The principle of time states that addressing spiritual issues with patients who wish to do so is most appropriate when these issues can be entertained and any actions completed within the time constraints of clinical practice.
Lack of time should not be used routinely as an excuse to withhold care. Though spiritual matters, like other lifestyle issues, take time to address, the time invested may prove beneficial in the long run and management will require less time during follow up if core issues are addressed early and possibly incorporated into therapy.
The principle of time allows the caregiver to evaluate the feasibility of addressing clinically-relevant spiritual issues given a limited amount of time.
Applying the principles
Together, the principles of evidence, belief, quality care, and time serve as ethical precepts for guiding an appropriate response to information gained from a patient’s spiritual history. The scale shown in Table 2, and applied to the following cases, illustrates how these principles might be used in the clinical setting. The scale differentiates between appropriate, potential, and inappropriate recommendations according to the number of principles upheld by each recommendation. While admittedly pragmatic and far from comprehensive, this scale allows for the consistent clinical application of an otherwise theoretical model.
TABLE 2
Using the 4 EBQT principles to determine the usefulness of an action in the physician-patient encounter
| Number of EBQT principles upheld to treatment | Appropriateness of adjunct |
|---|---|
| All 4 | APPROPRIATE recommendation: potentially useful to physicians when a patient’s history warrants such action. Likely ethical. |
| 2 or 3 | POTENTIAL recommendation: action is limited to special circumstances and may not be useful to all physicians, even if warranted by the patient’s history. |
| 0 or 1 | INAPPROPRIATE recommendation: unlikely to be useful in the clinical physician-patient encounter. Risks being unethical. |
Case 1
A physician who maintains a relationship with local clergy is treating a 55-year-old woman with diabetes who has end-stage renal disease. The patient is distraught over lifestyle changes necessitated by dialysis. A spiritual assessment reveals the patient finds strength in her religious faith, actively participates in a local church, and speaks well of the pastoral staff.
Is referral to clergy an appropriate recommendation for addressing the patient’s social and personal issues?
Principle of evidence [+]: Evidence suggests a beneficial role for clergy in facilitating the use of in-home and community-based health services.30 Additionally, a chaplain or minister who knows the patient would be able to ensure she has access and transportation to congregational activities, such as worship or support groups. Religious involvement is associated with better disability outcomes31 and lower use of hospital services32 by medically ill older adults. In contrast, lack of religious participation33 and absence of strength and comfort in religion4 are associated with higher mortality.
Finally, clergy may help facilitate the use of private religious activities, such as prayer or devotional reading, which appear to promote lower blood pressure,34 survival advantage,3 and a reduction in cognitive symptoms of depression.35 The latter finding is particularly relevant to this patient whose intrinsic religious beliefs, according to research, statistically and independently predict a faster remission from depression related to the medical illness.36
Principle of belief [+]: Upheld by physician, patient, and therapy congruence. The physician maintains a referral relationship with local clergy, the patient expresses trust in her pastoral staff, and spiritual support from a trusted pastoral counselor, minister, or chaplain is relevant to the patient’s therapy.
Principle of quality care [+]: Referral promotes a more complete care, advancing medical goals, such as adherence to a renal treatment protocol, in a way that reinforces the patient’s values.
Principle of time [+]: The recommendation can actually save time in a busy practice, assuming an existing relationship with qualified local clergy.
The referral to clergy in this setting upholds all 4 principles and may be considered appropriate.
Case 2
A 25-year-old man with cystic fibrosis is admitted to a private religious hospital for an exacerbation of his illness. The patient’s spiritual history reveals a distant belief in a supreme being, but no formal faith or religious practice.
Can a religiously devout physician recommend religious attendance or devotional reading given this patient’s spiritual history?
Principle of evidence [–]: Some patients may rely on religious activities as a positive means of coping with chronic illness; however, no evidence suggests an advantage for beginning religious activities or attendance for mere health benefits.
Principle of belief [–]: The suggestion violates the principle of belief due to physician-patient incongruence.
Principle of quality care [–]: The recommendation does not acknowledge the patient’s values and would fail to advance medical goals, thereby increasing the risk of compulsory, or worse, deficient care.