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Spirituality in Patient Care
WHY, HOW, WHEN, AND WHAT
By Harold G. Koenig
TEMPLETON PRESSCopyright © 2013 Harold G. Koenig
All rights reserved.
Why Include Spirituality?
WHY INCLUDE SPIRITUALITY in patient care? Why would an HP take time to address spiritual needs or support a patient's religious beliefs? HPs need to be able to answer such questions before tackling spiritual issues with patients. Here are nine reasons why HPs should do so:
1. Many patients are religious or spiritual, have spiritual needs related to illness, and want their health professional to know about them.
2. Religion influences the patient's ability to cope with illness.
3. Patients when hospitalized are often isolated from their religious communities.
4. Religious beliefs affect patients' medical decisions, may conflict with medical treatments, and can influence compliance with the treatment plan.
5. Physicians' religious beliefs often affect their medical decisions and influence the care they provide.
6. Religious involvement is associated with both mental and physical health, and likely affects the patient's response to medical and surgical treatments.
7. Religion influences the support and care that patients receive in the community.
8. Failure to address patients' spiritual needs increases health care costs.
9. Standards for accreditation and payment require an awareness of patients' spiritual beliefs.
MANY PATIENTS ARE RELIGIOUS AND HAVE SPIRITUAL NEEDS
Many people seen in health care settings in the United States (and many other areas of the world) are religious and have spiritual needs. A series of Gallup polls that surveyed 327,244 persons between January 2 and November 30, 2011, found that religious affiliations in the U.S. are diverse, with 78 percent of Americans identifying themselves as Christian (95 percent of those indicating a religious affiliation), 1.6 percent Jewish, 0.5 percent Muslim, and 2.4 percent other non-Christian. Furthermore, 15 percent of those surveyed indicated "none, atheist, or agnostic," and 2.5 percent did not give a response. That same survey found that 55 percent of Americans say that religion is very important to them, a figure that has remained relatively constant since 1976. Note also that a 2009 Gallup poll of 1,000 adults in each of 114 nations around the world found that 84 percent of respondents (on average) said that religion is an important part of daily life. A Gallup poll conducted in May 2011 found that 92 percent of Americans believe in God (including 87 percent of those with a postgraduate education and 84 percent of those ages 18–29), whereas 7 percent say they do not believe in God. In that same poll, 79 percent of Americans say they believe that the Bible is the actual or inspired word of God (including 71 percent of those with a postgraduate education). Other religious activities are also common. According to Gallup polls of 800,000 Americans conducted between February 2008 and May 2010, 43 percent reported attending religious services weekly or almost weekly (regardless of education level). Finally, nine in ten Americans say they pray (a proportion that has not changed during the past half-century based on Gallup polls), and three out of four Americans say that they pray on a daily basis.
Even if patients are not religious, there is a good chance that some will describe themselves as spiritual, since about one in five Americans considers themselves "spiritual but not religious." This is less true for older adults, who tend to be more traditionally religious and often equate spirituality with religion. A 2004 study of 838 medical inpatients ages sixty or over found that 88 percent said that they were both religious and spiritual, 7 percent that they were spiritual but not religious, 3 percent that they were religious but not spiritual, and 3 percent that they were neither religious nor spiritual.
Many people use religious beliefs or practices for health reasons. In a national random sample of 31,044 U.S. adults (2002 National Health Interview Survey), researchers found that of the ten most common complementary and alternative medicine (CAM) therapies that Americans engage in, "prayer for health reasons" was the most common (45.2 percent in the past twelve months and 55.3 percent in their lifetime). This is especially true for ethnic minorities. While only 41.5 percent of European Americans prayed for health reasons (either their own or someone else's) in the past twelve months, 49.5 percent of Hispanic Americans and 62.6 percent of African Americans did so. In another national survey of 3,728 Latino Americans (Pew Center's Latino Health Survey), 60 percent prayed for healing in the past twelve months, 49 percent asked otheers to pray for healing, and 69 percent considered spiritual healing very important.
Not only are the vast mmajority of patients religious and often use it for health, but many have spiritual needs that they would like addressed as parrrrt of their health care. Being religious or spiritual is part of who many people are—it forms the root of their identity as human beings and gives life meaning and purpose. This is especially true when medical illness threatens life or way of life. For example, in a study of 101 psychiatric and medical/surgical inpatients at a Chicago hospital, investigators found that the vast majority of psychiatric patients (88 percent) and medical/surgical patients (76 percent) reported three or more religious needs during hospitalization.
