Department of Family Medicine
Patients' Religious and Spiritual Lives
The Gallup organization has tracked US religious beliefs over the last 70 years.1 Almost half of Americans consider themselves very religious (43.7%). The most common formal religious activity is attendance at worship services. About 40 percent of Americans attend worship services weekly. Other frequent formal religious activities include scripture study classes, baptisms, weddings and funerals. Private religious activity is also prevalent, the most common of which is prayer. Only 2 in 10 Americans say that religion is not a very important part of daily life.1 Many people who are not involved in formal religious activities have spiritual beliefs and activities that influence their attitudes and behaviors and serve as a guide for living.2 Having an internal or intrinsic spiritual orientation has been associated with decreased stress and better performance when under stress.3
One of the most important reasons to address patients’ spiritual and religious beliefs in the health care setting is their impact on health-related decisions and behaviors. Sixty percent of Americans state that their religion is the most important influence in their daily lives.5 Patients undergoing inpatient or outpatient medical treatment express strong religious and spiritual orientations.4,5 One survey of 150 outpatients demonstrated that over 90 percent believed in God, 85 percent used prayer, and 74 percent felt close to God. A survey of inpatients at two hospitals revealed that 98 percent believed in God and that 93 percent were very strong or somewhat strong in their beliefs. Seventy-three percent prayed daily or more often. Ninety-four percent agreed that spiritual health is as important as physical health. Spiritual concerns are almost universal among hospitalized patients.5
The Joint Council for Accreditation of Healthcare Organizations (JCAHO) has recognized the influence of spirituality on hospitalized patients by requiring a hospital chaplain or access to pastoral services in the standards for accreditation of all hospitals since the late 1990’s. According to the JCAHO, a spiritual assessment should be performed on every patient, identifying, “at a minimum,” the patient’s denomination, beliefs, spiritual practices, and spiritual needs while hospitalized.
Health Beliefs Of Religious Groups
Clinicians should be aware of the more common health beliefs of religious groups in their practice, so that they will be able to better counsel and care for their patients. Health beliefs vary according to culture, education, and experience. Religious beliefs can be very strong and can be the deciding factor in medical decisions like abortion or withdrawal of life support.
Many factors add to the complexity of the interaction of religious and health beliefs, including differing beliefs between the patient and their family, between the patient and physician, between the patient and their religious tradition, and inconsistencies within the patient. The family may have different views than either the patient or the physician. While physicians presume that medical factors should play the lead role in medical decision-making, religious factors often play an equal or greater role.
Individuals’ beliefs do not always coincide with the principles of a specific religious code. Health professionals should be aware of the major moral and religious norms that guide the medical decision-making of many patients. Physicians should be especially mindful of potentially strong religion-based health beliefs when discussing life and death issues, contraception, abortion, and euthanasia.
Taking a Spiritual History
Patients’ spirituality should be assessed for several reasons: patients have views that affect their health; many patients want their spiritual needs addressed in the medical setting; and patients often use their faith as a resource for coping with an illness.1,6 Clinicians need to know whether the patient’s religious or spiritual views may affect medical decision-making. Hospitalized patients have expressed the desire to have their spiritual needs addressed and some would like physicians to pray with them. Koenig and others have documented the prevalence of religious coping in hospitalized patients, and that patients who use religious coping have less depression and better health.7 Spiritual issues may be hidden from view but will surface quickly once inquiry is made. It may take little more than asking the simple question “do you have a faith or religion that is important to you?” to open a dialogue about spiritual or religious needs or concerns the patient may have.
Taking a spiritual history is the process of gathering relevant information from a patient about spiritual values, religious beliefs, spiritual needs and concerns, and whatever gives the patient’s life and illness meaning. It should also include questions about how their religious and spiritual views affect their health, whether they use religious coping, whether they have specific spiritual concerns at the time, and whether they have a minister or other spiritual counselor on whom to call. Most patients (80%) believe in God and express a denominational affiliation, but only 40% are members of a particular congregation.1 Thus many hospitalized patients do not have their own minister or spiritual counselor; for them, chaplains are an important spiritual resource.
