J Relig Health (2012) 51:11241136

DOI 10.1007/s10943-010-9419-7
ORIGINAL PAPER

The Effects of Spirituality and Religion on Outcomes

in Patients with Chronic Heart Failure
Jesse J. Naghi Kiran J. Philip Anita Phan
Laurent Cleenewerck Ernst R. Schwarz

Published online: 2 November 2010

Springer Science+Business Media, LLC 2010

Abstract Heart failure (HF) is a chronic progressive disease with marked morbidity and
mortality. Patients enduring this condition suffer from fluctuations in symptom burden such
as fatigue, shortness of breath, chest pain, sexual dysfunction, dramatic changes in body
image and depression. As physicians, we often ask patients to trust in our ability to ameliorate their symptoms, but oftentimes we do not hold all of the answers, and our best efforts
are only modestly effective. The suffering endured by these individuals and their families
may even call into question ones faith in a higher power and portends to significant spiritual
struggle. In the face of incurable and chronic physical conditions, it seems logical that
patients would seek alternative or ancillary methods, notably spiritual ones, to improve their
ability to deal with their condition. Although difficult to study, spirituality has been evaluated and deemed to have a beneficial effect on multiple measures including global quality
of life, depression and medical compliance in the treatment of patients with HF. The model
of HF treatment incorporates a multidisciplinary approach. This should involve coordination
between primary care, cardiology, palliative care, nursing, patients and, importantly, individuals providing psychosocial as well as spiritual support. This review intends to outline the
current understanding and necessity of spiritualitys influence on those suffering from HF.
Keywords

Spirituality
Religion
Heart failure
Palliative care
Prayer

Introduction
Heart failure (HF) is a chronic progressive disease with marked morbidity and mortality.
Patients enduring this condition suffer from fluctuations in symptom burden such as
fatigue, shortness of breath, chest pain, sexual dysfunction, dramatic changes in body
image and depression (Hunt et al. 2009; Lang and Mancini 2007). In addition, the condition is complicated by medication side effects, requirements to strictly adhere to low-salt
J. J. Naghi
K. J. Philip
A. Phan
L. Cleenewerck
E. R. Schwarz (&)
Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd,
Suite 6215, Los Angeles, CA 90048, USA
e-mail: ernst.schwarz@cshs.org

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and low-calorie diets, a reduction in physical conditioning with reduced cardiac capacity as
well as hospitalizations sometimes requiring invasive diagnostics and treatment. Although
therapy has improved in the recent past and future therapies are promising, this debilitating
condition still portends a significant threat to patients quality of life (Hunt et al. 2009).
As physicians, we often ask patients to trust in our ability to ameliorate their symptoms,
but oftentimes we do not hold all of the answers, and our best efforts are only modestly
effective. In HF and other chronic diseases such as cancer and chronic obstructive pulmonary disease, this can be especially true and may add to the stress of these illnesses and
worsens the burden of the disease. In the face of incurable and chronic physical conditions,
it seems logical that patients would seek alternative or ancillary methods, notably spiritual
ones, to improve their ability to deal with their condition. Although patients are measurably
affected physically and mentally by their disease, the effect of chronic HF on ones
spirituality and reciprocally spiritualitys effect on ones HF are largely understudied. This
article will provide a systematic review of the current literature regarding the role which
spirituality plays in patients suffering with HF.

