Am Fam Physician. 2022;106(4):415-419
Related Letter to the Editor: The Importance of Inclusivity During the Spiritual Assessment
Author disclosure: No relevant financial relationships.
The spiritual assessment offers the opportunity to enhance the patient-physician relationship and incorporate patient views that may have a significant impact on clinical decision-making. Multiple studies have demonstrated that patients' expectations of spiritual discussions in the health care setting are not being met. Perceived barriers reported by physicians include lack of time, training, and experience. There is a variety of physician approaches to assess and incorporate spirituality in the health care setting. A spiritual assessment is recommended when a patient is admitted to the hospital, has a significant clinical decline while in the hospital, is receiving psychosocial services for the treatment of substance use disorder, or when addressing palliative care. Tools for spiritual assessment include the Open Invite mnemonic, which initiates the topic and relies on a conversational approach, and the HOPE questions, which offer a structured approach to determine the relevance of spirituality to the patient's overall health and assist with the development of an individualized care plan. Although physicians should respect the right of patients who do not want to discuss this topic, multiple studies demonstrate significant relationships between spiritual interventions and improved mental and physical health outcomes.
The physician-patient relationship is at the foundation of every interaction in family medicine. Understanding a patient's spirituality significantly impacts this relationship as well as clinical decision-making. Patients often view their health care with spirituality in mind, particularly at the end of life. Spiritual assessment is a component of the holistic or biopsychosocial-spiritual approach of caring for the patient.1
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Patients should be offered a spiritual assessment when addressing end-of-life care.3,8,9 | C | Consensus guidelines |
| Patients should be offered a spiritual assessment when receiving psychosocial services for the treatment of substance use disorders in the hospital setting.8,9 | C | Consensus guidelines |
| Patients should be offered a spiritual assessment at hospitalization or if a significant clinical decline occurs in the hospital setting.3,8,9,19 | C | Consensus guidelines |
Defining Spirituality
Although religion is the beliefs and practices with which one approaches the sacred, spirituality is broader and involves seeking meaning and connectedness behind human life.2,3 Here the term spirituality is used as opposed to religion to convey greater inclusivity in the context of the diverse views patients may have.4 A 2017 Gallup Poll showed that 87% of Americans believe in God or a universal spirit and this has remained between 86% and 92% since 2011.5 Spirituality may be expressed as a belief in God, but it can also include beliefs that give patients a sense of greater purpose in life through connection with nature, energy, art, music, and humankind.6
Scope of Spirituality
The scope of spirituality in medical practice is typically addressed during the discussion of end-of-life care. The COVID-19 pandemic has highlighted the importance of advance care planning and spiritual assessment as necessary elements to consider when discussing end-of-life issues with patients.3,7 The Joint Commission requires accommodation of spiritual issues in end-of-life care and for patients who receive psychosocial services for substance use disorders.8–10 The Association of American Medical Colleges has established learning goals for medical students regarding spirituality, including the ability to elicit a spiritual history.11
Multiple studies demonstrate that physicians are not meeting the expectations of patients to discuss spirituality. One outpatient survey showed that most family medicine patients desired spiritual discussions during challenging life events, including 70% of patients who indicated they desired spiritual discussions for loss of a loved one, 74% for serious medical conditions, and 77% for life-threatening illnesses.12 In the same study, patients identified the most important reasons for these discussions as desire for physician-patient understanding and the belief that spiritual needs would affect medical advice and treatment.12 A recent cross-sectional study showed that nearly one-half of patients in the outpatient setting wanted to partake in a spiritual assessment, but 90% of participants reported that they were never asked about their beliefs.13
