Open Access

Steven Hébert, Heiko Reutter, Gregor Hanslik, Joachim Woelfle, Melanie L. Conrad, Fabian B. Fahlbusch

• Background 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. Methods 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 analyzedBackground 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. Methods 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. Results 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. Conclusions 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.…