Another area thought to be integral to a whole-patient inte-grative medicine approach to care is spirituality. This broad and controversial subject is well reviewed (e.g., Sierpina and

Sierpina, 2004); some key issues are considered here. Working definitions and terms from the Samueli Conference on Definitions and Standards in Healing Research (Dossey, 2003) include the following:

Spirituality encompasses the feelings, thoughts, experiences, and behaviors that arise from a search for that which is generally considered sacred or holy. Spirituality is usually considered to involve a sense of connection with an absolute, imminent, or transcendent spiritual force, however named, as well as the conviction that meaning, value, direction, and purpose are valid aspects of the universe.

Religion is the codified and ritualized beliefs and behaviors of those involved in spirituality, usually taking place within a community of like-minded individuals.

Table 11-7 Guidelines in Prescribing an Anti-Inflammatory Diet

1. Omega-3 and omega-6 fatty acids are essential polyunsaturated fatty acids (i.e., they cannot be made by the human body).

2. The ratio of omega-6 to omega-3 fatty acids in the average Western diet has steadily increased in the past 100 years. The standard American diet has a ratio of omega-6 to omega-3 of more than 20:1, but the ideal range is less than 4:1.

3. To follow an anti-inflammatory diet, take the following steps:

a. Decrease red meat, poultry, and dairy intake.

b. Increase the intake of omega-3 fatty acids, such as cold-water fish, flaxseed, walnuts, and green leafy vegetables.

c. Even one meal of cold-water fish weekly reduces the risk of cardiac arrest. Consuming fish twice each week is ideal. If this is not possible, fish oil supplements can be taken at a dose of 500 to 2000 mg twice daily.

d. An alternative is ground flax seeds or flaxseed oil. Flax should be freshly ground because it can spoil after exposure to light or heat. Supplementation can be provided with 500 to 2000 mg of flax oil twice daily.

e. Reduce foods that contain omega-6 fatty acids, including the following:

(1) Margarine.

(2) Oils made from corn, cottonseed, grapeseed, peanut, safflower, sesame, soybean, or sunflower (avoid partially hydrogenated oils).

(3) Foods with a long shelf life, such as crackers and chips.

f. Cook with monounsaturated oils such as olive or canola oil.

4. Consider this dietary approach to treat the following:

a. Heart disease or associated risk factors.

b. Inflammatory rheumatic disorders.

c. Autoimmune diseases.

d. Chronic pain.

5. Low-carbohydrate, high-protein diets tend to have high omega-6 fat content and should be used with caution.

6. It may take up to 6 months to see the full clinical effects of an antiinflammatory diet.

From Rakel D, Rindfleisch A: Integrative medicine. In Essential Family Medicine: Fundamentals and Case Studies. Philadelphia, Saunders, 2006.

Table 11-8 Spiritual Assessment Tools

FICA Mnemonic

F: Faith or belief—What is your faith or belief?

I: Importance and influence—Is it important in your life? How?

C: Community—Are you part of a religious community?

A: Awareness and addressing—What would you want me as your physician to be aware of?

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

HOPE Mnemonic

H: Hope—What are your sources of hope, meaning, strength, peace, love, and connectedness?

O: Organized—Do you consider yourself part of an organized religion?

P: Personal spirituality and practices—What aspects of your spirituality or spiritual practices do you find most helpful?

E: Effects—How do your beliefs affect the kind of medical care you would like me to provide?

Three Questions

1. What helps you get through tough times?

2. Who do you turn to when you need support?

3. What meaning does this experience have for you?

Prayer is communication with an absolute, imminent, or transcendent spiritual force, however named. Such communication may take a variety of forms and may be theistic or nontheistic in nature, as in some forms of Buddhism. Intercessory prayer is an appeal to such a force to influence another person or thing. Healing prayer is an appeal to such a force for the healing and recovery of self or others. Directed prayer is offered with a specific outcome in mind. Nondirected prayer is offered with no specific outcome in mind, such as, "Thy will be done," or "May the best outcome prevail."

Given recent statistics on prayer from the 2002 National Health Interview Survey (NHIS) and Gallup Polls over the past six decades (showing that more than 90% of Americans believe in God or a universal spirit), it is not surprising that proponents and critics have agreed that taking a spiritual history is essential to a comprehensive and culturally sensitive medical consultation. Just as challenging as asking patients about substance abuse, domestic violence, and sexual practices, a spiritual history helps elucidate how spiritual beliefs or religious practices may impact health and health-related choices. Such discussions may be most relevant during times of a new diagnosis, loss of a loved one, onset of depression, or terminal illness. Continuity of care and sensitivity to the biopsychosocial aspects of a patient's life foster the rapport to facilitate such discussion. Such inquiry may also help engage support systems or identify deep conflicts. Although not all physicians may be comfortable addressing spirituality with their patients, referrals to colleagues in pastoral care and chaplaincy are options to consider.

Interviewing seven physicians recognized as leaders in the field of healing research, Egnew (2005) found that "healing was defined in terms of developing a sense of personal wholeness that involves physical, mental, emotional, social and spiritual aspects of human experience." The central theme in the responses provided an operational definition of healing: "Healing is the personal experience of the transcendence of suffering."

Various models have been suggested as guides to taking the spiritual history (Table 11-8) (Anandarajah and Hight, 2001; Kinney, 1999; Puchalski and Romer, 2000).

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