# Documented rituals in pediatric intensive care: a decade of sacramental and symbolic practices in a pluralistic clinical setting

## TL;DR

This paper explores how spiritual and symbolic rituals are used in pediatric intensive care units over a decade, highlighting their role in diverse clinical and cultural contexts.

## Contribution

The study provides a detailed characterization of sacramental and symbolic rituals in a German NICU/PICU, revealing patterns of initiation, faith alignment, and clinical timing.

## Key findings

- Most rituals were initiated by healthcare staff and performed by clergy.
- Rituals clustered in cases with uncertain survival outcomes and were often used in time-critical situations.
- Ritual–faith congruence increased with longer survival trajectories, and cross-faith rituals were rare.

## Abstract

Rituals with spiritual or symbolic meaning form an integral part of pediatric intensive care, yet their timing, initiators, and contextual functions remain insufficiently described. In secularizing and religiously diverse societies, understanding how such practices are documented and enacted is essential for ethically grounded care. This study characterizes sacramental and symbolic rituals in a German tertiary neonatal and pediatric intensive care unit (NICU/PICU), examining initiation patterns, faith alignment, and survival-related timing.

We conducted a retrospective descriptive analysis of 135 neonates and infants who received a documented ritual between 2013 and 2024. Rituals were categorized as sacramental or symbolic. Initiators, performers, clinical context, and survival category were recorded. Faith alignment was defined by the correspondence between family affiliation and ritual performer. Data from chaplaincy and clinical documentation were analyzed descriptively.

Most rituals were initiated by healthcare staff (≈ 67%) and performed by clergy (≈ 70%). Rituals occurred across the full range of survival outcomes but clustered in intermediate prognostic categories, where uncertainty was greatest. Symbolic and staff-led rituals were used predominantly in time-critical situations, particularly when clergy were unavailable or denominational alignment was unclear. Cross-faith rituals were rare and mainly observed in acute phases. Ritual–faith congruence increased with longer survival trajectories. No distinct non-sacramental religious rituals were documented, likely reflecting under-capture of informal practices.

Ritual practice in pediatric intensive care extends well beyond last rites, encompassing symbolic, anticipatory, and adaptively tailored acts integrated into routine clinical care. These patterns reflect the influence of urgency, availability, and cultural diversity on ritual expression. Documentation gaps limit full quantification and underscore the need for prospective, mixed-methods studies and inclusive institutional frameworks for culturally and spiritually responsive care.