Principles to make a spiritual assessment work in your practice

,; ,

Applied Evidence

Principles to make a spiritual assessment work in your practice

J Fam Pract. 2004 August;53(8):625-631

PDF Download

References

1. Osler W. The faith that heals. BMJ 1910;June 18:1470-1472.

2. Matthews D, McCullough M, Larson D, Koenig H, Sawyers J, Milano M. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med 1998;7:118-124.

3. Helm H, Hays J, Flint E, Koenig H, Blazer D. Does private religious activity prolong survival? A six-year follow-up study of 3,851 older adults. J Gerontol A Biol Sci Med Sci 2000;55:M400-M405.

4. Oxman T, Freeman D, Manheimer E. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosom Med 1995;57:5-15.

5. Koenig H, Cohen H, George L, Hays J, Larson D, Blazer D. Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults. Int J Psychiatry Med 1997;27:233-250.

6. Woods T, Antoni M, Ironson G, Kling D. Religiosity is associated with affective and immune status in symptomatic HIV-infected gay men. J Psychosom Res 1999;46:165-176.

7. Koenig H, George L, Meador K, Blazer D, Ford S. Religious practices and alcoholism in a southern adult population. Hosp Community Psychiatry 1994;45:225-231.

8. Pargament K, Koenig H, Tarakeshwar N, Hahn J. Religious struggle as a predictor of mortality among medically ill elderly patients. Arch Intern Med 2001;161:1881-1885.

9. Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician 2001;63:81-88.

10. Post S, Puchalski C, Larson D. Physicians and patient spirituality: professional boundaries, competency, and ethics. Ann Intern Med 2000;132:578-583.

11. Maugans T, Wadland W. Religion and family medicine: a survey of physicians and patients. J Fam Pract 1991;32:210-213.

12. Ehman J, Ott B, Short T, Ciampa R, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999;159:1803-1806.

13. Block S. Psychological considerations, growth, and transcendence at the end of life. JAMA 2001;285:2898-2905.

14. Sloan R, Bagiella E, VandeCreek L, et al. Should physicians prescribe religious activities? N Engl J Med 2000;342:1913-1916.

15. Koenig G, Idler E, Kasl S, et al. Religion, spirituality, and medicine: a rebuttal to skeptics. Int J Psychiatry Med 1999;29:123-131.

16. Sloan R, Bagiella E, Powell T. Religion, spirituality, and medicine. Lancet 1999;353:664-667.

17. Buryska J. Assessing the Ethical weight of cultural, religious and spiritual claims in the clinical context. J Med Ethics 2001;27:118-122.

18. Lo B, Ruston D, Kates L, Arnold R, Cohen C, Faber-Langendoen K, et al. Discussing religious and spiritual issues at the end of life. a practical guide for physicians. JAMA 2002;287:749-754.

19. Matthews D, McCullough M, Larson D, Koenig H, Swyers J, Milano M. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med 1998;7:118-124.

20. Mueller P, Plevak D, Rummans T. Religious involvement, spirituality, and medicine: implications for clinical practice. Mayo Clin Proc 2001;76:1225-1235.

21. Levin J, Puchalski C. Religion and spirituality in medicine: research and education. JAMA 1997;278:792-793.

22. Blumenthal D. Quality of health care, part 1: quality of care—what is it? N Engl J Med 1996;335:891-894.

23. Shum C, Humphreys A, Wheeler D, Cochrane M, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ 2000;320:1038-1043.

24. Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ 2000;320:1048-1053.

25. Jaen C, Stange K, Nutting P. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166-171.

26. Goodwin M, Flocke S, Borawski E, Zyzanski S, Stange K. Direct observation of health-habit counseling of adolescents. Arch Ped Ado Med 1999;153:367-373.

27. Fleming M, Manwell L, Barry K, Adams W, Stauffacher E. Brief physician advice for alcohol problems in older adults: a randomized community-based trial. J Fam Pract 1999;48:378-384.

28. Ellis M, Vinson D, Ewigman B. Addressing spiritual concerns of patients. J Fam Pract 1999;48:105-109.

29. Merenstein D, Green L, Fryer G, Dovey S. Shortchanging adolescents: room for improvement in preventive care by physicians. Fam Med 2001;33:120-123.

30. Schoenberg N, Campbell K, Johnson M. Physicians and clergy as facilitators of formal services for older adults. J Aging Soc Policy 1999;11(1):9-26.

31. Idler E, Kasl S. Religion among disabled and nondisabled persons ii: attendance at religious services as a predictor of the course of disability. J Gerontol B Psychol Sci Soc Sci 1997;52:S306-S316.

32. Koenig H, Larson D. Use of hospital services, religious attendance, and religious affiliation. South Med J 1998;91:925-932.