Spiritualitys Importance to Chronic Disease

Spirituality is a very common term, but one that is notoriously difficult to define, and this
makes studying spirituality uniquely challenging. This aspect of human nature relates to
deep, often religious, feelings and beliefs, including a persons sense of peace, purpose,
connection to others, who are often connected with beliefs or intuitions about the meaning
of life (Vachon et al. 2009). Spirituality may also be defined as an existential perspective
that may or may not be tied to organized religion.
Many individuals who consider themselves highly spiritual deny any religious ties
(Beery et al. 2002). For some, spirituality may involve belonging to a large group who
share a similar belief system, while others may find meaning, connection and inner peace
on an individual level significant only to themselves. The common theme among definitions of spirituality seems to relate to ones desire for finding purpose in life. In light of this
aspect of spirituality, it becomes apparent that those suffering from chronic diseases and
facing uncertainty as to the course of their lives would potentially benefit from spiritual
reflection (Coward and Reed 1996).
Assessment of spirituality, in terms of manifestations, degrees of intensity or psychosomatic effect, is challenging, given the multiple definitions and domains within spirituality itself. Tools used to achieve a gauge of spirituality include subjective interviews as
well as objective questionnaires. These questionnaires often include subscales to differentiate existential and religious variables. As a result, such variations in approach to
measurement can complicate reliability between studies. Although these questionnaires
may seem nebulous, the importance of spirituality in relation to clinical assessment should
be stressed since patients often harbor significant spiritual burdens that may complicate
disease management.
Certainly, spirituality is often connected with religion since the latter provides a
structured environment for spiritual exploration and practices in daily life. Religions such
as Judaism, Christianity or Hinduism are based on the existence of a higher power and the
healing properties of spiritual experiences. The stories told in both the Hebrew Bible and
the Christian Testament make a clear association between spirituality (sometimes
expressed as faith) and the power to cure illness. The practice of anointing of the sick,
for example as seen in the Roman Catholic sacramental tradition, is performed by a priest

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to bring spiritual and physical strength to those in need. Oftentimes, this anointing ritual is
performed when an individual is approaching death, but terminally ill patients are often
encouraged to call upon this healing practice earlier in the course of their disease
(David 2008).
Members of faith communities (congregations) typically hold regular meetings to
partake in a spiritual experience through services of prayers, praise and ritual events such
as Holy Communion. Although the message sent to these groups from their spiritual
leaders may be uniform, there is generally a subjective and personal interpretation of these
teachings such that the application of these spiritual teachings to daily life is highly
variable among individuals. A religion such as Buddhism, for example, has a different
approach to providing a structured spirituality to its followers than does the Abrahamic
religions. In Buddhism, group gatherings have less importance while individual efforts
toward self-reflection and inner-peace serve as a common value. However, the underlying
goal remains similar between religious groups inasmuch as most individuals who describe
themselves as practicing spirituality strive to achieve healing through an understanding that
there is a significant transcendent reality beyond the physical world.
Certainly, prayer is a fundamental component of religion and serves as a way for
individuals to express their spirituality. Prayer acts as a bridge between an individual and
their understanding of the spiritual world. Multiple forms of prayer exist, which include
conversational prayer, meditative prayer, intercessory prayer and ritualistic (or liturgical)
prayer (Jantos and Kiat 2007). In performing the act of prayer, one appeals to the notion
that there is the possibility of communication with a higher power. This higher power can
be praised for the good in an individuals life, questioned for the bad or asked for assistance in times of need. The central importance of prayer in religion is evident by the
ritualistic practices of each group. Among others, Christianity, Judaism, Islam and Buddhism all encourage a schedule of prayer that is meant to stimulate one to leave the realm
of daily physical existence and transcend to a spiritual level.
The desire to engage a higher power is understandably common among patients with
chronic disease states such as chronic heart failure as they wrestle with significant existential, religious and spiritual issues (Selman et al. 2007). The suffering endured by these
individuals and their families may even call into question ones faith in a higher power. In
addition, some may feel that their condition was brought on by unethical, immoral or
unspiritual conduct. Whatever the perception may be of the relationship of causality
between spirituality and the onset of ones condition, the loss of control of ones physical
state can have a significant impact on purpose and meaning in living. In some cases,
spirituality seems to be threatened by chronic disease states but at the same time, spirituality can be emboldened by the understanding of ones mortality (Griffin et al. 2007).
This threat may be responded to in several manners. In some, spirituality is disavowed
as a defense strategy, with patients feeling that they have been abandoned. On the opposite
end of the spectrum, others embrace spirituality as a method for holding on to and
improving their life. Indeed, religious struggle in patients with end-stage HF has been
associated with more depression, and fear of death when compared to those who have a
sense of religious well-being (Edmondson et al. 2008; Fitchett et al. 2004).
The assessment of spiritual adjustment in patients with chronic HF has yielded a threestep process (Westlake and Dracup 2001). In a study interviewing patients in different
stages of HF, it was observed that a generalized approach to spirituality was commonly
exhibited. In these patients, regret toward past behaviors and lifestyles predominated early
in disease. Following this phase, patients struggled to find meaning in their present
experience of HF symptoms. The final spiritual adjustment included a search for hope and