Physicians may view spirituality and its role in medicine differently. A qualitative study of general practitioners in Scotland demonstrated four major actions that physicians can take based on a patient's spiritual beliefs.14 Some physicians may choose not to explore a patient's spiritual beliefs.14 Other physicians use the spiritual assessment to provide relevant cultural information or clinical background and to understand patients' belief systems. In this action, physicians do not view spirituality as a shared experience with the patient, but as a data point in providing comprehensive care.14 Some physicians use the spiritual assessment to refer or recommend the patient to a spiritual advisor or member of the patient's faith community. In this situation, physicians may acknowledge the importance of the spiritual needs of the patient but do not view themselves as the person to address those needs.14 Some physicians choose to actively engage patients in a discussion about spirituality and how it affects their health, and may offer to pray with or for them.14
Although studies demonstrate that physicians see themselves as supportive of patients' spiritual well-being, there are multiple perceived barriers. These barriers include lack of time and training for, and experience with the spiritual assessment.15 Given the time constraints of office visits and lack of experience in conducting spiritual assessments, physicians report feeling uncertain or uncomfortable in initiating spiritual discussions.15 A quality improvement project in the palliative care setting that focused on encouraging physicians to perform spiritual assessments shows that barriers can be addressed. By integrating chaplains who joined physicians for the interview, documentation of completed spiritual assessments increased from 49% to 72%.16
Identifying Appropriate Clinical Situations
Physicians should consider performing a spiritual assessment for patients who are hospitalized, in a palliative care setting, or have a critical illness. A spiritual assessment can be helpful when a patient undergoes a significant change in clinical status, such as rapid decompensation.3 More than 40% of older patients who are hospitalized report spirituality as their primary coping mechanism.17,18 The Joint Commission notes that the following screening questions may be useful at admission: “Do you struggle with the loss of meaning and joy in your life?” and “Do you currently have what you would describe as religious or spiritual struggles?”9,19
Spiritual assessments can be used to introduce the discussion of advance directives and increase the number of patients who have documented advance directives. Only about one-third of Americans have any form of advance directive in place.20 Physicians should consider conducting a spiritual assessment in the clinic or during a home visit with older adults while discussing advance directives.21 Emerging evidence suggests that gradually introducing the spiritual assessment as the severity of chronic diseases advance increases the proportion of patients who welcome a spiritual assessment. 22 Multiple systematic reviews demonstrate significant relationships between spirituality and improved mental and physical health outcomes in conditions such as cardiovascular disease, renal disease, and cancer. This evidence reinforces the concept of introducing the spiritual assessment at various stages in the disease process.17,22,23
Conducting the Spiritual Assessment
The origin of spiritual assessment tools can be traced to the 1960s and the disciplines of pastoral care and psychiatry. There are more than 40 clinical tools available to perform a spiritual assessment, although few tools have been developed in the past decade.6 Given that most patients generally want to discuss spiritual beliefs or at minimum be asked about the topic, one technique to introduce is the Open Invite mnemonic (Table 14). When patients initiate the topic of spirituality, questions such as “Does your faith or spirituality impact the health decisions you make?” can help clarify a care plan. The benefit of this technique is that it initiates the topic and relies on a conversational approach.
