Religion and Spiritual Issues

There is currently more emphasis on being sensitive to the spiritual concerns of a patient (Levin et al., 1997; McCord et al., 2004). Some physicians believe that religion and spirituality discussions should be left to clergy and chaplains, who certainly should be included in patient care. However, Cumella (2002) suggests expanding Engel's biopsychosocial model to a biopsychosocial-spiritual model.

In the decade from 1994 to 2004, the percentage of U.S. medical schools offering curricula on spiritual history taking increased from 13% to 66% (Fortin and Barnett, 2004). In a 2004 survey, 43% of adults said they would welcome a discussion of spiritual matters with their physician during the taking of an initial medical history, and 77% said it is appropriate during a serious illness (McCord et al., 2004). However, only 10% report ever being asked by their physician about their faith and the possible impact their beliefs may have on their health care (Maugans and Wadland, 1991). Family physicians indicated that lack of time was the primary reason for omitting a spiritual history; 53% said a lack of training limited their ability to take a spiritual history, and 59% were concerned with projecting their own beliefs onto the patient (Ellis and Vinson, 1999).

However, taking a spiritual history can provide valuable information regarding a patient's perception of the disease and possible effects on treatment options and outcomes, as well as the availability of resources and social support for the patient. Some patients are not religious and have no interest in religion; some tend to become more religiously interested in times of crisis; and others are intensely religious. Some patients consider themselves to be spiritual, even though they do not identify with a particular religion or religious group.

Being religiously sensitive often includes being ethnically and culturally sensitive, and it is helpful for the physician to be comfortable with the level of religious concern that the patient may bring into the interview. For some patients and some physicians, all important decisions, including medical decisions, have some religious basis. When a physician is not sensitive to the patient's overall decision-making process, a patient who expresses appreciation at the end of the visit may then ignore all the physician's recommendations, because the patient feels the physician did not really understand what the illness means to the patient. In this regard, it is important for physicians to be aware of their own religious and spiritual heritage, whether it is absent, limited, or intense, because the values and beliefs and ethics of their religious heritage helped form their own decisions in patient care. Just as the patient's religion may influence medical decisions, so a physician's religious heritage may affect medical recommendations.

When taking a spiritual history, as with other elements of the review, it is often helpful to use open-ended questions that are nonjudgmental, such as the following: Do you have a religious background? Do you practice a particular faith? Are you a spiritual person?

A "no" answer to these questions is probably a stop point for further questions. The physician may go on to another subject in the interview. However, if the answer is "yes," the physician may inquire about how the patient's religious heritage is a resource in a time of illness or may be relevant to medical decision making. If deemed appropriate, the physician may indicate her or his own religious heritage and then discuss how the patient and physician can relate to one another's religious backgrounds.

Some physicians may find the following brief interview assessment helpful (Pulchaski and Romer, 2000)—FICA: Faith: Do you consider yourself to be a spiritual or religious person?

Importance: How important is your faith to you? Community: Are you a part of a spiritual or religious community?

Address: How would you like me to address these issues in your health care?

Because religious faith and spirituality are an important part of some patients' lives and experiences, an awareness of this information further enhances the establishment of rapport, respect, and relationship, and it clarifies the physician's commitment to holistic treatment of the patient. It is what Odell (2003) calls "including versus imposing" the clinician's religious or spiritual views in the interviewing process.

Pearl

Any discussion of religion and spirituality should always seek to focus on the patient's beliefs, not on the physician's beliefs.

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