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an inner quest to reclaim optimism. Although spirituality has been shown to have a
significant protective effect on fear, suffering, hopelessness and morbidity, it is understandable that substantial inner struggle with spiritual fastidiousness exists in these
chronically ill patients (Hall 1997, 1998; Levin 1996).
In chronic illness such as heart failure, spirituality may serve as a coping mechanism to
alleviate the physical and mental stress resulting from the condition and the possible end of
life. Although some individuals express a reaction of permanent or temporary spiritual
abandonment, existential anxiety and lack of purpose in life have been described as the
ultimate stress factors. Of interest, only little is known in regard to spiritual well-being in
patients with chronic HF.

The Role of Spirituality in Heart Failure

As a progressive, chronic disease, symptoms and co morbidities of HF are studied on a
timeline throughout the disease. Likewise, spirituality in HF has been approached as a
variable that may fluctuate throughout the course of a patients disease. Murray et al. studied
the patterns of social, psychological and spiritual decline in patients with HF (Murray et al.
2007). His group followed 24 patients with HF with sequential in-depth interviews conducted by a social scientist. During the interviews, questions mainly pertained to general
issues that the patients were facing as well as their views regarding care and support
received. Conversational responses were categorized under several dimensions and assessed
by level of need. In regard to social and psychological needs, these two aspects seemed to
closely parallel physical decline and were especially affected by acute exacerbations and
hospitalization. In an attempt to evaluate the spiritual component, the study showed that
although overall spirituality decreased during phases of physical decline, the relationship to
physical decline was not absolute. Indeed, spirituality seemed to fluctuate throughout the
early, middle and even terminal stages of disease. As the disease progressed, patients
interviews reflected progressive loss of identity, increased dependence and loss of a sense of
meaning in the world. At other times, patients were emboldened by coming to terms with
their life and a sense meaning. In addition, the authors reported that suffering, often a
subjective factor, was sometimes ameliorated by religious belief while others sometimes
concerned themselves with judgment or divine indifference. Interestingly, a patients level
of spirituality was reported to be influenced by health professionals understanding of this
aspect of care. Spirituality, unlike other physical and mental components of chronic disease,
seems to have a course independent of physical decline and suggests that even in late stages
of HF, this may serve as a potential avenue to affect the quality of life.
As symptoms in HF can be severely limiting, measures of quality of life become of
central importance in the effective treatment of this condition. Multiple assessments of
quality of life have been validated and include Health-Related Quality of Life (HRQOL),
Disease-Specific Quality of Life (DSQOL) and Global Quality of Life (GQOL). Several
studies have assessed the relationship between level of spirituality and its influence on
measures of quality of life. In a study performed by Westlake et al., physiologic measures,
neuroticism and spirituality were examined as variables possibly affecting HRQOL
(Westlake, et al., 2002). Interestingly, her groups study found a significant relationship
between functional class, 6-min walk test performance and neuroticism but no relationship
between the measurement of spirituality and HRQOL. A separate study performed by
Beery et al. looked more specifically at spiritualitys effect on different aspects of quality
of life (Beery et al. 2002). Once again, spirituality was seen to have no significant effect in

