spiritual care in the united states: understanding
TRANSCRIPT
Spiritual Care in the United States:
Understanding, Research and Practice
Harold G. Koenig, MD
Professor of Psychiatry and Associate Professor of Medicine
Duke University Medical Center
Distinguished Adjunct Professor, King Abdul Aziz University, Jeddah, Saudi Arabia
What is Spiritual Care? Who provides Spiritual Care? What is the basis for Spiritual Care? Why do it? How often do health professionals provide Spiritual Care in USA? How do health professionals in USA provide Spiritual Care? Open discussion
Overview 14:30-15:30
Further Reading:
Spirituality in Patient Care, Second Edition
Templeton Foundation Press, 2007 (reviewed in JAMA 2008; 299:1608-1609)
Spiritualitat in den Gesundheitsberufen: Ein proaxisorientierter Leitfaden Bearbeitet und mit enem Geleitwort von Rene Hefti
(Kohlhammer Press, 2012)
Part of care for the whole person: - physical body - emotional/psychological - social - spiritual
What is Spiritual Care?
Spiritual Care is NOT the same as providing medical or nursing care; that is provided by doctors and nurses
Spiritual Care is NOT the same as addressing the emotional and
psychological needs of patients; that is provided by mental health specialists (counselors, psychologists, psychiatrists)
Spiritual Care is NOT the same as addressing the social or family
needs of patients; that is provided by social workers
What Spiritual Care is Not:
Spiritual Care involves health professionals addressing that
aspect of the whole person that has to do with their relationship to the Transcendent and the spiritual needs that result from that relationship
Is Spiritual Care the same as providing “religious care”? Yes, broadly speaking. It is the only distinctive aspect of Spiritual Care that
separates and distinguishes it from the physical, psychological, and social aspects of care.
What is Spiritual Care?
Practically speaking, Spiritual Care involves: (1) Taking a spiritual history (talking with patients about
these issues) (2) Identifying spiritual needs (3) Ensuring that spiritual needs are met by someone (4) Providing healthcare in a spiritual way *Will say more about each of these later*
What is Involved in Spiritual Care?
Chaplains and other clergy (pastors or pastoral counselors), but also:
Medical doctors Nurses Social workers Counselors, psychologists, psychiatrists Other health professionals (physical/occupational therapy, etc.)
Who Provides Spiritual Care?
Why Provide Spiritual Care?
• Many patients are religious, and would like it addressed in their
health care (next)
• Many patients have spiritual needs related to illness that could
affect mental, social and physical health (next)
• Religious beliefs of patients affect healthcare decisions, and could
conflict with the medical care plan (discuss)
• Religious beliefs of health professionals (physicians/nurses) affect
their healthcare decisions; could conflict with patients’ beliefs (discuss)
• Religion influences support and care in the community (discuss)
Many Patients are Religious (and Most are Spiritual)
In the USA (general population; Gallup Polls Jan-Dec 2011):
- 40% are “very religious”
(religion important part of daily life, weekly or almost weekly attendance)
- 28% are “moderately religious” (religion important but not regular attenders, or religion not important but
are regular attenders)
- 32% are “non-religious”
(religion not important part of daily life and seldom or never attend
religious services)
When sick or stressed, many become religious and/or use it to cope
0
0.1-4.9
5.0-7.4
7.5-9.9
10
5.0%
5.0%
22.7%
27.3%
40.1%
Self-Rated Religious Coping
The Most Important Factor
Large Extent or More
Moderate to Large Extent
None
Responses by 337 consecutively admitted patients to Duke Hospital (Koenig 1998)
Small to Moderate
Religious Coping is Common in Response
to Stress
America’s Coping Response to Sept 11th:
1. Talking with others (98%)
2. Turning to religion (90%)
3. Checked safety of family/friends (75%)
4. Participating in group activities (60%)
5. Avoiding reminders (watching TV) (39%)
6. Making donations (36%)
Based on a random-digit dialing survey of the U.S. on Sept 14-16
New England Journal of Medicine 2001; 345:1507-1512
Many Patients Would Like it Addressed in their Health
Care by Medical Doctor (MD)
- MD should consider pt’s spiritual needs 77% - Want MD to ask about R/S 65% (33-84%)*
- MD should pray w pt if requested 64%
- Would like MD to pray with them 57% (33-78%)**
- [MDs who say pts would ever want prayer 37%
- R/S & medicine should be separate 28%
- MD should not ask 17%
- did MD every ask? 13% (9-20%)
* Based on 6 patient surveys, range depends on circumstances
**Based on 4 patient surveys
Many Patients Have Spiritual Needs Related to Illness
In a multi-site study by Harvard investigators, 230 patients
with advanced cancer were surveyed. Most (88%) considered
religious to be at least somewhat important. However, 47%
reported that their spiritual needs were minimally or not at all
supported by their religious community and 72% said their
spiritual needs were minimally or not at all supported by the
medical system (doctors, nurses or chaplains). Furthermore,
spiritual support provided by their medical team or religious
communities was associated with significantly higher quality of
life (p=0.0003) (Balboni et al, 2007).