Taking a spiritual history should be incorporated into the work-up of all hospital patients and should be a part of any complete history and physical examination. The physician should evaluate whether spirituality is important to a particular patient and whether spiritual factors are helping or hindering the healing process. Several clinicians have developed tools for taking a spiritual history that aid in the process and make the topics to cover easier to remember, including the SPIRITual history,8 FAITH,9 and the FICA tool.10
At MUSC, we teach the HOPE method of taking a spiritual history because of its ease of use and the way it smoothly transitions from social support to spiritual topics.11 The HOPE questions, which can be seen at on the web at www.aafp.org/afp/20010101/81.html, 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. The first part of the mnemonic, H, addresses the person’s basic spiritual resources, such as sources of hope, without immediately focusing on religion or spirituality. Using this method allows for meaningful dialogue with patients of diverse backgrounds, 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.
The second and third letters, O and P, focus on the importance of organized religion in patients' lives and the specific aspects of their personal spirituality and practices. If patients relate meaningful experiences at this point, then the interviewer can proceed with more specific questions regarding religion and personal spirituality. If not, then one can ask open-ended follow-up questions to open the door for patients to discuss important spiritual concerns they may have.
The final letter, E, focuses on the effects of a patient's spiritual and religious beliefs on medical care and end-of-life issues. These questions help re-direct the discussion back onto clinical issues and medical-decision-making.
Physicians and other caregivers who are sensitive to the biopsychosocial needs of patients should also consider patients’ spiritual needs. The prominent role of religious commitment and spirituality in patients’ private lives can have a tremendous impact on medical decision-making and coping with serious medical illness. Taking a spiritual history and referring patients with spiritual concerns to chaplains or ministers are basic clinical skills that every medical provider should learn. Inquiry into the spiritual areas of patients’ lives, previously considered taboo, is now taught as method of delivering more comprehensive and compassionate care at 90% of United States medical schools.12 Spiritual inquiry is justified by the need to obtain important medical information and explore the patient’s point of view regarding their illness, but must be done in such a way that respects the patient’s privacy, confidentiality, and autonomy. Effectively integrating spiritual sensitivity into clinical practice is a challenge that should be addressed by all physicians and clinical care providers.
References, Bibliography, and More Information
1. Newport F, Agrawal S, Witters D. Religious Americans Enjoy Higher Wellbeing. 2010. Retrieved from www.gallup.com on September 7, 2011.
2. McBride JL, Arthur G, Brooks R, Pilkington L. The relationship between patient’s spirituality and health experiences. Fam Med 1998; 30(2):122-126.
3. Inzlicht M, McGregor I, Hirsh J, Nash K. Neural Markers of Religious Conviction. Psychological Science. 2009; 20(3):385-392.
4. Koenig HG. Religion, spirituality, and medicine: research findings and implications for clinical practice. South Med J. 2004;97(12):1194-200.
5. King DE, Crisp J. Case discussion: do not neglect the spiritual history. South Med J. 2007; 100(4):426.
6. Fitchett G, Rasinski K, Cadge W, Curlin FA. Physicians’ Experience and Satisfaction With Chaplains: A National Survey. Arch Intern Med. 2009: 169:1808-1810.
7. Koenig HG. Psychoneuroimmunology and the faith factor. J Gend Specif Med. 2000;3(5):37-44.
8. Maugans TA, Wadland WC. Religion and family medicine: a survey of physicians and patients. J Fam Pract. 1991;32:210-213.
9. King DE, Keller AH Jr. Should religiosity be included in the medical history"? J S C Med Assoc. 2001;97(12):534-5.
10. Puchalski CM, Larson DB. Developing curricula in spirituality and medicine. Acad Med. 1998;73(9):970-974.
11. Anadarajah 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.
12. Koenig HG, Hooten EG, Lindsay-Calkins E, Meador KG. Spirituality in Medical Scholl Curricula: Findings from a National Survey. Int J Psychiatry Med. 2010;40(4):391-8.