Spirituality, health, and medical care of adults.

Among the more impressive discoveries in spirituality and health research in the last two decades has been finding that certain aspects of spirituality are consistently associated with lower morbidity and mortality in adults. As a result of this knowledge, clinicians should incorporate an appreciation for the influence of spirituality and religion on health when addressing the medical problems of adults. How should clinicians approach this aspect of care? The recommended approach described herein involves a few simple steps that can be accomplished by any clinician, with the help of a little training. An easy way to remember the steps is to think of "Spiritual-CPR": Spiritual History, Care, Prayer, and Resources.

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Taking a Spiritual History is the first step, and is especially important in inpatient care, care of the dying, and care of people with serious and/or chronic illness. (1) It is important to try to understand the patients' spiritual and religious views toward health, because such views may have a substantial impact on treatment choices, attitudes, coping, and even future health. There are many methods for taking a spiritual history, including semistructured, open-ended questioning, and more structured methods. The method currently taught at our institution is the HOPE method, first described by Anandarajah in 2001. The HOPE questions can be viewed on the web at www.aafp.org/afp/20010101/81.html and have been validated in the medical school teaching environment. (2)

This approach also leads naturally into the next area to address: Care. Caring for the patient may seem natural, and may not be connected to spirituality in everyone's mind. However, if one defines spirituality as the search for purpose and meaning in life, then compassion and care for patients relates directly to the caregiver's spirituality and feeds appropriately into the needs of patients. In patients who are dying, in whom there is little hope of medical cure, compassionate care becomes paramount and sometimes is the sole comfort that clinicians can provide. To be present in the patient's suffering, treating them as a person and being human with them on hospital rounds every day, is extremely important and is part of the essence of spiritual care. Too often there is a temptation to "skip" dying patients on morning rounds ("We can't do anything for her, so why are we rounding on this patient?") or to misinterpret do-not-resuscitate (DNR) with do-not-treat. Compassion and care are related to positive health outcomes and are essential to understanding the spiritual care of adults. (3)

The next element of Spiritual-CPR is Prayer. A sensitive, patient-centered approach that respects everyone is suggested. (4) In certain instances, such as terminal illness, loss of a loved one, presurgery, or other times of emotional upset and distress, the clinician may be asked by the patient to participate in prayer. Patient-centered prayer is a very natural by-product of creating an environment of permissiveness for discussion of spiritual issues. If one succeeds in creating such an environment, one will begin to receive requests for prayer from patients. The clinician does not need to feel obligated to lead prayer, but listening while the patient prays is a reasonable and doable task for most physicians. The level of reassurance with which this act can provide patients is incalculable. It speaks to our humanity and our willingness to meet them half-way in their hour of need. The doctor-patient relationship is almost always strengthened by such interaction. Physician-initiated proselytizing and coercion are unacceptable. However, participating in prayer when suggested by the patient or when there is known congruence of beliefs, is not only acceptable, but is also likely to be beneficial in creating a healing environment. (5)

The third element of Spiritual-CPR is Resources. If one determines the need for psychological counseling in a patient, one naturally and automatically refers them to a psychologist or psychiatrist for further care. When one determines that a patient has spiritual conflicts, need for spiritual comfort, or need for prayer and support, then one should just as automatically seek the help of a chaplain or counseling minister. For inpatients, chaplains are required to be available, thus one should have little trouble requesting assistance. For outpatients, many resources are available. Psychologists and family therapists are now integrating spiritual care into their counseling practice, and advertising these services. In addition, many clergy have advanced degrees in psychology and counseling. Pastoral counseling is a growing area of psychotherapy that uses spiritual resources as well as psychological understanding for healing and growth. Pastoral counselors are certified mental health professionals who also have had in-depth religious training. The American Association of Pastoral Counselors (AAPC) sets professional standards and certifies pastoral counselors. The organization is nonsectarian and respects the spiritual commitments and religious traditions of those who seek assistance without imposing counselor beliefs onto the client.

Spiritual-CPR can help you to help your patients and can assist you in addressing the spiritual aspects of medical care in adults.

References

1. Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician 2001;63:81-88.

2. King DE, Blue A, Mallin R, et al. Implementation and assessment of a spiritual history taking curriculum in the first year of medical school. Teach Learn Med 2004;16:64-68.

3. Steffen PR, Masters KS. Does compassion mediate the intrinsic religion-health relationship? Ann Behav Med 2005;30:217-224.

4. Koenig HG. The Healing Power of Faith. New York, Simon and Shuster, 1999.

5. McDonough-Means SI, Kreitzer MJ, Bell IR.. Fostering a healing presence and investigating its mediators. J Altern Complement Med 2004;10 (Suppl l):S25-41.

Curiosity is one of the permanent and certain characteristics of a
vigorous mind.
--Samuel Johnson

Dana E. King, MD, MS

From the Department of Family Medicine, Medical University of South Carolina, Charleston, SC.

Reprint requests to Dana E. King, MD, MS, Department of Family Medicine, Medical University of South Carolina, 295 Calhoun Street, Charleston, SC 29464. Email: [e-mail]