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 doctors office
or hospital
Spirituality should be seen as part of a
package rather than stand-alone treatment
modality
With Family Medicines whole person care
perspective, it is natural that those in Family
Medicine will have a good understanding in
this area

Spirituality
Broader

concept than religion and is primarily a

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

Religion
Organizes

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 care

Recognition

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 Assessment
The

process by which the health care provider

can identify a patients 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 studies

900 mental health studies
100 mortality studies

Use of spiritual/religious variables in Medical

Research
3.5%

of family practice studies

1.1% of internal medicine studies
11.8% of adolescent health studies
10% 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 ones
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 PREREQUISITES
Several

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 patientcentered 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 selfassessment 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 physicians 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

Maslows 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 patients spiritual
beliefs may reveal more about a patients 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 ASSESSMENT

A

formal spiritual assessment involves asking

specific questions during a medical interview to
determine whether spiritual factors may play a
role in the patients illness or recovery and
whether these factors affect the medical
treatment plan.
Possible formats for conducting a formal spiritual
assessment include:
The FICA Spiritual History
HOPE questions
The 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 patients
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 questions

These

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

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

spirituality in adjuvant care.

the treatment plan.

Modifications can be made based on better understanding

of the patients 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

patients 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 Jehovahs 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 patients permission, offer to
contact the patients 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 physicians 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 physician
For

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.

Mortality
18

studies show religiously involved persons live

longer

Cardiovascular Disease
12/16

found religious involvement associated

with less CV disease and mortality

Hypertension
14/16

studies found religious involvement

associated with lower BP
9/13 clinical trials found religious/spiritual
practices significantly reduce BP

Mental Health
24/29

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 Illness

Less

depression during illness

Lower levels of despair, anger, hostility, and
social isolation

Barriers
Physician
Patient
Mutual
Situational
Communication

Facilitators
Actions
Situational

factors

Resources
Physician

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 subject

By assessment of the patients 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 patients
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 patients
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