Family medicine emphasizes medical care of the whole person, which includes an understanding of a patient's family and environment, as well as the social, cultural and psychologic situation. Over the past several years, it has been suggested that spirituality is another important, yet often neglected, factor in the health of patients.^1,2 Up to 77 percent of patients would like spiritual issues considered as part of their medical care,³ yet only 10 to 20 percent of physicians discuss these issues with their patients.^3,4 Reports such as these have increased interest in the incorporation of spirituality into the practice of medicine. Nearly 50 medical schools currently offer courses in spirituality and medicine.⁵

Relationship Between Spirituality and Medicine

The evidence in the medical literature that suggests a strong relationship between spirituality and medicine is increasing (Table 1^3,4,6–24). Polls of the U.S. population⁶ have consistently shown that 95 percent of Americans believe in God. One study³ found that 94 percent of patients admitted to hospitals believe that spiritual health is as important as physical health, 77 percent believe that physicians should consider their patients' spiritual needs as part of their medical care, and 37 percent want their physician to discuss their religious beliefs more. However, 80 percent reported that physicians never or rarely discuss spiritual or religious issues with them.

One study⁴ of physicians and patients in an outpatient setting found that 91 percent of patients believe in God, compared with 64 percent of physicians. In this study, 40 percent of patients felt that physicians should discuss pertinent religious issues; however, only 11 percent of physicians frequently or always did. Another study⁷ has reported similar findings. A recent national survey⁹ of family physicians reports that the percentage of physicians who have spiritual beliefs is closer to that of the general population.

The relationship between religious commitment and health outcomes has also been reviewed in detail.^1,2,13,14 Although some disagree,²⁴ most authors^2,14–16 report that a positive relationship between religious commitment and mental and physical health was found in up to 84 percent of studies that included a measure of religious commitment as part of the study. Religious commitment was helpful in the prevention of illness (including depression, substance abuse and physical illness), in coping with illness and in recovery from illness.^1,2

A recent study¹⁷ of elderly patients undergoing elective cardiac surgery showed that lack of strength and comfort from religion was independently related to the risk of death during the six-month period following surgery. A prospective cohort study¹⁸ of elderly poor forced to move from their homes showed that those who were more religiously committed were twice as likely to survive the two-year study period as persons without such religious commitment. The most influential study variable was strength and comfort derived from religion.

Some studies^11,12 have evaluated the effects of the relaxation response and meditation on health outcomes. The relaxation response can be elicited by a simple two-step procedure: (1) repeating a word, phrase or muscular activity, and (2) passively disregarding any obtrusive thoughts that come to mind and returning to the repetition. When practiced regularly, this technique results in a reproducible set of physiologic effects and is effective therapy for several medical conditions (Table 2¹¹). Benson¹¹ reports that 80 percent of patients, when given the choice between a religious or secular phrase, voluntarily chose a religious phrase to elicit the relaxation response. One quarter of the patients described a feeling of increased spirituality as a result of practicing the technique. These same patients were more likely to have better measurable medical outcomes than those who did not experience increased spirituality.¹¹

Although still preliminary, other areas of study regarding spirituality and medicine include the effects of prayer^21–23 and the placebo effect.^19,20

Definition of Terms

SPIRITUALITY VS. RELIGION

In order to have a meaningful discussion with patients regarding spirituality and medical care, a common understanding of terminology is essential. Many authors^25–30 recommend clarifying the difference between the terms “spirituality” and “religion.” They advocate a universal, broad-based definition of spirituality that encompasses religious and nonreligious perspectives.

Spirituality is a complex and multidimensional part of the human experience. It has cognitive, experiential and behavior aspects. The cognitive or philosophic aspects include the search for meaning, purpose and truth in life^{5,10,25–29,31,32} and the beliefs and values by which an individual lives.^26,31,33 The experiential and emotional aspects involve feelings of hope, love, connection, inner peace, comfort and support. These are reflected in the quality of an individual's inner resources,^28,31,33 the ability to give and receive spiritual love,²⁸ and the types of relationships and connections^25,29–32 that exist with self, the community, the environment and nature,³¹ and the transcendent^27,28,30,31 (e.g., power greater than self, a value system, God, cosmic consciousness). The behavior aspects of spirituality involve the way a person externally manifests individual spiritual beliefs and inner spiritual state.

Many people find spirituality through religion or through a personal relationship with the divine. However, others may find it through a connection to nature, through music and the arts, through a set of values and principles or through a quest for scientific truth.

Study of the world's religions^34,35 reveals that each religion attempts to help answer mankind's spiritual questions and that each has developed a specific set of beliefs, teachings and practices.^25,26,30 A person's experience with religious organizations may range from extremely positive to extremely negative.

SPIRITUAL DISTRESS

Spiritual distress^28,32 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.