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improving HRQOL or DSQOL but surprisingly, GQOL was significantly improved in

patients reporting higher spirituality. In this case, spirituality was further parsed into
existential and religious components. Most of the improvement obtained in GQOL was due
to higher existential well-being.
Interestingly, existential well-being did not correlate significantly with religious wellbeing, which suggests that these two aspects of spirituality are indeed separate. An
explanation of the difference in impact which spirituality has on various measures of
quality of life stems from the questions asked in each model. The HRQOL and DSQOL
predominantly assess physical symptoms, whereas GQOL is more balanced between
physical and emotional components. Physical symptoms are less likely to be improved by
spirituality, as noticed in the HRQOL and DSQOL measurements. On the other hand,
emotional aspects of HF are more amenable to spiritual well-being and do show correlation
in all three assessments. In summary, spiritual well-being is beneficial to GQOL, an
important measure of the emotional and mental response to disease in the treatment of HF.

Psychological Factors
Psychological factors are intimately related to symptom burden in patients with HF which
may be ameliorated by spiritual well-being (Vaccarino et al. 2001; Williams et al. 2002). In
fact, modification of psychological suffering, such as anxiety and depression, is of central
importance in a holistic treatment of patients with HF (Gottlieb et al. 2007). Patients with
HF and concurrent depression have a statistically significant increase in symptom burden
(Gusick 2008). As much as 16% of symptom frequency and 18% of symptom intensity can
be attributed to depression. Concurrently, spirituality has been shown to moderate
depressive symptoms in patients with HF (Bekelman et al. 2007; Bekelman et al., 2009). In
a study performed by Bekelman et al., spiritual well-being in patients with HF, assessed on
two subscales (faith and meaning/peace), was compared to the prevalence of depression
among these patients. Greater spirituality was independently associated with less depression, regardless of the patients overall health status. On further subscale analysis, the
benefit was entirely derived from patients showing higher meaning or peace. Interestingly,
patients with HF who have more religious attendance, prayer, Bible study and high
intrinsic religiosity often have significantly faster remission of depression (Koenig et al.
1988). These results are in concordance with the previous studies and suggest that patients
suffering from chronic HF have higher spirituality benefit in terms of less depression and
symptom burden.

End of Life Planning

Patients with HF have a variable prognosis and often meet an unexpected death. In this
context, end of life planning is multifaceted and includes self-assessment of goals and
values in medical care, stabilization of financial arrangements, interpersonal and spiritual
peace as well as self-reflection on the meaning of ones life. Central to reaching these goals
is the acceptance of a realistic prognosis. Spirituality can provide the framework that
patients use to accept the realism of death in the relatively near future. Patients experience
spirituality in a variety of ways when confronting the end of life, which may include
spiritual despair, renewed spiritual effort and spiritual well-being (Williams 2006). The
ability for one to make spiritual peace influences patients readiness to accept and face the

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reality of their disease process. A unique study performed by Park et al. investigated the
relationship between HF patients expectancy of longevity and measures of spirituality
(Park 2008). Patients with HF were asked to predict how long they had left to live at two
clinic visits separated by 6 months. They were simultaneously assessed for spiritual forgiveness, religious meaning, daily spiritual experience and spiritual struggle. On analysis,
patients were shown to have overly optimistic estimates of their longevity, regardless of
functional capacity or physiologic prognostic indicators performed at each clinic visit.
Interestingly, those patients who had a significant decrease in estimation of longevity over
the 6-month period were seen to have an increase in religious life meaning and spiritual
forgiveness. Their group also noted a decrease in spiritual struggle among those with
shifting longevity estimates toward less time. The significance of this study suggests that
patients with HF who engage in spiritual practice and see increased religious meaning in
their life become more comfortable in accepting a realistic prognosis to their condition. In
addition, the amount of spiritual struggle, which is related to poorer health and depression,
is ameliorated in these patients (Exline et al. 2000). It is therefore possible to conclude that
realistic goals and expectations can be affected by spirituality in patients with chronic HF
and are important when discussing treatment options as well as end of life planning.

