Patients’ spiritual needs often go unaddressed due to providers’ lack of prioritization, time, and training. A novel training program pairs clinicians and chaplains, with the goal of:

• assessing patients’ spiritual needs;

• knowing how to give referrals;

• understanding how to work with spiritual care professionals.

It’s critical that all clinicians routinely assess patients for spiritual distress, identify appropriate treatment strategies, and work closely with trained spiritual care professionals, according to a recent paper.1

“It’s as essential that we care for spiritual needs as it is to care for physical, psychological, and social needs,” says Betty Ferrell, RN, PhD, one of the paper’s authors. Ferrell is director of the division of nursing research and education at City of Hope National Medical Center in Duarte, CA.

Ignoring patients’ spiritual needs is “unacceptable and unethical care,” adds Ferrell. “For virtually every ethical dilemma you can name, there is an underlying spiritual issue.”

This is most apparent when decisions are made on life-sustaining treatments, says Ferrell. “Those decisions are influenced by what we believe about life. We can’t really say we practice healthcare in an ethical way if we ignore spirituality.”

Least Comfortable Topic

The End-of-Life Nursing Education Consortium gathered data on training programs in all 50 states and 96 countries.2 Clinicians named spirituality as the topic they were least comfortable discussing with patients. “We laughingly say it’s a bad sign when clinicians are more comfortable talking about sexuality than spirituality,” says Ferrell, the paper’s lead author.

Ferrell says that in the past, physicians rarely talked with patients about sexuality. “But we learned that we had to. And if we ignore it and don’t do a good assessment, then patient care will suffer.”

She says the same is true of spirituality. “A classic case would be an ICU patient who comes to us in a state of crisis, whatever the crisis may be,” Ferrell explains. The initial effort is focused on a rush to diagnose the problem, perform the necessary laboratory tests, and stabilize the patient. “But if we continue to focus only on the physical without asking, ‘Who is this person and who is their family?’ we are setting ourselves up for disaster,” she says.

Ferrell offers this alternative: That on the first day of care, someone on the team, whether the physician, nurse, or social worker, as part of routine practice, asks the family these questions:

• Are you part of a faith community?

• Is religion or spirituality important in your healthcare? Does it influence the way you make decisions?

• What will be important as we care for your loved one in the ICU?

“We need to be aware of spiritual issues in the same way we are aware of what drugs the patient is taking,” says Ferrell. The clinician may learn that the family is part of a congregation that believes in miracles. “That should be a huge flag, because this is the exact patient and family that we are going to have a standoff with,” says Ferrell. Such a family is likely to insist a patient is full code even as all clinical team members recognize that the patient is terminally ill.

“Unless we ask about religion, we don’t know. And if we don’t know, we are setting ourselves up for ethical crisis,” says Ferrell.

For a Muslim family, says Ferrell, this may mean the family won’t make any important decisions without consulting their imam, or won’t want family conferences scheduled during prayer time. The clinical team may learn that a patient hasn’t been to church in years, and now feels that God is punishing him, indicating a need for chaplain involvement.

Ferrell says that in healthcare settings, there is increased awareness of the importance of assessing patients’ cultural needs. But sometimes it turns out that issues are more spiritual than cultural, she says: “With our Latino population, we often find that the ethical dilemmas we are facing are really about being Catholic.”

‘Spiritual Distress Is Pandemic’

Spiritual care is lacking, primarily due to staff members’ deprioritization and lack of time, according to a recent study that explored patient’s spiritual care needs, experiences, preferences, and research priorities.3 Patient and caregiver focus groups were conducted at 11 countries, with the goal of developing standards.

“One of the questions that came up was, ‘What is the evidence on what people want in their care?” says Christina M. Puchalski, MD, OCDS, FACP, FAAHPM, director of the George Washington Institute for Spirituality and Health in Washington, DC.

The fact that spirituality was important wasn’t surprising, “although they expanded the disease trajectory,” says Puchalski. One patient shared that when the doctor asked about spirituality, it was the first time she had ever thought about it in the context of her health. “I share that story when I talk to my physician colleagues. This is why we need to do a spiritual history,” says Puchalski. Clinicians described distress over being so rushed that they can’t listen to the patient’s whole story.

A newly implemented training program at the George Washington Institute, called the Interprofessional Spiritual Care Education Curriculum, pairs clinicians with chaplains. The goal is to give physicians, nurses, social workers, and psychologists practical skills in how to assess patients’ spiritual needs. This includes how to give referrals and how to work with chaplains.

There already is great demand for the program, reports Puchalski: “What’s driving this is that spiritual distress is pandemic. We need to be able to attend to that.” It’s not only individual physicians, but also health systems, that have an ethical obligation to address spiritual suffering, she stresses.

Intense interest in spirituality on the clinical front is now being mirrored in the research arena, she says. “It’s phenomenal how much research is being done in this area. People are recognizing how important spirituality is in addressing the totality of the suffering of patients.”

Puchalski notes that the traditional approach is for the clinical team to take care of the patient’s physical health, while psychologists take care of emotional health, and chaplains take care of spiritual health. “But we can’t parse it out that way. More people are moving away from that medical model,” she says.

The chaplain can care for spiritual pain as an expert. But others on the clinical team can do it as generalists, says Puchalski: “All of us on the team need to address the whole person.”


1. Puchalski CM, King SDW, Ferrell BR. Spiritual considerations. Hematol Oncol Clin North Am 2018; 32(3):505-517.

2. Ferrell B, Malloy P, Virani R. The End of Life Nursing Education Nursing Consortium project. Ann Palliat Med 2015; 4(2):61-69.

3. Selman LE, Brighton LJ, Sinclair S, et al. Patients’ and caregivers’ needs, experiences, preferences and research priorities in spiritual care: A focus group study across nine countries. Palliat Med 2018; 32(1):216-230.


• Betty Ferrell, RN, PhD, Director, Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA. Phone: (626) 256-4673.

• Christina M. Puchalski, MD, OCDS, FACP, FAAHPM, Director, George Washington Institute for Spirituality and Health, George Washington University, Washington, DC. Phone: (202) 994-6220. Email: cpuchals@gwu.edu.