Spirituality in Healthcare

Scenarios

1. Mr A.J, diagnosed with systemic hypertension, however not compliant with medication as he hopes to be healed miraculously. He presented 2 years later with haemorrhagic stroke.
2. Mrs I.G, who has just received a histology report confirming stage 1 breast cancer following a 6/12 history of left breast lump, and blurts out “My God will put the doctors report to shame”. She represented later with stage 4 breast cancer.
3. Mr and Mrs D.T, who presented based on counsel by their religious leader to seek medical help with respect to their challenge of infertility.
4. Mr H.M, who insists that his cleric should pray for him before he is moved to theatre for his scheduled surgery.

Definitions

• Health can be defined (WHO)
  • Physical, mental, social wellbeing
  • Not just absence of disease and infirmity
• Now, definition is enlarged to encompass body, mind and spirit
  • Physical, mental, social and spiritual well-being (Croat Med J, 2017)
• The word ‘Spirituality’ is from the Latin word ‘Spiritus’, meaning breath of life
• Spirituality has been defined by various authors
  • According to Sandra Hassink, Spirituality is the awareness of the divine or sacred core that underlies everyday life.
  • Shea’s definition: Sets of beliefs, practices, stories that respond to a basic human desire to find meaning and purpose in an integrated way.
  • Bright-Long: The personal search for meaning, purpose and truth in one’s life.

American Academy of Family Physicians (AAFP) defined Spirituality as the way one finds meaning, hope, comfort and inner peace

• Spirituality is a part of human (spirit, soul and body)
• It is a known fact that many people use their spirituality to cope with health issues
• Hence a person's spiritual practice can affect clinical outcomes

Spirituality vs Religion

• Religion is the organization of spiritual experiences of a group of people into a system of beliefs and practices
• Many people find spirituality through religion
• Apart from religion, some people find spirituality by communing with nature, music, arts, quest for scientific truth or a set of values and principles

Feature	Religion	Spirituality
Focus	Community-focused	Individualistic-focused
Visibility	Observable, measurable, objective	Less visible, measurable, subjective
Structure	Formal, orthodox organized	Less formal, unorthodox
Doctrine	'Good/evil' doctrine	Non-doctrine oriented
Direction	Authority directed	Self directed
Orientation	Behaviour oriented, outward practices	Emotionally oriented, inward directed
Practices	Religious practices such as prayers, reading of holy texts- Bible/Quran/Torah	Spiritual practices such as meditation, music, hiking, nature walks

History

• In the earliest times, the practice of medicine was inherently spiritual as the priests were also the custodians of remedies.
• The French revolution of the 18th century marked the separation of religion from science and hence medicine.

Epidemiology - America

• Religious practice is very important or fairly important for 73% of Americans (Gallup 2020)

• Spiritual distress is said to occur when there is a discordance between a person’s belief and their real-life experiences.
• This could have a significant impact on patient cooperation and eventually treatment outcomes.
• Potential triggers include:
  • After a trauma (e.g. accident or assault)
  • After bad news
  • When a situation becomes life-threatening or terminal
  • Bereavement
  • When isolated etc.
• Signs of distress include:
  • Tearfulness or asking ‘why me?’
  • Withdrawal or lack of interest
  • Restlessness
  • Anger
  • Sudden abandonment of spiritual belief
  • Poor sleep
  • Feeling of guilt/deserving of punishment etc.

• Biomedical model of care (Postulated by Hippocrates also derived from Louis Pasteur’s germ theory)
• Biopsychosocial model of care proposed by Engel and White (1976)
• Extended to encompass the spiritual aspect by Daniel Sulmasy (2002)

Spiritual care has to do with:

• Recognizing and responding to the expressions of spirituality we encounter in our patients and families
• Involves showing compassion, actively listening, and encouragement of realistic hope
• According to the Biopsychosocial-spiritual model, everyone has a spiritual history

Spiritual care givers include:

• Health care workers
• Family and friends
• Hospital imam/Chaplains
• Spiritual clerics
• Community leaders

Prerequisites for Spiritual Care:

• Compassionate Presence: Listening to and supporting patients through suffering – physical, emotional, and spiritual
• A provider needs to understand his/her own spiritual beliefs, values, and biases
• Understand the spirituality of the patient to remain patient-centered and non-judgmental
• Establish a good provider-patient relationship
• Involve relevant spiritual leaders as members of the interdisciplinary health care team
• Appropriate timing for discussion and conducive environment

Who May Benefit from Spiritual Care?