33. Strawbridge W, Cohen R, Shema S, Kaplan G. Frequent attendance at religious services and mortality over 28 years. Am J Pub Health 1997;87:957-968.

34. Koenig H, George L, Hays J, Larson D, Cohen H, Blazer D. The relationship between religious activities and blood pressure in older adults. Int J Psychiatry Med 1998;28:189-213.

35. Koenig H, Cohen H, Blazer D, Kudler H, Drishnan K, Sibert T. Religious coping and cognitive symptoms of depression in elderly medical patients. Psychosomatics 1995;36(4):369-375.

36. Koenig H, George L, Peterson B. Religiosity and remission of depression in medically ill older adults. Am J Psychiatry 1998;155:536-542.

One might logically question whether evidence exists at all to support a physician addressing spiritual issues. Several authors have thoroughly reviewed the evidence for a connection between spiritual commitment and health outcomes.^19-21 It is not our intent to repeat their effort here. However, in reviewing their findings, we were struck by the varying quality of evidence found in the medical literature. In some cases, spiritually related actions are supported by abundant evidence; other spiritual practices lack sufficient data for recommendation in the clinical setting. As empirical evidence accumulates, physicians will be increasingly able to discern the therapeutic benefit of certain faith-based practices. Evidence alone, however, does not establish an ethical imperative to address a patient’s spiritual or faith-based practices. The physician’s belief, medical and patient values, and available time must also be taken into account.

Principle of belief

Belief in a given therapy, by both the patient and the physician, is a major part of successful doctor-patient interactions. Researchers recognize that a caregiver’s belief or disbelief in a given therapy can significantly alter a patient’s response to treatment; otherwise there would be no need to double-blind studies.

The principle of belief, illustrated in Figure 1, states a spiritual adjunct to therapy is maximally beneficial when congruence exists between the patient’s belief, the caregiver’s belief, and the relevance of that shared belief to therapy. Conversely, a spiritual adjunct to treatment is less appropriate when the principle of belief is violated by caregiver incongruence, patient incongruence, incongruence of therapy, or extreme incongruence of the caregiver, patient, and therapy.

FIGURE 1
Congruence of belief

Spiritual adjuncts to therapy are maximally beneficial when congruence exists between the patient’s belief (PT), the caregiver’s belief (CG), and the relevance of that shared belief to therapy (Tx).

A physician may respectfully observe and document the faith-based practices of a patient without supporting or criticizing these practices. Encouraging or integrating the patient’s faith-based practices into therapy, however, requires a personal judgment concerning how the patient’s beliefs and those of the caregiver are relevant to a medical condition. Even in cases of incongruence, using this model may lead to serendipitous therapeutic options as a caregiver and patient work together to find common ground for relevant recommendations.

Principle of quality care

The principle of quality care states that a patient’s spiritual beliefs are most appropriately incorporated into therapy when and if doing so improves the quality of care received by the patient.

A popular definition characterizes quality care as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes....”²² Many definitions of quality care share this narrow focus on health outcomes. However, patients may more broadly define quality of care by including the degree to which personal values are preserved. A comprehensive definition of quality care, illustrated in Figure 2, takes into account both desired health outcomes and the patient’s values.

Complete care occurs when medical goals are achieved and the patient’s values are preserved.

Accommodative care occurs when medical treatment is adjusted for the sake of a patient’s values, as when a patient declines vaccination or other therapies for religious reasons.

Compulsory care describes forced medical therapy without preservation of the patient’s values. This type of care may result from conflicts between religious beliefs and medical standards leading to a patient being treated against his or her will. The adverse effects of compulsory care can be minimized by a thorough patient history that includes questions concerning personal beliefs that may conflict with standard treatment.

Deficient care, defined as failure to achieve medical goals while also violating patient values, can result from poor medical management, patient non-adherence, or lack of communication.

During any clinical encounter, the caregiver’s ultimate goal should be to provide complete care. Accommodative care and compulsory care may be necessary at times, but deficient care should always be avoided.

FIGURE 2
Criteria for defining quality of care

Principle of time

Research underscores the commonly recognized relation between longer consultations and general satisfaction among patients.^23,24 Yet time is too often a clinical luxury. Primary care physicians report lack of time as a barrier to providing a variety of potentially beneficial preventive services, including basic counsel on health issues,^25-26 despite evidence that brief physician advice can lead to changes in a patient’s health behaviors.²⁷ Similarly, family physicians²⁸ report lack of time as the number one barrier to discussions of spiritual issues.

Generally, preventive health counseling in a primary care setting increases the length of time with a patient anywhere from 2.5 to 3.8 minutes.^26,29 Time like this must be taken into account when weighing the importance of addressing spiritual issues with one patient against the time committed to other patients.