Most of the available data on patients' attitudes toward HPs addressing spiritual needs comes from studies asking about their physicians. Early studies (1994–1998) indicated that about three-quarters of family practice patients said physicians should consider their spiritual needs or know about their religious beliefs. In a latter study (2003), however, patients' attitudes varied depending on the setting and severity of their illness, ranging from 33 percent wanting the physician to ask about their religious beliefs during routine office visits to 84 percent if they were terminally ill. Admittedly, these studies took place in the Southern and Southeastern U.S. and so may represent higher-end estimates. However, a study from the Northeastern U.S. found about one-half (53 percent) of HIV-positive inpatients felt that it was important for them to discuss spiritual needs with their physicians.
Research published more recently updates these earlier reports. In a study of 3,141 general medical inpatients at the University of Chicago Medical Center, patients were asked whether they would like to discuss religious or spiritual concerns with someone while in the hospital. They were also asked whether someone had spoken with them about religious or spiritual issues, and if so, who did so. Results indicated that 41 percent desired to discuss religious or spiritual concerns with someone; 32 percent indicated that such a discussion did take place; and 8 percent said that the person with whom they discussed religious or spiritual concerns was their physician, 61 percent a chaplain, 12 percent a member of their own religious community, and 12 percent someone else. Those who wished to discuss religious or spiritual concerns were older, had less education, had experienced severe pain, and were more religious. Satisfaction with care was significantly greater among those who had such discussions. Interestingly, satisfaction with care was significantly greater even among the 315 patients who didn't want such discussions but ended up having them anyway.
Adult patients are not the only ones who want physicians to know about their spiritual beliefs and concerns. In a study of 151 adolescent outpatients with asthma, participants were asked about their preferences regarding the clinical encounter. Nearly one-half (42 percent) indicated their provider should play a role in their spiritual or religious life. In addition, 52 percent felt their provider should be aware of their spiritual/religious beliefs. Of the latter, 71 percent said provider awareness of their beliefs was important in order for the provider to understand how those beliefs helped them to cope with their asthma.
Studies outside the U.S. have also found that patients often desire that physicians know about their religious beliefs and spiritual needs. For example, a survey of patients and families in a public teaching hospital in Sydney, Australia, found that the majority felt it would be helpful for health staff to know about their religious beliefs and they were willing to be asked about those beliefs. Australia is ranked 135 out of 147 countries in terms of religiosity (twelfth from the bottom), according to the World Gallup Poll conducted in 2006–2008. Also, in a small German study of 30 medical patients, researchers asked the question: "How should physicians deal with spiritual questions?" Responses were 13 percent "not at all," 70 percent "talk about it," 3 percent "refer to chaplain," and 17 percent "other/do not know." When asked whether they wanted to continue the dialogue about spirituality, 60 percent (n = 18) wanted to continue the interview with the physician. In another German study of 580 patients with chronic pain, 37 percent said that it was important to talk with the medical doctor about their spiritual needs. Germany was ranked 120 out of 147 countries in religiosity based on the Gallup poll above (twenty-seventh from the bottom). Thus, patients in the U.S. are not the only ones who wish to discuss these issues with their medical providers. Even in countries whose populations are not particularly religious, many patients feel similarly.
Feeling that health care providers should know about their spiritual concerns is especially common among patients with severe illness such as advanced cancer. In a multisite study, Harvard investigators surveyed 230 patients with advanced cancer. Most (88 percent) considered religion to be at least somewhat important. However, 47 percent reported that their spiritual needs were minimally or not at all supported by their religious community. Furthermore, 72 percent said their spiritual needs were minimally or not at all supported by the medical system (doctors, nurses, or chaplains). However, when the medical team or religious community did provide spiritual support to patients, this was associated with significantly higher quality of life (p = 0.0003). Another study by this research group involved 69 patients with advanced cancer receiving palliative radiation therapy recruited from four hospital sites in Boston. Most of these patients said that attention to their spiritual concerns should be an important part of cancer care by physicians (87 percent) and nurses (85 percent). Investigators also found that patient spirituality and religious coping were associated with overall better quality of life (p < 0.001 and p < 0.01, respectively), independent of other predictors of quality of life. Almost all of these patients (86 percent) voiced one or more spiritual concerns, with a median of four spiritual concerns per patient. Spiritual concerns/struggles were associated with worse psychological health and poorer adaptation to illness.