Not Addressing Spiritual Needs is Expensive
Multi-site, prospective study of 345 patients with advanced cancer who were
followed to their death. They found that intensive, expensive, futile life-
prolonging care (mechanical ventilation or resuscitation in last week of life) was
significantly more common among those with high levels of religious coping
(Phelps et al, 2009, JAMA).
When these investigators examined who among those using religion to cope
were using more expensive health services, they found that this was primarily
among those whose spiritual needs were not being addressed by the medical
team. Among high religious copers whose spiritual needs were to a large extent
or completely supported (vs. not supported), the likelihood of receiving hospice
increased 5-fold (p<0.005) and of receiving aggressive care towards the end of
life decreased by 72% (range 21% to 96%) (p=0.02) (Balboni et al., 2010,
Journal of Clinical Oncology).
Religiousness of European Countries (EURODEP) (n=22,570, over age 65) (Braam)
Weekly Attend Orthodox Beliefs (0-12)
#1. Ireland 81% 9.0
#2. Italy 38% 6.9
#3. Spain 30% 5.8
#4. Netherlands 27% 4.7
#5. Belgium 27% 4.6
#6. Germany 18% 5.2
#7. UK 14% 6.4
#8. France 10% 4.4
#9. Finland 4% 6.2
#10. Sweden 4% 3.8
#11. Iceland 2% 6.4
Religious Coping in Europe (see Handbook of Religion and Health, 2nd ed., 2012)
Sweden 1% rely on R faith
0.2 times/week sought spiritual support (GI cancer)
Norway 43% no belief in God; 45% no comfort whatsoever (terminal CA)
Finland 4% attend services regularly; 70% religion not important
Denmark 63% believe in God; 3% attend services regularly (1981)
60 of 1,425 (4%) youth identified with religious groups
Of those over 50, 21% pray daily and 30% weekly (49% never)
United Kingdom 27% religion important (73% not)
Religious coping ranked 13th of 14 (just ahead of alcohol/drugs)
Terminally ill – 43% spiritual beliefs major part of life
France 30% religion important (all ages); 10% regular attenders
Netherlands 33% religion important (all ages); 35% of over 50 pray daily
Germany 41% religion important (all ages); 18% regular attenders
29% used religion “a lot” to cope (older persons w dentures)
57% used religion to cope (ALS patients)
Italy 71% religion important (all ages) (highest except Greeks, 71%)
Switzerland 42% religion important (all ages)
42% religion very important or essential for coping (schizophrenia)
The Research (systematic review 1872-2010 of all quantitative research published in
peer reviewed academic scientific journals in the English language
listed in PsychInfo and Medline)
This research is documented in:
Handbook of Religion and Health, (Oxford University Press, 2001)
Handbook of Religion and Health, Second Edition (Oxford
University Press, 2012)
Research on Religion and Mental Health
Emotional disorders
Depression Suicide Substance use Positive emotions/virtues
Well-being and happiness Meaning, purpose, and hope Forgiveness, altruism, gratitude, compassion Social health
Social support
Social capital
Marital stability
Religious involvement is related to: Less depression, faster recovery from depression 272 of 444 studies (61%) [67% of best] More depression (6%)
Depression (systematic review)
Religious involvement is related to: Less suicide and more negative attitudes toward suicide 106 of 141 studies (75%)
Suicide (systematic review)
Religious involvement is related to: Less alcohol use / abuse / dependence 240 of 278 studies (86%) [90% of best]
Alcohol Use/Abuse/Dependence (systematic review)
Drug Use/Abuse/Dependence (systematic review)
Religious involvement is related to: Less drug use / abuse / dependence 155 of 185 studies (84%) [86% of best] [95% of RCT or experimental studies]
Religious involvement is related to: Greater well-being and happiness 256 of 326 studies (79%) [82% of best] Lower well-being or happiness (<1%)
Well-being and Happiness (systematic review)
Religious involvement is related to: Significantly greater meaning and purpose in life 42 of 45 studies (93%) [100% of best] Significantly greater hope
29 of 40 studies (73%) Significantly great optimism
26 of 32 studies (81%)
Meaning, Purpose, Hope, Optimism (systematic review)
Religious involvement is related to: Significantly more forgiveness 34 of 40 studies (85%) [70% of best] Significantly more altruism / volunteering 33 of 47 studies (70%) [75% of best]
Significantly more gratitude, compassion, kindness
8 of 8 studies (100%)
Positive Human Virtues / Character Traits (systematic review)
Religious involvement is related to: Significantly greater social support 61 of 74 studies (82%) [93% of best]
Social Support (systematic review)
Religious involvement is related to: Significantly greater social capital 11 of 14 studies (79%)
Social Capital (systematic review)
Religion, Health Behaviors, and Disease
Prevention
Exercise Weight Sexual behavior Cigarette smoking Diet Cholesterol Seatbelt use Disease screening Treatment compliance