Treatment Compliance
Spirituality can affect the willingness of patients to accept and comply with medical
therapy in chronic HF which is a condition requiring long-term commitment to medical
therapy, lifestyle modifications and the possibility of risky therapeutic interventions.
Medical non-adherence represents a major barrier to HF therapy observed in 3080% of
patients (Powell et al. 2008). Many psycho-social aspects contribute to medical adherence.
By applying Roys Self-Concept Model to patients with HF, Thomas was able to identify
several predictors of medical compliance (Roy et al. 2009; Thomas 2007). Roys SelfConcept model states that any stimulus is perceived as either a threat or a challenge to
ones self-concept of body image, body sensation, self-consistency, self-ideal and moral
ethicalspiritual self.
Stimuli perceived as a threat are generally reacted to with defense mechanisms and a
lack of adherence. On the other hand, stimuli perceived as a challenge are reacted to with
problem-solving behaviors and accepted with adherence. Thomas (2007) assessed medications, diet and exercise as stimuli when studying patients with HF. She found that
patients perceiving the recommended HF regimen as a threat to body image, self-consistency, body sensation and self-ideal were significantly less likely to adhere to the regimen.
Conversely, those who perceived the regimen as a challenge to moralethicalspiritual self
were the most likely to adhere to medical therapy.
In addition to medical compliance, patients with HF are often asked to undergo therapies with inherent risk in order to improve their condition. Spiritual coping methods have
been identified, which affect patients willingness to undergo such treatments (Van Ness
et al. 2008). In particular, patients who report more closeness to God and spiritual growth
are more likely to undergo potentially life-sustaining interventions involving risk. The
medical treatment of HF involves significant life adjustments to be made, and varying
levels of compliance to these regimens are observed. Based on these studies at hand,
spirituality has a significant effect on a patients willingness to adhere to and accept risk
involved with HF therapies.

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Therapeutic Implications of Prayer in Heart Failure

Prayer may have multiple therapeutic implications for patients with HF. Spirituality often
incorporates prayer as a method of communicating with a higher power. For instance, the
prevalence of prayer for health conditions among adults reached 35% in Harvard Medical
School. Among these, 70% reported prayer to be helpful in their condition (McCaffrey
et al. 2004). Although prayer is technically difficult to study in an objective manner,
several proposed benefits of prayer have been described. First, individuals performing
prayer have a slowed respiratory rate, decreased heart rate and blood pressure as well as
increased peripheral perfusion, slower brain wave activity and hypometabolic state
(Benson et al. 1974). These physiologic responses are in contrast to the undesirable
vasoconstriction and hypermetabolic state found in patients with HF, which makes them
potentially beneficial.
Prayer also has a positive effect on emotion and can improve anxiety (Seeman et al.
2003). In addition, prayer relies on the belief in the supernatural, eternal and transcendent.
For those suffering from physical or emotional symptoms of HF, prayer provides the
means for a temporary respite from the world of space, time and matter (the natural world).
This is described by many patients as a mechanism that is able to alleviate suffering by
allowing transcendence into a supernatural state in which a higher power can provide care
(Jantos and Kiat 2007). Although such conclusions are necessarily controversial and open
to interpretation, it may be argued that intercessory prayer (prayers petitioned on behalf of
others) have been shown to significantly improve outcomes in patients undergoing coronary artery bypass grafting and those admitted to the cardiac (intensive) care unit (Benson
et al. 2006; Byrd 1988). In summary, we suggest that prayer, as an expression of
spirituality, has potential to benefit patients with HF.

Self-care and Spirituality

Spirituality should be addressed as an essential facet of self-care in patients with HF
(Steinhauser et al. 2006). Recently, the American Heart Association published a statement
calling for increasing self-care among patients with HF. This would include personal
attention to medical and dietary compliance, exercise regimens, vaccinations and emotional as well as social support (Riegel et al. 2009). This statement has important implications as it places a responsibility upon patients for their own health. In addition, it calls
for health care providers to promote self-awareness and self-care among our patients
through open discussions. It is safe to conclude that spirituality should be included in selfcare inasmuch as it functions as a unique method to provide emotional support. In practical
terms, we suggest that during clinic visits, patients spiritual well-being as well as changes
in spirituality should be noted and discussed. Referral to spiritual advisors as an adjunct to
medical treatment may have significant benefit. By discussing spiritual issues early on in
the disease process, a framework for future discussions can be created to build upon.