SPIRITUAL CARE AND SPIRITUAL ASSESSMENT

General spiritual care can be defined as recognizing and responding to the “multifaceted expressions of spirituality we encounter in our patients and their families.”³⁰ It involves compassion, presence, listening and the encouragement of realistic hope,³⁶ and might not involve any discussion of God or religion. General spiritual care may be provided by anyone. Specialized spiritual care often involves understanding and helping with specific theologic beliefs and conflicts. It is ideally performed by persons with special training in this area, such as those trained as Clinical Pastoral Education (CPE) chaplains.

Spiritual assessment is the process by which health care providers can identify a patient's spiritual needs pertaining to medical care.

Role of the Physician

Family physicians are concerned with any factors that affect their patients' health. It is important that physicians maintain a balanced, open-minded approach to medical care without sacrificing scientific integrity. Physicians can begin to incorporate spirituality into medical practice in three ways: (1) by scientific study of the subject; (2) by assessment of the patient's spirituality and diagnosis of spiritual distress; and (3) by therapeutic interventions.

Scientific study involves evaluating the current evidence 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.

For assessment and diagnosis, the physician should evaluate whether spirituality is important to a particular patient and whether spiritual factors are helping or hindering the healing process.

Therapeutic interventions include consideration of a patient's spirituality in recommendations regarding prevention, medical treatment and adjuvant care. In addition, elements of general spiritual care should be incorporated into the routine medical encounter. Although not easily measurable, a physician's ability to offer connection, compassion and presence can be a powerful therapeutic intervention.

Spiritual Assessment

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

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 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 tool described in this article. Spiritual self-care is integral to serving the multiple needs and demands of patients in the current health care system. 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 skillful 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, a 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.³⁷ 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 CPE chaplains. 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 patient's illness or recovery and whether these factors affect the medical treatment plan. There are many possible formats for conducting a formal spiritual assessment, and several have been reviewed elsewhere (www.gwu.edu/~cicd/toolkit/spiritual.htm).^38,39 Most of these tools were developed for use in the hospice setting, for use by pastoral counselors or nurses, or as research instruments.^{28,33,38–41} Little has been written about approaches developed for use by practicing physicians in a routine medical encounter.^42–44

The HOPE Questions

The HOPE questions, outlined below, were developed as a teaching tool to help medical students, residents and practicing physicians begin the process of incorporating a spiritual assessment into the medical interview. These questions have not been validated by research, but the strength of this particular approach is that it allows for an open-ended exploration of an individual's general spiritual resources and concerns and serves as a natural follow-up to discussion of other support systems. It does not immediately focus on the word “spirituality” or “religion.” This minimizes barriers to discussion based on use of language.

The HOPE questions cover the basic areas of inquiry for physicians to use in formal spiritual assessments (Table 3). The first part of the mnemonic, H, pertains to a patient's basic spiritual resources, such as sources of hope, without immediately focusing on religion or spirituality. This approach allows for meaningful conversation with a variety of patients, including those whose spirituality lies outside the boundaries of traditional religion or those who have been alienated in some way from their religion. It also allows those for whom religion, God or prayer is important to volunteer this information. There are many ways of asking these questions (Table 4).

The second and third letters, O and P, refer to areas of inquiry about the importance of organized religion in patients' lives and the specific aspects of their personal spirituality and practices that are most helpful. A useful way to introduce these questions is a normalizing statement such as: “For some people, their religious or spiritual beliefs act as a source of comfort and strength in dealing with life's ups and downs. Is this true for you?”

If the answer to this question is “Yes,” inquiry can proceed with specific questions regarding religion and personal spirituality (Table 4). If the answer to the question is “No,” the physician can end this line of questioning or, if the patient appears to be at ease, ask follow-up questions such as: “Was it ever important to you?” If the answer is “Yes,” then the question “What changed?” opens the door for patients to discuss important spiritual concerns that may have an impact on their medical care.

The final letter of the mnemonic, E, pertains to the effects of a patient's spirituality and beliefs on medical care and end-of-life issues. These questions can help focus the discussion back onto clinical management. Table 4 suggests several areas of inquiry, including barriers to the access of usual spiritual resources; fears, concerns or conflicts regarding the patient's belief system and the current medical situation; and the effects of specific beliefs or rituals on medical management. Understanding spiritual issues in the care of the dying has been addressed in detail elsewhere.^30,36,39 Major themes include fear of disconnection or isolation and the ability to make peace with the death that is approaching as well as with the life that is ending.

Effects of Spiritual Assessment on Medical Management

Many possible steps may follow the spiritual assessment.

1. 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.

2. 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, t'ai chi, walks in the country or listening to soothing music.

3. 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.

4. 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.

Final Comment

Spirituality is an important, multidimensional aspect of the human experience that is difficult to fully understand or measure using the scientific method, yet convincing evidence in the medical literature supports its beneficial role in the practice of medicine. It will take many more years of study to understand exactly which aspects of spirituality hold the most benefit for health and well-being. The world's great wisdom traditions suggest that some of the most important aspects of spirituality lie in the sense of connection and inner strength, comfort, love and peace that individuals derive from their relationship with self, others, nature and the transcendent.

As family 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. The future exploration of this field offers physicians the opportunity to improve care and gain a clearer understanding of some of life's and medicine's greatest mysteries.