The Serenity Prayer, and Shared Powerlessness

God, grant me the serenity to accept the things I cannot change,
the courage to change the things I can,
and the wisdom to know the difference.

—Reinhold Niebuhr, 1892-1971

By IAHPC Chair Lukas Radbruch, MD

My term as chair of the board of directors of the IAHPC ends this year, when I will gladly pass the position over to Mary Callaway. During my tenure, I wanted to focus on improving the plight of suffering people in all those regions of the world that are unable to access adequate palliative care, be it for cancer, HIV, other diseases, or because of humanitarian emergencies. 

Thinking about these years I wonder whether I did make a difference at all. There has been progress with the development of palliative care in some countries, but it is so slow, and recently funding streams for international or global health have been diminished rather than increased, in spite of dire situations in so many low- and middle-income countries. On the other hand, I have also been really impressed what the IAHPC has managed to achieve with so little means, fueled only by the engagement and enthusiasm of a small number of dedicated persons. 

IAHPC recently published the Essential and Expanded Palliative Care Packages for Children and Adults as well as a Manual on the Use of Essential Palliative Care Medicines for Adults, which is also available as an online app. We are already receiving feedback that these resources help healthcare professionals working in resource-poor settings. I am really grateful to Liliana De Lima as a motor to all of these projects, but also to others who contributed their time and energy. Katherine Pettus has led our advocacy work, building a formidable network and relationships within international organizations, which makes palliative care visible and, at times, has succeeded in including palliative care in the international agenda. So I am feeling rather ambivalent about our ongoing work: both powerless and courageous.

The following text is based on a manuscript prepared for publication in the German journal Leidfaden [a play on Leitfaden (guideline) and Leid (suffering)], translated using DeepL.com. It seems for me to be a fitting comment on the state of affairs that I, and so many other palliative care experts, are struggling with in countries where they live and in organizations such as the IAHPC. 

Serenity Prayer emerges in the literature

The scientific literature database Pubmed sometimes holds little surprises, and so, for example, six publications from 2011 to 2024 actually appear under the keyword “Serenity Prayer.” The topics are wide-ranging. In one editorial, the serenity prayer is used as a metaphor for new recommendations for dealing with transplant rejection (Vogelsang 2012), or it is recommended to healthcare professionals for dealing with a new electronic patient record (Lee und Smith 2011), or for coping with the approval (or rejection) of research applications (Araj et al. 2024). However, the Serenity Prayer has also been used specifically as a therapy. A pilot study reported the results of nine patients with diabetes mellitus who recited the Serenity Prayer at least once a day but, alas, no effect on blood sugar levels could be demonstrated (Sacco et al. 2011). In a systematic review of Gamblers Anonymous self-help groups, however, the Serenity Prayer was presented as part of a reflective culture that is recited more than 100 times a day—even by atheists, like a mantra—to convey honesty, acceptance, and humility, leading to greater financial freedom, acceptance of reality, and improved social relationships (Schuler et al. 2016). 

The last of the serenity publications provides a completely different connection. An article in the Journal of Palliative Care offers two stories from India that are a hundred years apart (George und Narayanan 2017). It tells the story of Ida Scudder, who as a young woman visited her father in India and was visited during the night by three men, all of whom asked her for help for their young wives during labor when the difficulty of the birth was beyond the help of women in the village. She referred them to her father, the doctor, but all three emphasized that their wives would rather die than be treated by a man. In the morning, she sent her servant to inquire about the fate of the three women and learned that had all died during the night. For Ida Scudder, who wanted to study art in the USA and could not imagine a life in India, this was a turning point. She had the courage to change her plans: study medicine, then return to India in 1900 to work in her father's small clinic to help the women in Vellore in southern India. 

Ida Scudder also had the patience to persevere, while accepting fate. During her first house call to a dying patient, she felt that she had little relief to offer, but had the patient brought from a dark room to the cool veranda, alleviated her suffering as best she could. She stayed for hours, until the end. 

The article continues with a story by one of the two authors, who studied medicine at the college founded by Ida Scudder in Vellore 100 years later. As a young doctor, he treated an elderly patient with advanced cancer. This patient wanted to return home for her final days rather than undergo chemotherapy, which the doctor arranged. Her son, an experienced doctor from the USA, had been with her throughout this time, but did not interfere with the young doctor's treatment. Afterward, the son expressed his heartfelt thanks. The author described his surprise at this gratitude, because he felt that he had failed and had only conveyed bad news. He could only find one explanation: even though he had not succeeded in saving the patient, he was there when the patient needed him.