Spirituality as Palliative Care

The treatment of HF should take a comprehensive approach including multiple aspects of
care (Goodlin 2009). Palliative care has an important role even in the early stages of HF and
can be instrumental in assessing and directing patients to appropriate spiritual goals (Oates

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2004). The supportive care given by these specialists provide therapy focused on communication, education, psychosocial and spiritual issues in addition to symptom management.
Specifically, palliative care can provide coping techniques to patients and families, which
may alleviate the uncertainty of the new diagnosis of HF. Patients with HF suffer from a
chronic, progressive disease process that is accompanied with not only physical but substantial psychological and spiritual hardships. It is paramount to include a comprehensive
palliative treatment program including spiritual well-being as a goal of therapy.

Spirituality in Cardiac Transplantation

For patients with end-stage chronic HF, the final treatment possibility is cardiac transplantation. Along with this potential therapy comes substantial spiritual, moral and ethical
controversy. This option can cause significant stress, debate and resistance to treatment
among those who are not aware of their religions teachings regarding organ transplantation. Although no religion directly opposes cardiac transplantation, several caveats
regarding appropriateness remain. As the donor of a heart must be deceased, the definition
of death has come to central importance. Recently, Pope Benedict XVI discussed the
conditions for cardiac transplantation. His statement included the topic of brain death and
respect for the life of the donor as a necessary requirement for organ donation. Interestingly, he described organ donation as the purest form of altruism and called for the
recipient to respond to this with an equally generous display of love (Schwarz and Rosanio
2009). In this regard, we suggest that patients who undergo cardiac transplantation would
benefit from spiritual guidance and exploration before and after transplantation. The
prolonged hospitalization requires coping strategies including family support, religious
conviction and diversional activities (Savage and Canody 1999).
Of relevance here is the work of Walton et al. who have developed a spiritual model that
explains the benefit of faith, presence and sustaining hope in the recovery phase after
cardiac transplantation (Walton and St Clair 2000). According to this model, cardiac
transplantation is influenced by spirituality. In terms of practical recommendations, this
implies that patients should be well informed of their religions viewpoint on transplantation. Furthermore, health care providers should feel comfortable communicating to their
patients the notion that spirituality serves as a strong method of coping with both the
preparation for and the recovery after transplantation surgery.

Religious Teachings on Heart Transplantation

The majority of the worlds religions have a relatively passive position in regard to
donating or accepting organs and believe that this should be an individual decision. Several
religions do take a more active and assertive point of view in supporting the life-saving
ability of organ donation and encourage this as a good deed. The viewpoints of various
religions on this topic are outlined in Table 1.
As stated above, the Roman Catholic Church has adopted an active role in encouraging
cardiac donation and regards transplantation as a beneficial act. According to recent
statements, it is taught that the fraternal bond between humans dictates that this act should
be undertaken given the pre-existing willingness and confirmed death of the donor. The
family of the deceased may find comfort in knowing that their loss has greater meaning and
has provided a gift to another. In addition, organ donation is considered the ultimate form

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Table 1 Summary of specific religions beliefs regarding organ and tissue donation
Religion

Views on transplantation

African Methodist
Episcopalian

Transplantation is an act of neighborly love and charity. Donation is encouraged

Amish

Approved if there is a definite indication that the health of the recipient would
improve, but reluctant if the outcome is questionable

Bahai

Transplantation is acceptable if it is prescribed by medical authorities. Bahaists

are permitted to donate their organs and bodies for restorative purposes and
medical research

Baptist

Donation is supported as an act of charity, and the church leaves the decision to
donate up to the individual

Brethren

The 1993 Church of Brethrens Annual Conference resolution in support of

donation states: We have the opportunity to help others out of love for Christ,
through the donation of organs and tissues.

