks of nurses, as the key members of health team, they should respect the patients’ beliefs and values in addition to considering their physical and mental conditions.

INTRODUCTION

Although the mortality rate in diabetic patients due to ketoacidosis and infection is declining, deaths from diabetes complications including diabetic foot complications has increased dramatically.[1] According to some reports, its rate in the first year after amputation is 13–40 percent, in the third year, 35–65 percent and in the fifth year it is 39–80 percent, which figures are comparable to death rates in malignancies.[2] In addition, the loss of job and the need for medical and nursing care, reduction in social and family interactions, and lifestyle changes are the major problems that influence the family and socioeconomic status of these patients.[3] The absence of the feet and lower limbs can be extremely problematic for these patients and exerts too much energy for walking; therefore, amputation of higher limbs or development of ulcers may occur.[4] Ultimately, these patients with amputated legs need long-term hospitalization, rehabilitation, home care and social support.[5]

Organ amputation due to diabetes causes crisis in the physical, mental, and spiritual life of the patients. In this case, the spiritual health is the unique element that can harmonize physical, mental and social aspects of the human life and is necessary for coping with the disease.[6] As a matter of fact, when the spiritual health is seriously at risk, a person may experience emotional disturbances such as loneliness, depression and loss of meaning in life.[7]

The spirit of prayer is a deep human instinct, which is the center of humanity, and where the passion and knowledge to communicate with the world comes from. Forms and statements of people who pray are different: speaking, listening, waiting and wailing.[8]

Organ amputation due to diabetes makes patients physically and mentally disabled. It exposes them to severe stress and they seek different approaches to cope and adapt to life. Koenig believes that religion creates a positive attitude towards the world and makes the person powerful against unfortunate events in life such as diseases and helps to improve the life with motivation and energy. This increases tolerance and acceptance of situations that cannot be changed. In many cases of emergency in which science is unable to help a person, this issue is of vital importance especially in serious cases.[9]

The increasing interest of medical scientists to the impact of praying in the treatment of other diseases can be indicative of treatment of some diseases in case of modern medicine failure. On the other hand, medical researchers also acknowledge the importance of medical procedures of traditional and complementary therapies including prayer to treat the diseases. Even the western scientific community has recently published articles showing that doctors cannot be indifferent to the religious beliefs of patients for treatment.[10] This study was conducted to understand the spiritual experiences of the patients with organ amputation due to diabetes.

MATERIALS AND METHODS

This is a qualitative and phenomenological study. The aim of phenomenological studies is to understand the phenomena of human experience through the analysis of participants’ verbal explanations of experiences. The study population consisted of patients with defects, caused by diabetes, who had referred to rehabilitation centers in Esfahan and Zanjan provinces. Sampling was purposive and the inclusion criteria for participants were the injury caused by diabetes and the willingness to participate in the interview. There were 15 participants entered the study (8 men and 7 women at 50–70 years of age).

Data were collected based on deep interviews that took about 60 minutes. The interviews were performed at patients’ homes in a quiet place for patients. All interviews were fully recorded and all participants were given a code based on the interviews. In this study, the researcher tried to be cautious with the information collected to be free from any kind of bias and to avoid persons with poor memory and those who could not provide the correct information. In the interviews, the researcher attempted to withdraw his assumptions about the phenomenon under study and thus help to strengthen the data.

Open questions were asked during interviews to allow participants freely describe their experiences. They were asked that “How has your life changed compared to before the disease?” In response, they described their life experiences with this disability, and how their performance was changed due to the disease. During the interview, the patients focused on cases where the disease led to their functioning. When it was necessary to clarify the data in specific areas, the questions were asked in details. Finally, participants were asked if they wanted to provide alternative explanations in relationship with their disease.

The data were analyzed using Colaizzi’s seven stages. The researcher wrote down the participants’ statements through repeated listening to in-depth interviews. Ambiguous cases were tackled on the telephone or in person (step one). After the formation of concepts and ideas from each interview, the next interview was conducted. The above process was repeated for each interview (second stage of Colaizzi’s method). After the all interviews, the concepts were formulated in particular subjects and were classified into categories (third stage) and eventually all ideas were combined so that a complete description of the phenomenon under the study was derived and presented (the fourth, fifth and sixth stages). Finally, the concepts were returned to the participants and were analyzed (the seventh).

In this study, the criteria for validity and reliability of data were Lincoln and Guba. In order to make the study believable, the researcher was engaged in long-term data collection and analysis. The participants and the research partners also reviewed all the data. To achieve reliability and objectivity of the research data, the account access was used. To increase the portability of the present study, the complete research project was introduced.