| Category | Sample questions |
|---|---|
| Open (i.e., open the door to conversation) | May I ask your faith? 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 you would like me to account for your spirituality in your health care? Is there a way I or another member of the medical team can provide you with support? Are there resources in your faith community that you would like me to help mobilize on your behalf? |
The HOPE mnemonic (sources of Hope, Organized religion, Personal spirituality and practices, and Effects on medical care and end-of-life issues) is another method that offers an organized approach to spiritual assessment (Table 224). This tool was originally designed to aid in teaching medical learners how to conduct a spiritual assessment.6 An advantage of the HOPE tool is that the initial question does not focus on the words faith, spirituality, or religion. Instead, the physician asks the patient for sources of hope, strength, comfort, and peace. These questions offer the physician a conversation opening that minimizes barriers based on the perception of language while offering questions to assess spirituality based on the patient's responses.24
| Category | Sample questions |
|---|---|
| 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 spirituality and practices | Do you have personal spiritual beliefs? What aspects of your spirituality or spiritual practices do you find most helpful? |
| E: effects on medical care and end-of-life issues | Does your current situation affect your ability to do things that help you spiritually? As a doctor, is there anything that I can do to help you access resources that help you? Are there any specific practices or restrictions that I should know when 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? |
Care Plan With Spiritual Needs in Mind
There is no consensus on the best means for incorporating the spiritual assessment into patient care plans. The importance of the spiritual assessment is understanding how or if a patient's spirituality affects their health care or how health care should be delivered. The assessment tools incorporate questions that can be used to understand the impact of spirituality on individual care plans. Recognizing that there are limitations in a physician's training and ability to address spiritual issues, it is important to engage the services of a chaplain or trained spiritual adviser based on patient needs. For example, if a patient's spiritual beliefs are thought to be harmful to their health, a physician should refer the patient to a specialist in spiritual care to help explore their belief system, which can provide clarity for the patient and physician.25 Patients may benefit from being connected with health-related resources offered by a faith-based organization.26
Even in situations where spiritual needs may have a significant clinical impact, metrics for assessment and implementation are limited. A systematic review revealed that only three of 35 instruments are designed to identify those in spiritual distress who may need intervention with a chaplain.27 Another systematic review found that only 4% of palliative care quality measures for cancer address spiritual domains.28 The role and interplay of health care team members in addressing spiritual needs were not specified.
Potential Benefits and Limitations to Spiritual Assessment
Much of the research regarding the benefit and limitations of addressing spirituality comes from the palliative care community. A systematic review performed for the National Consensus Project for Quality Palliative Care found that spiritual interventions have a positive impact on the patient's spiritual well-being and may impact other outcomes such as meaning, purpose, will to live, acceptance of death, and emotional well-being.29 A recent meta-analysis demonstrated that spiritual interventions such as mindfulness, imagination, meditation, and prayer decreased depression and anxiety symptoms and improved quality of life in patients with cancer.30
Although there are limited data on the potential harms of conducting a spiritual assessment, physicians should be aware that investigating and discussing spiritual beliefs can lead to negative reactions from patients. Some patients may view spiritual discussions as beneficial and others may find them offensive and a barrier to developing a therapeutic alliance. Physicians should respect the right of every patient who does not want to discuss spirituality.
This article updates previous articles on this topic by Anandarajah and Hight24 and Saguil and Phelps.4
Data Sources: A PubMed search was completed using the following key words and medical subject headings (MeSH): faith, spiritual, and religion. The search included randomized clinical trials, clinical trials, meta-analyses, systematic reviews, and review articles. Articles were cross-referenced in PubMed and reviewed for relevance. References from articles were reviewed for primary-source evidence. Search dates: September to December 2021, and May 30, 2022.
Editor's Note: This article reviews the suggested uses and potential benefits of spiritual assessment in clinical practice. We anticipate that readers along the broad spectrum of religious belief may have varying views on this topic. Some readers may think that spirituality is not an ethically appropriate area for family physicians to address, especially when the faith traditions of physicians and patients differ. In addition, associations between religious beliefs and health outcomes are inconsistent.1 Others may feel that a generic spiritual, rather than religious, assessment trivializes religious beliefs and minimizes potential benefits of incorporating faith into patient encounters to promote holistic healing.2 We welcome your responses to this article and look forward to the discussion. Tell us what you think by posting a comment online, on our Facebook page (https://www.facebook.com/AFPJournal), or by emailing us at afpedit@ aafp.org.—Kenny Lin, MD, MPH, Deputy Editor, and Sumi Sexton, MD, Editor-in-Chief
1. Weaver AJ, Koenig HG. Religion, spirituality, and their relevance to medicine: an update. Am Fam Physician. 2006;73(8):1336-1337.
2. Larimore WL. Providing basic spiritual care for patients: should it be the exclusive domain of pastoral professionals? Am Fam Physician. 2001;63(1):36-40.
The authors acknowledge the contribution of Anne Mounsey, MD, who reviewed and offered suggestions during the development of this article.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the U.S. Department of the Navy, U.S. Department of Defense, or the U.S. government.