Buddhism

Organ and tissue donation is a matter of individual conscience and places a high
value on acts of compassion

Catholicism

Donation is viewed as an act of charity and fraternal love. Donation is something

good that can result from a tragedy and a way for families to find comfort by
helping others

Christianity

The Christian Church encourages organ and tissue donation, stating that we were
created for Gods glory and for sharing Gods love

Christian Scientist

Donation and transplantation are an individuals decision. The Church of Christ

Scientist takes no specific position on transplants or organ donation as distinct
from other medical or surgical procedures

Episcopalian

The Episcopal Church passed a resolution in 1982 recognizing the life-giving

benefits of organ and tissue donation and encourages all Christians to become
organ, blood and tissue donors as part of their ministry to others in the name of
Christ, who gave his life that we may have life in its fullness.

Evangelical

A resolution passed in 1982 encouraged the members to sign and carry Organ
Donor Cards. The resolution also recommended that it become the policy of
our pastors, teachers and counselors to encourage awareness of organ donation
in all our congregations.

Greek Orthodox

Not opposed to organ donation as long as the organs and tissue in question are
used to better human life

Hinduism

Hindus are not prohibited by religious law from donating their organs and tissue.
This act is an individual decision. Hindu mythology has stories in which the
parts of the human body are used for the benefit of other humans and society.
There is nothing in the Hindu religion indicating that parts of humans, dead or
alive, cannot be used to alleviate the suffering of other humans

Islam

The religion of Islam strongly believes in the principle of saving human lives. The
majority of the Muslim scholars belonging to various schools of Islamic law
have invoked the principle of priority of saving human life and have permitted
the organ transplant as a necessity to procure that noble end. Organs should not
be stored but transplanted immediately

Jehovahs Witness

According to the Watch Tower Society, Jehovahs Witnesses believe donation is a

matter of individual decision. Jehovahs Witnesses are often assumed to be
opposed to donation because of their belief against blood transfusion. However,
this merely means that all blood must be removed from the organs and tissue
before being transplanted

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Table 1 continued
Judaism

All four branches of Judaism (Orthodox, Conservative, Reform and

Reconstructionist) support and encourage donation. If it is possible to donate an
organ to save anothers life, it is obligatory to do so, even if the donor never
knows who the beneficiary will be. The basic principle of Jewish ethicsthe
infinite worth of the human beingalso includes donation of corneas, since
eyesight restoration is considered a life-saving operation. Organ donation is
actually a moral obligation. It is the only mitzvot or good deed an
individual can perform after death

Lutheran Church

This was the first national church to publicly call for Americans to donate their
organs after death by signing an Organ Donor Card

Mormon

The Church of Jesus Christ of Latter-Day Saints believes that the decision to
donate is an individual one made in conjunction with family, medical personnel
and prayer. Donation is not opposed

Pentecostal

Pentecostals believe that the decision to donate should be left up to the individual

Presbyterian

Presbyterian churches encourage and support donation. They respect a persons

right to make decisions regarding their own body

Protestantism

Encourage and endorse organ donation

Seventh-Day Adventists Donation and transplantation are strongly encouraged

Shinto

In Shinto, the dead body is considered to be impure and dangerous, and thus quite
powerful, so injuring the dead body is a serious crime. Donation is considered to
be such an injury. Family is concerned that the itaithe relationship between
the dead person and the bereaved peoplenot be harmed

Quakers

Organ and tissue donation is believed to be an individual decision

Unitarian Universalist

Organ and tissue donation is widely supported by Unitarian Universalists. They

view it as an act of love and selfless giving

United Church of Christ United Church of Christ people, churches and agencies are extremely and
overwhelmingly supportive of organ sharing
United Methodist