• Older patients (often love to share their beliefs with their health care providers and vice-versa)
• In-patients
• Patients with end-of-life problems.
• Patients with chronic illnesses or worsening illnesses
• Patients with mental illnesses (new and old)
• Patients who drop hints/casual remarks about faith
• Concerns voiced during FIFE Questions

The process by which the health care provider is able to identify a patient’s spiritual needs pertaining to medical care.

Assess if the patient’s spirituality is helpful and harmful.

Being able to monitor and mitigate spiritual health risks.

SPIRITUAL ASSESSMENT MODELS

Structured or Unstructured

Unstructured; interacting with the patient and picking out salient points.

Structured; designed tools for obtaining information on spirituality.

Structured spiritual models are designed tools to help Providers’ approach the subject of spirituality of a patient using open ended questions to obtain the views of the patient about his/her health care.

These tools are based on brevity, content, patient centredness, credibility and ease of memorizing.

They include HOPE, FAITH, FICA, SPIRIT, KUHNS.

HOPE Questions (Ananda Rajah and Hight, 2001)

H – Sources of Hope, meaning, comfort, strength, peace, love, and connection

O – Organized religion; Are you part of a religious/spiritual community?

P – Personal spirituality and practices;

• Do you have any personal spiritual beliefs that are independent of organized religion?
• Which aspects of spiritual practices do you find most helpful personally?

E – Effects on medical care and end-of-life issues

FAITH Questions (King, 2002)

F - Do you have Faith or religion that is important to you?

A - How do your beliefs Apply to your health

I - Are you Involved in a faith community?

T - How do your spiritual views affect your views about Treatment

H - How can I Help you with any spiritual concerns

Others

FICAA Spiritual Assessment Tool (FICAA) - Christina Puchalski (2000)

Maugan’s Spiritual History (SPIRIT) - Todd Maugan (1996)

FACT Tool (Mark LA Rocca – Pitts 2008)

ACP Spiritual History [American College of Physicians]

Kuhn’s Spiritual Inventory (Clifford Kuhn)

Matthew’s Spiritual History (Dale Matthew)

LET GO (Storey and Knight 1997)

SPIR (Frick et al)

Spiritual Assessment - Ethical Considerations

• Autonomy: Respect patient’s belief.
• Non-maleficence: Patients are vulnerable, don’t be judgmental. Never ridicule a patient’s beliefs.
• Beneficence: Your assessment should add value to patient’s care.
• Justice: Ensure fairness in spiritual assessment.

Spiritual Assessment - Provider’s Plight

• Discussing spirituality with a wrong patient who may complain of harassment.
• Discussing spirituality with a patient who may not have confidence in you due to different religious groups.
• Provider’s bias on patient's spiritual belief.
• Patient requesting some medical care be kept away from caregivers when it opposes the religious doctrine.

Spiritual Assessment - Barriers

• Lack of training on spiritual assessment.
• Time constraints.
• Physician’s burnout.
• Differences in spiritual beliefs.
• Lack of experience/confidence of caregivers.
• Lack of continuity of care.
• Lack of privacy.

What are the Health Benefits of Spirituality? - Patient

• Healthy grief after a loss.
• Improved self-esteem and confidence. Hope renewed.
• Improved relationships (with self, others, and God).
• Distress and disability easily endured.
• 'Dignified death' for the terminally ill.

What are the Health Benefits of Spirituality? - Health Care Provider

• Better understanding of life's and medicine's mysteries.
• Better job satisfaction.
• Improved Patient-Provider relationship.

Drawbacks of Spirituality on Health

• Affects medical decision-making.
• Generates beliefs that conflict with medical care.
• Folly of fatalism - belief that all things have been predestined, therefore no need for personal input (e.g., refusal of vaccination).
• Refusal of medical treatment.
• Engaging in dangerous practices (e.g., handling dangerous snakes and drinking poisons during religious practices).
• Interferes with disease detection and treatment compliance.
• Harmful effects occur when they encourage excessive guilt, fear, and lowered self-worth.
• Implications that one's ill-health is a result of insufficient faith or sin that must be suffered for.
• Substitution of medical care by prayer instead of making both complementary.
• Spiritual practices resulting in physical illness.

• "The good Physician treats the disease, the great Physician treats the patient who has the disease" - William Osler, 1905
• Spirituality is a key determinant in patient management.
• Health care workers should be vast in engaging patients' spirituality in the course of management.
• Health care givers must respect the privacy of patients with regard to their spirituality and should not impose their own belief on the patient.
• Make referrals to colleagues and senior colleagues when needed.
• Involve spiritual leaders or hospital chaplains/imams as required.
• Remember: "Cure sometimes; Relieve often; Comfort always" - William Osler, 1905