DR. J.I. NWAPI, MBBS, FWACP, FMCFM

Lecturer I/Consultant Family Physician

Introduction Definition of terms Statistics History Spiritual Assessment Benefits/Barriers/Facilitators Role of the family physician in spiritual

care

Spirituality is a human experience that does not magically disappear in the doctor’s office or hospital

Spirituality should be seen as part of a package rather than stand-alone treatment modality

With Family Medicine’s whole person care perspective, it is natural that those in Family Medicine will have a good understanding in this area

SpiritualityBroader concept than religion and is

primarily a dynamic, personal, experiential process. Features of spirituality include quest for meaning and purpose, transcendence, connectedness, and values

ReligionOrganizes the collective spiritual

experiences of a group of people into a system of beliefs and practices

Spiritual distress/crisis-occurs when individuals are unable to find sources of meaning, hope, love, peace, comfort, strength and connection in life or when conflict occurs between their beliefs and what is happening in their life.

This distress can have a detrimental effect on physical and mental health

General spiritual careRecognition and response to the

multifaceted expressions of spirituality we encounter in our patients and their families. It involves compassion, presence, listening and the encouragement of realistic hope and might not involve any discussion of God or religion

Spiritual AssessmentThe process by which the health care

provider can identify a patient’s spiritual needs pertaining to medical care

SPIRITUAL DISTRESS Spiritual distress and spiritual crisis

occur when individuals are unable to find sources of meaning, hope, love, peace, comfort, strength and connection in life or when conflict occurs between their beliefs and what is happening in their life.

This distress can have a detrimental effect on physical and mental health. Medical illness and impending death can often trigger spiritual distress in patients and family members.

94% Regard their spiritual and physical health as

equally important 77%

Believe physicians should consider their spiritual needs

73% Believe they should share their religious

beliefs with their physician

40% Want physicians to discuss religious beliefs

more frequently 68%

Report their physician had NEVER discussed religious beliefs with them

96%Family Physicians believe spiritual well-

being is an important factor in health 11%

Inquire at least frequently about spiritual issues

Studies using spiritual and religious variables find religious involvement and spirituality associated with better health outcomes:350 physical health studies900 mental health studies100 mortality studies

Use of spiritual/religious variables in Medical Research3.5% of family practice studies1.1% of internal medicine studies11.8% of adolescent health studies10% of nursing mental health studies

*Neglect of religious/spiritual variables likely due to reliance on biomedical model where physical evidence is paramount.

Medical science originally evolved from a religious framework

Priest and Medicine Man were the same person

Physical health and spiritual health were viewed as part of a unity

Many medical institutions started with backing of religious organizations

Scientific method develops with the discovery of “germs”

Distinction and separation of physical and spiritual health

Growing interest in alternative medicine develops because of a desire to find treatments more compatible with one’s personal beliefs

Formalized (measured) discoveries of spiritual care benefits

Viewed that much of sickness has no biological cause as its aetiology

A spiritual assessment performed during a medical encounter is a practical way to begin incorporating spirituality into medical practice.

It could be formal or informal

GENERAL PREREQUISITESSeveral factors can increase the success of a

discussion of spiritual issues with patients. Spiritual Self-Understanding and Self-Care.

A physician needs to understand his or her own spiritual beliefs, values and biases in order to remain patient-centered and non-judgmental when dealing with the spiritual concerns of patients.

This is especially true when the beliefs of the patient differ from those of the physician. One way to promote self-understanding is to perform a formal spiritual self-assessment using the necessary tools

Self-care can take the form of reconnecting with family and friends, time alone (for quiet contemplation, playing a sport, recreational reading, nature watching, etc.), community service, or religious practice.

Self-care and self-understanding can help physicians prepare for difficult questions, such as “Why is this happening to my child [or me]?” or questions regarding the physician’s beliefs.

It can also help physicians prepare for times when patients may make requests for prayer, or prepare for emotional responses from the patient or the physician.

Establishment of a Good Physician-Patient Relationship.

The patient is more likely to discuss spiritual concerns within the context of a trusting and therapeutic physician-patient relationship.

Appropriate Timing of Discussions Maslow’s hierarchy of needs (i.e., physical, then

mental and spiritual) is one way to help determine when timing is appropriate. Routine inquiry about spiritual resources can flow naturally following discussion of other support systems and may open the door for further discussion.

Appropriate timing for more in-depth discussion requires skilful interpretation of verbal and nonverbal cues from patients and families and the willingness to explore further with gentle, open-ended interview techniques.

The topic of spirituality may be introduced during discussion of:

Advance directives New diagnosis of severe illness Terminal care planning Addiction Chronic pain Chronic illness Domestic violence or grieving.

INFORMAL SPIRITUAL ASSESSMENT Informal spiritual assessment may be accomplished at

any time during the medical encounter. Because most patients use symbolic and metaphoric

language when expressing spiritual thoughts, spiritual assessment often involves listening carefully to the stories that patients tell regarding their lives and illness and then interpreting the spiritual issues involved.