The United Methodist Church passes a policy statement regarding donation

stating that The United Methodist Church recognizes the life-giving benefits of
organ and tissue donation, and thereby encourages all Christians to become
organ and tissue donors by signing and carrying donor cards or drivers licenses,
attesting to their commitment of such organs upon their death, to those in need,
as a part of their ministry to others in the name of Christ, who gave his life that
we might have life in its fullness.

of altruistic charity. Orthodox Christian theologians and national churches have typically
expressed comparable support for transplantation (Harakas 1990).
Protestants, which by history and self-declaration include Evangelicals and Episcopalians, are also strong supporters of organ donation. Many denominations have adopted
policies encouraging their members to obtain organ donor cards. Likewise, Judaism
strongly supports and encourages organ transplantation. One of the primary tenets of
Judaism is the infinite value of human life. Consequently, any effort to sustain or save a
human life is mandated by many rabbis. The act of organ donation is considered a commandment, or mitzvah. Cardiac donation, as well as other organ donation, is one of the few
good deeds that can be performed after death.
Similarly, Islam teaches the supreme value of human life. To save a human life is of
prime importance, and organ transplantation is regarded as one of the noblest means to this
end among many Muslim scholars (al-Mousawi et al. 1997; NHSU 2009).

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The teachings of Hinduism have several views on organ transplantation. For one,
Hindus believe in reincarnation and an individuals Karma. When an individual donates an
organ or blood, some of their Karma is transferred to the recipient. However, Hindus hope
that they will be liberated from the cycle of rebirth. Yet by donating an organ, it is assumed
that they will have a next life in which the recipient will repay their lost Karma. Of note,
Dharma or righteous giving is supported as one of the most significant of virtues by
Hinduism, and thus organ transplantation is regarded as one of the highest levels of
sacrifice (Randhawa et al. 2010).

Conclusion
The chronicity of symptoms in HF contributes to both physical and mental morbidity.
Although recent advances in medical management continue to improve outcomes in these
patients, there is still significant potential for improvement in quality of life issues. In this
regard, spirituality has been shown to affect patients with chronic HF on multiple psychosocial levels. Importantly, spirituality can remain intact as a potential coping method
throughout late and even terminal stages of HF. During these times, spirituality can offer
peace and a sense of deeper meaning in ones life. In addition, spirituality often enables
patients to accept that not everything is under their control (Vollman et al. 2009). In terms
of potential benefits that have been studied, significant reductions in stress, depression and
symptom burden have been observed in patients who take an active role in improving their
spiritual lives. Measurements of global quality of life show significant improvement in
those who report spiritual well-being.
As medical and lifestyle modification compliance is central to HF therapy, it is
important to note that patients with more spirituality tend to adhere to these medical
recommendations. Unfortunately, HF remains a condition in which mortality is still high
and variable. Patients who are able to grow spiritually and confront their condition have an
increased likelihood of having more realistic outlook and may benefit in terms of having
significant closure on their lives.
Finally, the topic of heart transplantation should not be disconnected from its spiritual
implications. Understanding the variety and complexity of world religions views (which
are often connected with spirituality) regarding organ transplantation can be difficult to
fully understand. Health care professionals may certainly conclude that this is outside the
scope of their practice. However, it is suggested that referral to a specialist or inclusion of
an acceptable spiritual advisor in discussions with the patients should be considered.
Even among devout members of each faith, trepidation in regard to religious views is
common and may interfere with a patients decision to undergo life-saving transplantation.
Serious attention and sensitivity to each individuals spiritual understanding of the
meaning of cardiac transplantation should be evaluated. Although no religion directly
forbids transplantation, consultation and discussion between patients and religious leaders
should be encouraged to alleviate any concerns and provide necessary spiritual support
prior to undergoing the stresses of transplantation. In conclusion, the effects of spirituality
in chronic HF are substantial enough to warrant further studies aimed at understanding and
documenting the depth of their benefit. Certainly, greater importance should be placed in
assessing this component in patients with HF.
Conflict of interest The authors have no conflict of interest.

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