Don't use rigid approach for spiritual assessment

Search for clues, elicit what inspires patients

A 2004 study published in the Annals of Family Medicine analyzed when patients want a discussion about spirituality and what they want done with the information.1 The authors found that of the 800 people who answered the survey, 83% wanted some sort of discourse about their spiritual selves.

Whether the patient feels his or her spirituality or religious beliefs are crucial to health and recovery, or simply has certain things that bring feelings of hope and comfort, that information is important for the hospice provider to know. Eliciting that information, or taking a spiritual assessment or spiritual "history," takes a deft hand, and not a rigid question-and-answer session.

"It's not like taking a [medical] history, with a checklist," says J. Vincent Guss Jr., MDiv, a pastoral care and bioethics consultant in Alexandria, VA, and advocacy commissioner for the Associa-tion of Professional Chaplains. "It needs to be done in a sensitive and caring way as one looks for clues about what is spiritually significant."

Guss says sometimes a patient will respond to questions of spirituality less than enthusiastically, particularly if the patient does not consider him or herself to be "religious" and perceives the conversation to be about religion. The person attempting the spiritual assessment should make clear that the purpose of the inquiry is to determine what is important to that patient in particular. "The spiritual dimensions of a person are those values he holds dearest, his ultimate concerns, whether he has a God or gods, the source of meaning in his life," Guss explains. "What is their sense of grace and providence? What do they consider holy? What is their sense of hope or despair, their sense of vocation or calling in life? These relate very much to our emotional, mental, and physical well-being."

The ethics literature urges clinicians to bear in mind that their own sense of spirituality or religion can affect the provider-patient relationship, and providers who hold strong feelings of being very religious or very nonreligious should exercise care with patients whose feelings are the opposite.

A spiritual assessment is a search for clues about a patient's spiritual needs and preferences. It might involve direct questions and answers, or be more conversational in nature. It might be done in one sitting or in bits and pieces. Information might be gleaned by more than one person. Family members or clergy might provide insight.

"However it is conducted, the patient should be made to feel that the person talking with him or her is interested in the patient and is comfortable having the conversation," Guss adds. "It can be weird if the patient feels the [provider] is uncomfortable having the conversation."

Mnemonics can help

One of the pioneering advocates of spiritual assessments, Christine M. Puchalski, MD, director of the George Washington Institute for Spirituality and Health (GWISH) at The George Washington University Medical Center, developed the FICA mnemonic to help guide the taking of a spiritual history or assessment, and it's the one Guss says he most often relies on.

There are others that can work as well, Guss says. The important thing is that the person taking an assessment uses a mnemonic as a reminder of points to cover, not as a checklist that causes the assessment interviews to sound rote. (See table, below, for descriptions of mnemonics relating to patient spiritual assessment.)

Mnemonic Tools for Use in Making a Spiritual Assessment

The FICA tool:
F: Faith — Does the patient consider himself or herself spiritual? What gives his or her life meaning?
I: Importance — What importance does faith or belief have in the patient's life?
C: Community — Does the patient belong to a spiritual or religious community that is meaningful to him or her?
A: Address in care — How does the patient want his or her spirituality to be addressed by the health care team?

Source: Puchalski CM, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Pall Med 2000; 3:129-37.

The HOPE mnemonic:
H: Hope — Sources of meaning, comfort, strength, peace, love, and connection.
O: Organized religion.
P: Personal spirituality and practices.
E: Effects on medical care and end-of-life decisions.

Source: Anandarajah G, Hight E. Spirituality and medical practice: Using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician 2001; 63:81-88.

The FAITH tool:
F: Faith — Do you have a faith or religion that is important to you?
A: Apply — Do your beliefs apply to your health?
I: Involved — Are you involved in a church or faith community?
T: Treatment — How do your spiritual views affect your views about treatment?
H: Help — How can I help you with any spiritual concerns?

Source: King DE. "Spirituality and Medicine." In: Fundamentals of Clinical Practice. Mengel MB, Holleman WA, Fields SL, eds. New York City: Plenum; 2002, pp. 651-669.

The SPIRIT mnemonic:
— Spiritual belief system.
P — Personal spirituality.
I — Integration and Involvement in a spiritual community.
R — Ritualized practices and restrictions.
I — Implications for medical care.
T — Terminal events planning (advance directives).

Source: Maugans TA. The SPIRITual history. Arch Fam Med 1996; 5:11-16.

"When a checklist is used to take a spiritual history in an interrogatory manner, the pastoral care that the assessment is geared to help enhance in the first place is interrupted," Guss notes. "The assessment can unfold gradually, and it's important to establish a rapport."

A 2007 study by Harvard medical researchers showed nearly three-quarters of advanced cancer patients surveyed felt their spiritual needs were not met by the medical system.2 People who had spiritual support tended to have better quality of life, and people who described themselves as religious were twice as likely to want more aggressive treatment to extend their lives, the authors report.


1. McCord G. Discussing spirituality with patients: A rational and ethical approach. Ann Fam Med 2004; 2:356-361.

2. Balboni TA, Vanderwerker LC, Block SD, et al. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol 2007; 25:555-560.

Need More Information?

  • J. Vincent Guss Jr., MDiv, Pastoral Care and Bioethics Consultant, Alexandria, VA; advocacy commissioner, Association of Professional Chaplains. Phone: (703) 404-5215.