Themes such as the search for meaning, feelings of connection versus isolation, hope versus hopelessness, fear of the unknown, are clues that the patient may be struggling with spiritual issues.

Perceiving these clues and following with open-ended as well as specific questions regarding the patient’s spiritual beliefs may reveal more about a patient’s spiritual needs than direct inquiry with a formal spiritual assessment.

This is the approach most often employed by chaplains. However, many family physicians notice such clues instinctively and can easily continue to develop this perception skill once they know what to look for.

FORMAL SPIRITUAL ASSESSMENTA formal spiritual assessment involves

asking specific questions during a medical interview to determine whether spiritual factors may play a role in the patient’s illness or recovery and whether these factors affect the medical treatment plan.

Possible formats for conducting a formal spiritual assessment include:

The FICA Spiritual HistoryHOPE questionsThe Open Invite Mnemonic

The FICA Spiritual History Tool Uses an acronym to guide health

professionals through a series of questions designed to elicit patient spirituality and its potential effect on health care. Starting with queries about faith and belief, it proceeds to ask about their importance to the patient, the patient’s community of faith, and how the patient wishes the physician to address spirituality in his or her care.

Faith and belief Do you have spiritual beliefs that help you cope with stress? If the patient responds “no,” consider asking: what gives your life meaning?

Importance Have your beliefs influenced how you take care of yourself in this illness?

Community Are you part of a spiritual or religious community? Is this of support to you, and how?

Address in care How would you like me to address these issues in your health care?

The HOPE questionsThese questions lead the physician from

general concepts to specific applications by asking about patients’ sources of hope and meaning, whether they belong to an organized religion, their personal spirituality and practices, and what effect their spirituality may have on medical care and end-of-life decisions.

H: sources of hope

What are your sources of hope, strength, comfort, and peace? What do you hold on to during difficult times?

O: organized religion

Are you part of a religious or spiritual community? Does it help you? How?

P: personal spirituality and practices

Do you have personal spiritual beliefs? What aspects of your spirituality or spiritual practices do you find most helpful?

E: effects on medical care and end-of-life issues

Does your current situation affect your ability to do the things that usually help you spiritually? As a doctor, is there anything that I can do to help you access the resources that usually help you? Are there any specific practices or restrictions I should know about in providing your medical care? If the patient is dying: How do your beliefs affect the kind of medical care you would like me to provide over the next few days/weeks/months?

The Open Invite Mnemonic This is a patient-focused approach to encouraging

a spiritual dialogue. It is structured to allow patients who are spiritual to speak further, and to allow those who are not to easily opt out.

Firstly, it reminds physicians that their role is to open the door to conversation and invite (never require) patients to discuss their needs.

Secondly, Open Invite provides a mnemonic for the general types of questions a physician may use (see below). The tool provides questions that allow the physician to broach the topic of spirituality.

The key to this approach is to use questions that are natural and conversational while being respectful and non-threatening

Open (i.e., open the door to conversation)

May I ask your faith background? Do you have a spiritual or faith preference? What helps you through hard times?

Invite (i.e., invite the patient to discuss spiritual needs)

Do you feel that your spiritual health is affecting your physical health? Does your spirituality impact the health decisions you make? Is there a way in which you would like for me to account for your spirituality in your health care? Is there a way in which I or another member of the medical team can provide you with support? Are there resources in your faith community that you would like for me to help mobilize on your behalf?

Many possible steps may follow the spiritual assessment. Take no further action.

Spiritual concerns and questions often have no clear answers or solutions, yet they can significantly affect the quality of a patient’s suffering. Experienced physicians know that in many cases there is little they can offer to their patients in the way of medical solutions and cure. At these times, the best therapeutic intervention is to offer their presence, understanding, acceptance and compassion.

Incorporate spirituality into preventive health care. Patients can be helped to identify and mobilize their

own internal spiritual resources as a preventive health care measure. These resources may include prayer, meditation, yoga, walks in the country or listening to soothing music.

Include spirituality in adjuvant care. The physician can help patients identify spiritually

based measures that can be useful to them in conjunction with standard medical treatment. For example, a patient may choose to say the rosary while taking medication or may need to listen to music or read scripture before surgery.

Modify the treatment plan. Modifications can be made based on better

understanding of the patient’s spiritual needs as related to medical care. This can include such measures as stopping or continuing chemotherapy in a patient with metastatic cancer; referring a patient in spiritual distress or crisis to a clinical chaplain; using community cultural or religious resources; and teaching the relaxation response or other meditation techniques to patients with chronic pain or insomnia.

After spiritual needs have been identified, the physician may incorporate the results of the assessment into patient care. The most basic thing a physician can do is to listen compassionately. Regardless of whether patients are devout in their spiritual traditions, their beliefs are important to them. By listening, physicians signal their care for their patients and recognition of this dimension of their lives. Empathetic listening may be all the support a patient requires.

