AMA Journal of Ethics^®

During the last 10 years there has been a considerable increase in the number of studies showing positive associations between spirituality and health.^1,2 Incorporating spirituality into medical practice, however, continues to pose many challenges.³ These include the multicultural milieu in which medicine is practiced and the deeply personal meaning these issues carry for both patients and health care providers. A culturally sensitive spiritual assessment is a first step towards addressing the spiritual needs of patients.⁴ It also provides a tool through which health professionals can understand their own beliefs, biases, values, and needs as related to health care.

Terminology

Words such as spirituality and religion carry a variety of meanings for different people. For some these terms evoke positive feelings and for others they may trigger negative responses. Although debate continues regarding the exact meaning of these and related words, it is helpful to have some common ground from which to start.

A. Whole person—Human beings are complex, with physical, mental, and spiritual aspects. Suffering can result from issues pertaining to any of these aspects.

B. Spirituality—Pertains to people's understanding of and beliefs about the meaning of life and their sense of connection to the world around them. It is multidimensional and can encompass both secular and religious perspectives.⁴

1. Cognitive aspects have to do with the way we make sense of the world around us. They include the big picture questions such as: "What is the nature of the universe?" "Is there a God?" "Why do bad things happen to good people?" "What happens after death?" "What beliefs and values are most important to me?"
2. Experiential aspects have to do with connection and inner resilience. They encompass questions such as: "Am I alone or am I connected to something bigger?" "Am I able to give and receive love?" "Do I feel an inner sense of peace and resilience?" "Can I find hope in this difficult situation?"
3. Behavioral aspects have to do with ways in which a person's spiritual beliefs and inner spiritual state affect his or her behavior and life choices.

C. Religion—organized or institutionalized belief systems that attempt to provide specific answers to mankind's general spiritual needs and questions. For many people, religion provides an important foundation from which to meet the numerous challenges that life presents. For others religion may be associated with negative experiences.

D. Faith—can mean a person's belief and trust in something (eg, God) and may or may not pertain directly to religion (as in "What is your faith?").

E. Spiritual distress/crisis—This is a state of suffering due to spiritual causes. For example: (1) a mother having difficulty understanding why a loving God would allow her child to die; or (2) a dying patient feeling cut off from sources of spiritual love.

F. Spiritual Assessment—Methods to identify a patient's spiritual suffering and spiritual needs related to medical care.

G. Spiritual Care—Therapeutic aspects of spirituality and medicine.

1. General spiritual care—bringing presence, compassion, understanding, and listening to each encounter. This can be provided by anyone at any time. It can traverse all cultural barriers by meeting a universal spiritual need without specific discussion about beliefs or God.
2. Specific or specialized spiritual care—addressing the individual needs of the patient. Simple issues may be addressed by physicians. More complex issues will likely require the expertise of well-trained spiritual care counselors such as chaplains trained in Clinical Pastoral Education.

Ethical and Boundary Considerations

There has been a great deal of discussion in the literature regarding the ethical and boundary issues involved in incorporating spirituality into medical care.⁵ In a multicultural society, it is important to keep in mind that physicians and patients frequently do not come from the same cultural background or belief system. Since patients in medical and spiritual distress are often in a vulnerable position, it is critical that health care providers be sensitive and careful in their approach to patients. Physicians should also be aware of their limitations in training and expertise in spiritual care and should utilize the help of trained chaplains in complex or difficult situations.

Providing a Spiritual Assessment

A. Goals

1. Provide a safe, therapeutic setting for patients to discuss their spiritual needs related to medical care.
2. Use an approach that will be acceptable and helpful for any patient regardless of religious or cultural background.
3. Keep patient's needs as the primary focus.
4. Use self-understanding, self-care, and reflection skills to help negotiate through ethical and boundary challenges.
5. Maintain compassionate care as the foundation to every interaction.

B. Methods

1. Informal spiritual assessment – Perhaps the most valuable way to gain an appreciation of a patient's spiritual beliefs and concerns is to listen carefully to the patient's stories and narrative and recognize spiritual themes as they arise. Often, spiritual values and beliefs present in the form of metaphors and stories rather than in response to direct questions. Recognizing these themes (such as search for meaning, or connection versus isolation) and following with open-ended and specific questions about patients' beliefs may reveal a great deal about a patient's source of suffering.
2. Formal spiritual assessment – This involves asking specific questions during the course of a medical encounter in order to determine if spiritual issues play a role in the patient's illness or recovery.

C. The HOPE questions are an example of one approach to spiritual assessment.⁴ These questions were designed as a starting place for health care professionals interested in the spiritual health of their patients. They may open the door for more in-depth discussion when needed. The HOPE approach asks about:

1. H—The sources of hope, meaning, comfort, strength, peace, love and connection.By focusing on a patient's basic spiritual resources without immediately introducing the words religion or spirituality, these questions allow for conversations with people from a wide variety of backgrounds and beliefs.
2. O—Organized religion's role for the patient.
3. P—Personal spirituality and practices.
4. E—Effects of the patient's beliefs and values on medical care and end-of-life decisions.

Examples of questions for each of these domains can be found online in an article describing the HOPE tool.⁴

Spiritual Care

Once a patient's spiritual needs have been assessed, there are several possible options for health care professionals not specifically trained as clinical chaplains.

1. Do no more—sometimes just giving the patient the opportunity to express his or her concerns in a safe, compassionate environment is enough.
2. Incorporate the patient's own spiritual resources into preventive care or as adjuvant care.
3. Modify the treatment plan based on the patient's identified spiritual needs; eg, continue or stop heroic life sustaining measures; refer a patient in spiritual distress to a trained clinical chaplain; teach simple relaxation or meditation techniques to patients interested in this approach; consider alternatives to blood products for patients who are Jehovah's Witnesses.

Summary

The spiritual assessment is the first step towards addressing the spiritual as well as mental and physical well-being of patients. If done in a compassionate, culturally sensitive way, it can help provide a great deal of relief to our suffering patients.