Addressing the Spiritual Side of Medicine
The Joint Commission mandates that healthcare institutions “Identify patient cultural, religious, or spiritual beliefs and practices that influence care” and accommodate them when possible.1 Their stance is that patient beliefs and practices may affect a patient’s (and/or family’s) perception of the illness, the treatment plan and the possible outcomes. Specific guidelines and suggestions for fulfilling these goals can be found in The Joint Commission document, Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care.2
Should discussions on spirituality be avoided like politics?
Dr. Robert Klitzman’s opinion on the matter of meeting patients’ spiritual needs published in The New York Times is clear; Physicians may be failing to address them.3 A primary reason for this, in his case of treating a terminally ill patient, was his uncertainty it was an area where a doctor should venture. As he watched the decline of his patient, it led Klitzman to wonder if he should address this particular dimension of his patient’s well being. He had seen indications of the young cancer patient’s Christian faith and thought perhaps she could benefit from talking with someone to help alleviate her isolation and fears. Being from a Jewish background himself, he wasn’t sure if he should offer to bring in a priest, or if making the offer would indicate he was giving up on the situation. The discomfort of asking the question was overridden by his concern for his patient and led to asking his resident if “we ever call a priest”. The author tells us the resident looked at him “as if I were nuts”. In this particular setting, physicians simply did not mention religion or spirituality at all.
There are various viewpoints on dealing with a patient’s spiritual needs. Some physicians initiate a spiritual discussion, perhaps even praying with a patient. Others may see engaging in a conversation only as deemed appropriate; if the discussion is initiated by the patient.4 However, simply waiting for the patient can be problematic as many patients are not comfortable enough to bring it up to their doctor. Continuing along the spectrum, some physicians may incorporate formal spiritual assessments, while others do not address it at all. Finally, some have the desire to assist in this area but don’t know how or when, or fear somehow doing the wrong thing (e.g. being seen as pushing their own spiritual viewpoints).
Using HOPE to guide the conversation
Determining spiritual needs could certainly be part of formal assessments which already measure bio-psycho-social history. Understanding the Role of Spirituality in Medicine - A Resource for Medical Students5 discusses several formal assessments a practitioner or organization may consider implementing. One of the assessments is the HOPE Questions for a Formal Spiritual Assessment in a Medical Interview. HOPE questions seek answers to four areas6:
H: Sources of hope, meaning, comfort, strength, peace, love and connection (e.g. What are your sources of hope, strength, comfort, and peace?; What do you hold on to during difficult times?)
O: Organized religion (e.g. What aspects of your religion are helpful and not so helpful to you?, Do you consider yourself part of an organized religion?)
P: Personal spirituality and practices (e.g. Do you have personal spiritual beliefs that are independent of organized religion? What are they?, Do you believe in God? What kind of relationship do you have with God?)
E: Effects on medical care and end-of-life issues (e.g. As a doctor, is there anything that I can do to help you access the resources that usually help you?, Are you worried about any conflicts between your beliefs and your medical situation/care/decisions?, Would it be helpful for you to speak to a clinical chaplain/community spiritual leader?)
Spirituality is an important dimension in overall well being
his article “Spirituality and Medicine”, Thomas McKormick suggested referring patients to the chaplain or other appropriate clergy who can assist them with spiritual or religious struggles impacting their health and well being. He states, “Most patients will be grateful for an inquiry about their spirituality and for the physician’s respect for their spiritual as well as their physical well being.”7
Dr. Klitzman notes that while more doctors are receiving training, many do not, or they feel their training was inadequate. Still others believe there is too little time to deal with it, or as mentioned earlier; they don’t know how or are uncomfortable with addressing this dimension of their patient’s well being. Klitzman ends his piece with advice that seems to be an approach all physicians could use; just ask. You don’t have to be spiritual or religious yourself. You don’t have to engage in conversations about their spiritual needs. What you can do is say, “Some patients would like to have a discussion with someone here about spiritual issues; some patients wouldn’t. If you would like to, we can arrange for someone to talk with you.”8
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