Another way to incorporate the spiritual assessment is to document the patient’s spiritual perspective, background, stated impact on medical care, and openness to discussing the topic. Physicians may find this information helpful when readdressing the subject in the future or during times of crisis when sources of comfort and meaning become crucial. This documentation also helps meet hospital regulatory requirements for conducting a spiritual assessment.

An additional way to incorporate the assessment is to consider how different traditions and practices may affect standard medical practice. For instance, patients of the Jehovah’s Witness tradition tend to refuse blood transfusion; believers in faith healing may delay traditional medical care in hopes of a miracle; and Muslim and Hindu women tend to decline sensitive (and sometimes general) examinations by male physicians. Patients with certain beliefs may experience substantial psychological duress if they believe a condition is caused by a lack of belief or transgressions on their part.

Physicians also need to consider how practices may influence acute or chronic health states. For example, many Muslims fast during Ramadan, which may affect glucose control and other physiologic factors in the ambulatory and inpatient settings. Persons of some faiths observe strict dietary codes, such as halal and kosher laws, which may require physicians to alter traditional nutrition counselling. It is important to remember, however, that patients may not adhere to each specific belief or practice of their faith. Physicians should avoid making assumptions when asking patients how their particular practices may affect their medical care.

The spiritual assessment also allows patients to identify spiritual beliefs, practices, and resources that tmay positively impact their health. Helpful questions include, “Do you have spiritual practices, such as praying, meditating, listening to music, or reading sacred text, that you find helpful or comforting?” and “Are you part of a faith community? If so, does it have resources such as a home visitation program, a food pantry, or health screening?” Physicians can reinforce positive coping behaviours and, with the patient’s permission, offer to contact the patient’s spiritual community to mobilize community faith resources as appropriate.

Finally, there may be some instances in which physician and patient faith traditions coincide. In these cases, if the patient requests, the physician may consider offering faith-specific support. This may include patient- or physician-led prayer. Given the variety of spiritual practices followed in multicultural societies, it is best not to assume that a physician’s spirituality mirrors that of his or her patients. Prayer should not be a goal of a spiritual assessment, and physicians should not attempt to get patients to agree with them on specific faith issues.

To the patient Assessing and integrating patient spirituality

into the health care encounter can build trust and rapport, broadening the physician-patient relationship and increasing its effectiveness. Practical outcomes may include Improved adherence to physician-recommended

lifestyle changes or compliance with therapeutic recommendations. Additionally, the assessment may help patients recognize spiritual or emotional challenges that are affecting their physical and mental health. Addressing spiritual issues may let them tap into an effective source of healing or coping.

To the physicianFor physicians, incorporating patient

spirituality brings the potential for renewal, resiliency, and growth, even in difficult encounters. Sometimes physicians have few medical solutions for problems that cause suffering, such as incurable disease, chronic pain, grief, domestic violence, and broken relationships. In these situations, providing comfort to patients can increase professional satisfaction and prevent burnout.

Mortality18 studies show religiously involved persons

live longer Cardiovascular Disease

12/16 found religious involvement associated with less CV disease and mortality

Hypertension14/16 studies found religious involvement

associated with lower BP9/13 clinical trials found religious/spiritual

practices significantly reduce BP

Mental Health24/29 studies found religiously involved

persons had fewer depressive symptoms and less depression

70 studies found religious involvement associated with less anxiety and fear

Coping with IllnessLess depression during illnessLower levels of despair, anger, hostility, and

social isolation

BarriersPhysicianPatientMutualSituational Communication

FacilitatorsActionsSituational factorsResourcesPhysician qualities

Physicians and other health care providers

Family and Friends Chaplains Spiritual Leaders Community leaders/resources

Family Physicians incorporate spirituality into medical practice in three ways: By scientific study of the subjectBy assessment of the patient’s

spirituality and diagnosis of spiritual distress

By therapeutic interventions.

Scientific study Current evidence is evaluated for a link

between spirituality and health and planning further study to clarify these effects.

It is important to keep an open mind regarding new methods of study and to be aware that there are some things that may never be fully understood.

Assessment and diagnosis The family physician evaluates whether

spirituality is important to a particular patient and whether spiritual factors are helping or hindering the healing process.

Therapeutic interventions Consideration is given to a patient’s

spirituality in recommendations regarding prevention, medical treatment and adjuvant care.

Also, elements of general spiritual care are incorporated into the routine medical encounter.

Spirituality is an important, multidimensional aspect of the human experience that is difficult to fully understand or measure using the scientific method

Convincing evidence in the medical literature supports its beneficial role in the practice of medicine

As physicians begin the process of integrating spirituality into medical practice, it is important to keep in mind the advice to “do no harm” and to maintain the utmost respect for the patient’s rights to autonomy and freedom of thought and belief.

If done responsibly, the practice of medicine may be the best arena for integrating science and spirituality