My colleague Martina Kern calls this "shared powerlessness", staying with the patient in difficult situations when those providing care feel that there is nothing more they can do. Being with the patient and enduring this shared powerlessness has a value of its own. However, it requires overcoming the asymmetry in care, because even in holistic and patient-oriented hospice and palliative care, the hierarchical structure of the healthcare system cannot be eliminated. 

A Canadian study examined the power relations between nurses and patients in home palliative care (Oudshoorn et al. 2007). A total of 33 interviews with nurses and patients were evaluated. The authors refer to a definition by Antony Giddens, "Power is the use of resources—of whatever kind—to achieve a specific result" (Giddens 1984). Both nurses and patients felt powerless. 

However, for nursing staff, it was primarily the framework conditions of their work (at the macro level) within the economic and time pressures of the institution and the standards and guidelines: the power of the system overrides the professional autonomy of nursing staff. At the meso level, nursing staff exercised power over patients, but this could be exercised in both a controlling and liberating manner. Dominant power was exercised by management, e.g., by setting appointments, obtaining information about relatives, or influencing patients to make decisions. In contrast, liberating power was used by taking into account the individual values and goals of patients, respecting patients as experts in their own lives, and making decisions about care together.

At the meso level—the authors quote Foucault: "where there is power, there is resistance" (Foucault 1980)—patients resisted the dominant power claims of nursing staff by not following orders, refusing home visits, or demanding a change of nurse. At the micro level, however, patients felt that these efforts were largely unsuccessful. They felt powerless when the nature and extent of their care was changed without their input or when the continuity of care was not guaranteed. There were many examples of this powerlessness. In some cases, the powerlessness was subtly reinforced by nursing staff, for example, when it was emphasized that the nurse was calling outside of working hours or when nursing staff only used positive reinforcement for the decisions they wanted.

While nurses and patients both exercised power at the meso level, nurses at the macro level and patients at the micro level felt powerless and helpless. At the same time, however, the study also reported positive experiences when patients exercised their "liberating" power to strengthen their self-determination and sense of control. This helped them avoid the feeling of powerlessness. The authors conclude that nurses must not only work to improve their working conditions, but also analyze their working methods. This includes recognizing the power relationships between healthcare professionals and patients, and critically reflecting on how healthcare professionals have used power in their patient interactions. The authors call for further studies on power relations in palliative care to study, for example, to what extent the financing systems for care influence these power relations. 

With this knowledge, we could then specifically consider where we need the courage to change, and where we need the composure to persevere despite our own helplessness and powerlessness and to endure our shared powerlessness together with those affected. 

References

Araj H, Worth L, Jr., Yeung DT (2024). Elements of successful NIH grant applications. Proc Natl Acad Sci U S A  121(15): e2315735121.

Foucault M (1980). Power/Knowledge: Selected Inteviews and Other Writings. New York: Vintage Books

George R, Narayanan K (2017). Beyond Competence: Perspectives From Two Centuries. J Palliat Care  32(3-4): 144–147.

Giddens A (1984). The Constitution of Society: Outline of the Theory of Structuration Berkeley and Los Angeles: University of California Press

Lee KJ, Smith RM (2011). EHR/EMR: "Meaningful use," stimulus money, and the Serenity Prayer. Ear Nose Throat J  90(2): E25.

Oudshoorn A, Ward-Griffin C, McWilliam C (2007). Client-nurse relationships in home-based palliative care: a critical analysis of power relations. J Clin Nurs  16(8): 1435–43.

Pastrana T, de Lima L, Portenoy R, Dudgeon D, Voeuk A, Ahmed E, Radbruch L. Manual on the use of essential palliative care medicines in adults.  2025a. (abgerufen am 15.12.2025).

Pastrana T, Lima L, Dussel V, Kwete XJ, Downing J, Fallon M, Grant L, Bhadelia A, Radbruch L (2025b). Global Consensus-Based Essential and Expanded Packages for Palliative Care and Pain Relief for Adults and Children: A Delphi Study. J Pain Symptom Manage.

Sacco LM, Griffin MT, McNulty R, Fitzpatrick JJ (2011). Use of the Serenity Prayer among adults with type 2 diabetes: a pilot study. Holist Nurs Pract  25(4): 192–8.

Schuler A, Ferentzy P, Turner NE, Skinner W, McIsaac KE, Ziegler CP, Matheson FI (2016). Gamblers Anonymous as a Recovery Pathway: A Scoping Review. J Gambl Stud  32(4): 1261–1278.

Vogelsang GB (2012). The Serenity Prayer for acute GVHD. Blood  119(1): 3–4.