Religious involvement is related to: • More exercise/physical activity 25 of 37 studies (68%) [76% of best] • Less extra-marital sex, safer sexual practices (fewer partners) 82 of 95 studies (86%) [84% of best] • Lower weight (7 of 36 studies) (19%) Heavier weight (14 of 36 studies) (39%)
Health Behaviors (systematic review)
Religious involvement related to: • Less cigarette smoking, especially among the young 122 of 135 studies (90%) [90% of best] • Better diet 13 of 21 studies (62%)
• Lower cholesterol 12 of 23 studies (52%)
• More likely to wear seat belts 3 of 3 studies
Health Behaviors (cont)
Research on Religion and Physical Health
Heart disease
Hypertension
Immune function
Endocrine function
Cancer
Overall mortality
Religious involvement is related to: Significantly lower rates of coronary artery disease 12 of 19 studies (63%) [69% of best] Lower cardiovascular reactivity, greater heart rate variability, more positive cardiovascular functions 10 of 16 studies (63%) [62% of best]
Heart Disease (systematic review)
Religious involvement is related to: • Lower BP or lower rates of hypertension 36 of 63 studies (63%)
Hypertension (systematic review)
Religious involvement is related to: • Better immune function (higher lymphocyte counts, lower
inflammatory markers, etc.) 14 of 25 studies (56%) [60% of best] • Better endocrine function (cortisol, epi and norepinephrine) 23 of 31 studies (74%)
Immune and Endocrine Function (systematic review)
Religious involvement is related to: • Lower rates of cancer or better prognosis 17 of 28 studies (61%) [65% of best]
Cancer (systematic review)
Religious involvement is related to: • Lower mortality, longer survival 82 of 120 studies (68%) [66% of best] [76% of very best]
Overall Mortality (systematic review)
0
500
1000
1500
2000
2500
C NG (NG) M (P) P NA
C
NG
(NG)
M
(P)
P
NA
Number of studies includes some studies counted more than once (see Appendices of 1st and 2nd editions).
Prepared by Dr. Wolfgang v. Ungern-Sternberg
The Relationship between Religion and Health: All Studies
Belief in,
attachment to
God
Public prac, rit
Priv ate prac, rit
R commitment
R coping
Positiv e Emotions
Negativ e EmotionsMental Disorders
Social Connections
Ph
ysic
al H
ea
lth a
nd
Lo
ng
evity
Imm
une, E
ndocrine, C
ard
iovascula
r F
unctions
Theoretical Model of Causal Pathways
Genetics, Dev elopmental Experiences, Personality
Decisions, Lif esty le Choices, Health Behav iors
SOURCE
R experiences
Spirituality
faith
community
Psy chologicalTraits / Virtues
Forgiv enessHonestyCourageSelf -disciplineAltruismHumilityGratef ulnessPatienceDependability
Theolo
gic
al V
irtues:
faith
, hope, lo
ve
faith
community
*Model f or Western monotheistic religions (Christianity , Judaism, and Islam)
(c) Handbook of Religion & Health, 2nd ed
Thus,
Spiritual Care is Important for Medical Reasons,
Psychological Reasons, Social Reasons, and
Financial Reasons
Take a Spiritual History
1. Health professionals should take a screening spiritual history (2-4
minutes); this is not the same as a spiritual assessment (chaplain or
pastoral care specialist)
2. The purpose of the SH is to obtain information about religious
background, beliefs, and rituals that are relevant to their mental health
care
3. If patients indicate from the start that they are not religious or spiritual,
then questions should be re-directed to asking about what gives life
meaning & purpose and how this can be addressed in their care
A Brief Explanation Should Precede the
Spiritual History
1. Patients may become alarmed or anxious if a health professionals begins
talking about religious or spiritual issues
2. The health professional should be careful not to send an unintended
message to the patient that may be misinterpreted
3. Make it clear that such inquiry has nothing to do with the patient’s
diagnosis or the severity of their medical condition
4. Indicate that such inquiry is routine, required, and an attempt to be
sensitive to the spiritual needs that some patients may have
Physician Should Take
The Spiritual History
• Patient needs to feel comfortable talking with physician about spiritual
issues
• Patients’ medical decisions are influenced by their religious beliefs
• Patients’ compliance with medical treatments are influence by religious
beliefs
• Taking spiritual history enhances doctor-patient relationship & may itself
affect health outcomes
• Spiritual struggles, if undetected, can adversely affect health outcomes
Religious Struggle 444 hospitalized medical patients followed for 2 years
Wondered whether God had abandoned me
Felt punished by God for my lack of devotion
Wondered what I did for God to punish me
Questioned the God’s love for me
Wondered whether my church had abandoned me
Decided the Devil made this happen
Questioned the power of God
Each of 7 items below rated on a 0 to 3 scale, based on agreement. For every 1 point increase on religious struggle scale (range 0-21), there was a 6% increase in mortality, independent of physical and mental health (Arch Intern Med, 2001; 161: 1881-1885)