FINDINGS

There were 15 patients participating in this study, comprised of 7 women and 8 men. The age range of participants was between 50-75 years with mean age of 59.7 years. Length of diabetes was between 5–30 years and the length of organ amputation caused by diabetes also varied from 2 weeks to 11 years with mean of 4.2 years. The education level comprised of uneducated to junior high school. Regarding employment, 53.3 percent of the participants (8 people) lost their jobs and were unemployed due to organ amputation caused by diabetes. About 66.6 percent (10 people), a leg was amputated below the knee and 26.6 percent of the participants (4 people) both legs were amputated below the knee area. In one patient both legs below the knee and the middle finger were amputated due to diabetes.

The results of the interviews were classified in 173 codes and 2 categories. The inferred subjects were spiritual health disorder and promotion of communication with God. The concepts derived from patients’ experiences as factors interfering spiritual health in the treatment process were disappointment and hopelessness, guilt, feeling distant from God, quitting obligatory acts and considering God cruel. Factors promoting the healing process were deemed by God, fear of God’ punishment, belief in miracles, being closer to God, believing God to be merciful, returning to religious practice, enjoying life and indicating the disease as the atonement of sins.

Most of the participants, encounteringdiabetes-related organ amputatio, said that in such circumstances, intellectual protections, religious sources, and having a strong relationship with a higher power could improve the quality of life, and support the individuals and reduce the severity of symptoms. One of the participants expressed his experiences in turning to practice religion as follows:

“I was deemed to cut my foot to know God, I am sure there is a wisdom behind this, I’ve been weak in a prayer. I was wavering, but when my leg was cut, I Celt much closer to God, I know God took my foot, but after this incident, I feel that God wanted to try me, before this, if my prayer was late, I did not become upset. But now, if I do not perform my prayer on time, I will get upset, I feel that I did not do an important job, I become worried with no reason …” (Participant 1). Another participant stated “When my uncle came to visit me, he said the disease is the expiation of sins. Whenever this is said, my heart becomes calm, but I did not commit a sin to deserve such a punishment. Even, I had not bothered anything in my life. I had satisfied all my customers and they were all happy with me. I do not know if there was a sin. I do not remember, I wish, everything could be finished in this world …” (Participant 3). “Since my foot (right foot) has been cut off, I rub it every day. As I cannot bend, I kiss the palm of my hand instead of my foot. I apologize to my leg; I ask it to forgive me. I’m afraid; it may give testimony against me in the doomsday and tells God that I had been overeating because our hands and legs have rights and we must consider this …” (Participant 5). “Our tenant is a believer who always reads the Quran. I was once in a bad mood one afternoon. I called her to come to our house. When she saw that I was confused, she said, let me read the Koran for you to be calm. I was as relaxed as she started reading. Although I am illiterate and I do not understand anything from the Quran, when I hear the peaceful verses of the Quran, I forget my sorrows …” (Participant 7). “I participate in the middle of Moharram mourning ceremony every year and in mourning ceremonies every Thursday, but when my leg was cut, I did not go there anymore because I feel I’m too far from God and as a result, these ceremonies cannot help …” (Participant 10). “It is a few months that I have quitted my prayer now. When the wounds of the foot were fine after surgery, at fast; I performed my prayer in sitting position, but I realized that I do not feel good in just sitting and praying, I just hurt myself …” (Participant 15).

DISCUSSION

The prayer and vow are likely to enhance the human’s tolerance against diseases and problems[11] Communication with the source of existence and asking him to help would repair the physical and mental powersof man and relieves a lot of disorders and diseases[12]. Therefore, the appeal to the Imams in patients with organ amputation due to diabetes is high. Several studies have also shown that when the spiritual health is at a serious risk, prayers in acute cases may face difficulty. In these cases, praying for the patient can be an important spiritual intervention. One of the most useful sentences in the form of prayers could be the short ones, asking God for fulfillment of the needs, melting away the fears and giving hopes to the patient and ultimately remembering that God is able to meet the needs of the patients.

If the patient is depressed, angry or upset or suffering from extreme pain, the expression of praying sentences is like the salt to the wound. Nurses should pay close attention in the implementation of these provisions, and if the patients are upset, they should leave them alone.[13] In this regard, a research by Tracy et al. was conducted on two thousand nurses in critical care units in which 55% of nurses reported that patients and families were asking them to pray.[14] Another study which studied the effects of prayer on blood infection, randomly employed 1691 experimental and 1702 control patients. Parameters studied included duration of fever in patients, duration of hospitalization and mortality in the hospital. The results of this study showed a significant difference between the duration of fever and length of patients’ stay that was lower in the intervention group compared to the control group. The frequency of deaths was not significantly different in both groups.[15]

Nowadays, some of the organizations that evaluate health care systems and are responsible for granting accreditation to them, suggest that the spiritual needs of the patients in health care should be also evaluated. American Psychiatric Association recommends that doctors should ask for patients’ spiritual or religious orientation. These recommendations indirectly mean that patient care and treatment include respecting various patients’ needs.[16] Finally, the importance of spiritual and religious care, which is today considered as one of nurses’ tasks, urges them as the key members of health teams to respect patients’ beliefs and values as well as their physical and mental aspects.[11]