Not only are spiritual needs important to patients, but 66 to 81 percent of general medical patients say they would have greater trust in their physician if he or she asked about their religious/spiritual beliefs. Furthermore, research has shown a significant improvement in the doctor-patient relationship when a physician has done so. Religious patients are not only more likely to want their doctor to ask about religious/ spiritual beliefs, but also are more likely to receive regular medical care, undergo regular disease screening, and comply with prescribed treatments. They are also more likely to leave medical decisions up to their doctors (vs. making their own decisions about their care). Even among psychiatric patients with schizophrenia, research shows that those randomly assigned to receive a spiritual assessment by their physician were significantly more likely to attend future appointments. Thus, while addressing religious patients' spiritual needs may take some additional time, it is worth it in the long run.
Besides wanting their physicians to know about their religious beliefs and spiritual concerns, some patients even want to pray with their health care providers. Some physicians are quite open to this and believe it is beneficial (see address given by president Dr. Donn Schroder of the Midwest Surgical Association). The percentage of patients who would like their physician to pray with them ranges widely from 19 percent to 78 percent, depending on the setting, severity of illness, and the religiousness of the patient. For example, in a Yale study of HIV/AIDS patients, 46 percent indicated that it would be helpful to pray with their physicians. In general, patients who are sicker and more religious are more likely to want to pray with their HPs. However, only 10–20 percent of patients report that a physician ever asked them about spiritual issues or prayed with them.
Although many patients want HPs to know about their religious or spiritual beliefs, many patients (from one-quarter to one-half) don't want to discuss these matters with physicians. When a sample of healthy people (nonpatients) were surveyed, over two-thirds said they would want to discuss spiritual concerns with someone, particularly if they were seriously ill. Most, however, wanted to discuss spiritual concerns with their minister, not a physician. Unfortunately, ministers may not be available in medical settings when patients need to discuss these issues. Also, "discussing" religious beliefs with physicians is not the same as a health care provider simply inquiring about a patient's religious or spiritual beliefs, which I suspect patients would be more receptive to. Of course, most patients do not want HPs inquiring or discussing spiritual matters until after they have competently dealt with medical issues.
MANY PATIENTS DEPEND ON RELIGION TO COPE
Not only is religion vital to the personal identity of many people, it is often used to cope with loss, fear, medical problems, and other stressful life circumstances. Consider a report published in the New England Journal of Medicine, which involved a random survey of the U.S. population one week after the terrorist attacks on September 11, 2001. Investigators found that 90 percent of Americans turned to religion in order to cope with the stress of these events. Likewise, in certain parts of the United States, over 90 percent of medical patients indicate that religious beliefs and practices are ways they cope with and make sense of physical illness, and over 40 percent say that religion is the most important factor that keeps them going. Research shows that religious coping is widespread among patients with heart disease, stroke, Parkinson's disease, spinal cord injury, emphysema, kidney disease, cystic fibrosis, diabetes, cancer, gynecologic cancer, HIV/AIDS, arthritis, chronic pain, terminal illness, schizophrenia, and in nursing home patients and dementia caregivers—i.e., almost every type of medical condition, psychiatric disorder, or stressful situation studied.
What exactly is "religious coping"? Religious coping is the use of religious beliefs or practices to reduce the emotional distress caused by loss or change. Patients may ask God to heal their health problems or to give them the strength to cope with them. They may "turn over" their problems to God, trusting God to handle them so that they don't have to ruminate or worry about those problems. They may believe that God has a purpose in allowing them to experience pain or suffering, which gives their suffering meaning and makes it more bearable. A host of religious beliefs and behaviors like these may be mobilized to reduce anxiety, increase hope, or convey a sense of control. With regard to religious practices that facilitate coping, patients will pray, meditate, read religious scriptures, worship at religious services, go on a pilgrimage, perform religious rituals (light a candle, receive the sacraments, or be anointed with oil, for example), or rely on support from clergy or members of their church, synagogue, mosque, or temple. Religious beliefs and practices are often used in these ways to regulate emotion during times of illness, change, and circumstances that are out of their personal control.
Excerpted from Spirituality in Patient Care by Harold G. Koenig. Copyright © 2013 Harold G. Koenig. Excerpted by permission of TEMPLETON PRESS.
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