Contents of the Spiritual History
1. What is patient’s religious or spiritual (R/S) background (if any)
2. R/S beliefs used to cope with illness, or alternatively, that may be a
source of stress or distress
3. R/S beliefs that might conflict with medical (or psychiatric) care or might
influence medical decisions
4. Involvement in a R/S community and whether that community is
supportive
5. Spiritual needs that may be present and need to be addressed for health
reasons
See JAMA 2002; 288 (4):487-493
Medical Doctors Say It’s Important, but Don’t Do it
Attitudes
- SWB important part of health 96% (Ellis)
- should be aware of pt’s R/S beliefs 85% (Monroe)
- MD has right to inquire about R/S 89% (Maugans)
- should ask about R/S beliefs 35% (Monroe)
- has responsibility to ask R/S 52% (Maugans)
- usually/always appropriate to ask 55% (Curlin)
Practices
- often/always take a spiritual history 8% (7-10%)
Besides Taking a Spiritual History…
1. Support the religious/spiritual beliefs of the patient (verbally, non-verbally)
2. Ensure patient has resources to support their spirituality – refer patients
with spiritual needs to CHAPLAINS
3. Accommodate environment to meet spiritual needs of patient
4. Be willing to communicate with patients about spiritual issues
5. Prescribe religion to improve health (?)
6. Pray with patients if requested (?)
Refer to Professional Chaplains
1. Get to know your chaplains. Are they competent? If yes, then…
2. If any but the most simple of spiritual needs come up, always refer
3. Need to know the local pastoral care resources that are available, and
the degree to which they can be relied on
4. Before referral, explain to patients what a chaplain is and does (they
won’t know)
5. Explain why you think they should see a chaplain
The way health care is provided – by physicians, nurses, social workers, counselors, physical therapists, occupational therapists, dieticians, etc. – can be Spiritual (recognizing the Sacred nature of the person and the Holy obligation and privilege that health professionals have) What does this mean? - providing care with respect for the individual patient - inquiring about how patient wishes to be cared for - providing care in a kind and gentle manner - providing care in a competent manner - taking extra time with patients who really need it
This is not easy to do
Providing Care in a Spiritual Way
Limitations
1. Do not prescribe religion to non-religious patients
2. Do not force a spiritual history if patient not religious
3. Do not coerce patients in any way to believe or practice
4. Do not pray with a patient before taking a spiritual history and unless the patient asks
5. Do not spiritually counsel patients (always refer to trained professional chaplains or pastoral counselors)
6. Do not do any activity that is not patient-centered and patient-directed
Summary
• There is a solid rationale for addressing patients’
spiritual needs in clinical settings
• Many patients in the United States and Europe
are religious or spiritual, and have spiritual needs
that must be addressed
• Identify spiritual needs by taking a spiritual history
and explore the role that spiritual factors may play
in either (1) coping with the illness or (2)
contributing to the illness (spiritual struggles)
• Utilize trained professional chaplains or pastoral
counselors to address patients’ spiritual needs
1. Spirituality in Patient Care (Templeton Press, 2007) (clinician)
2. Healing Power of Faith (Simon & Schuster, 2001) (patient)
3. Medicine, Religion and Health (Templeton Press, 2008)
(patient/clinician)
4. Spirituality and Health Research: Methodology, Measurement,
Analyses, and Resources (Templeton Press, 2011) (researcher)
5. Handbook of Religion and Health (Oxford University Press, 2001;
and Second Edition, 2012) (clinician and researcher)
Further Reading
Summer Research Workshops Durham, North Carolina
5-day intensive research workshops focus on what we know about the relationship between
spirituality and health, applications, how to conduct research and develop an academic career
in this area. Leading spirituality-health researchers at Duke, UMSC, and elsewhere will give
presentations:
-Strengths and weaknesses of previous research
-Theological considerations and concerns
-Highest priority studies for future research
-Strengths and weaknesses of measures of religion/spirituality
-Designing different types of research projects
- Primer on statistical analysis of religious/spiritual variables
-Carrying out and managing a research project
-Writing a grant to NIH or private foundations
-Where to obtain funding for research in this area
-Writing a research paper for publication; getting it published
-Presenting research to professional and public audiences; working with the media
Scholarships are available for the financially destitute
If interested, contact Harold G. Koenig: [email protected]