Patients’ spirituality: Should it play a role in their care?

Provider role uncertain when patients want to discuss beliefs

A nurse checks in on a 72-year-old patient recovering from pneumonia and, after checking her vital signs, asks if there’s anything the patient needs.

Instead of asking for water or a snack, the patient replies, "Will you pray with me?"

What is the appropriate answer? What if the patient is Christian and the nurse or doctor is Jewish, Islamic, or holds no spiritual beliefs?

Standard medicine is, for the most part, less in tune to patients’ spiritual needs, with physicians, nurses, and therapists absorbed instead in the sometimes monumental clinical tasks necessary to stabilize or heal a patient’s body.

But when a patient indicates that his or her primary need is spiritual, medical staff sometimes find themselves searching for the appropriate response.

"The physician doesn’t have the training and is pressed for time," says Lisa Lehmann, MD, assistant professor of medical ethics, department of social medicine at Harvard Medical School and an instructor at Brigham and Women’s Hospital in Boston. "It’s something they probably aren’t comfortable doing. A discussion of someone’s spiritual beliefs takes time, and most physicians don’t have the time built into their schedules."

Physicians and nurses commonly are asked to pray for a patient or to lead a patient or family in prayer. The clinicians may feel conflicted and uncertain about how to be supportive to the patient, respect professional and personal boundaries, and remain true to their own religious beliefs.

The role of spirituality — that of the patient and of the medical staff caring for the patient — in medicine is a controversial one. Opinions diverge over whether prayer and spirituality actually can help in a patient’s physical recovery, and whether clinical staff should encourage, discourage, or ignore spirituality in treating patients.

More accepted, ethicists say, are the positive effects that strong religious beliefs can have on patients’ emotional health and outlook.

How to respond to patient requests 

According to Kate Kwiatkowski, at the End-Of-Life Physician Education Resource Center, there are options that allow a physician or nurse to support a patient’s emotional needs while maintaining the integrity of his or her own beliefs.

"It is entirely appropriate for physicians to pray if they feel [comfortable doing so]," she says.

Kwiatkowski suggests that the clinician who is uncomfortable praying with or for a patient may lend support by sitting quietly and providing company to the patient while he or she prays, without actively participating and endorsing a particular belief system. This might be a good choice when the physician or nurse does not hold the same spiritual beliefs as the patient, or when the caregiver feels that to offer spiritual care is violating a professional boundary.

Simply declining the patient’s request, respectfully, is another option. The physician or nurse should do so in a way that lets the patient know that he or she is not being rejected, but that the clinician does not feel comfortable lending spiritual support. Calling in a hospital chaplain, if the patient agrees, is one resource for meeting patients’ spiritual needs.

What a doctor or nurse should not do is try to impose his or her own religious beliefs on a patient. If willing to lead a prayer, a health care provider should offer a nondenominational prayer, including neutral, inclusive terms such as "God" rather than Jesus, Allah, or Buddha, the End-of-Life Physician Education Resource Center advises. And asking for God’s support, rather than for a particular outcome (particularly when a patient is near death), is advisable.

Prayer — a useful adjunct?

Researchers have reached vastly different conclusions about what role religion should play in patient care. Studies, including a 1999 study published in the Archives of Internal Medicine, show that there is a significant benefit to intercessory prayer (others praying for a patient). The 1999 study examined patients admitted to a coronary care unit and found that prayer on the patients’ behalf was a "useful adjunct" to their medical care.1

But when debating religion or alternative medicine, other studies do not reflect favorable results. A 2001 study published in Mayo Clinic Proceedings reports that researchers found intercessory prayer has "no significant effect on medical outcomes" in a coronary care unit.2

A 2001 report on a study in the American Heart Journal found that, while results were not statistically significant for any of the outcome comparisons employed in the study of 150 coronary care patients, "the lowest complication rates were observed in patients who received off-site intercessory prayer."3

The evidence that many patients believe that there are benefits from prayer is more important than whether there are data proving that such benefits actually exist.

Findings published in the July/August 2004 issue of Annals of Family Medicine revealed that 83% of the 921 adults included in a study want to discuss their spiritual beliefs with their doctors. The study cites evidence that that patients who describe themselves as more spiritual or religious have lower mortality rates and overall better health. In this study, the patients at five family practice offices in Ohio were asked to rate their spirituality on a scale of 1 to 5, and to describe how their beliefs play a role in their health care decisions.

Participants in the survey said they found discussion of religion most acceptable when they were dealing with a life-threatening illness or impending death of themselves or loved ones. The authors of the study cite ethical conflicts, lack of training, and reluctance to venture outside the bounds of proven medicine as some reasons physicians do not more readily engage their patients in discussions of faith.

What patients want vs. what they get

In the Ohio study, respondents indicated that they were not getting what they wanted from their doctors, in terms of spiritual discussion.

When asked what kind of discussion they wanted, 63% of the respondents said they wanted their physicians to ask about their spiritual beliefs, if the situation warranted it (serious illness, illness of a loved one, etc.). Twenty percent said they always want their physician to know about their beliefs, and slightly fewer (17%) said they never want to discuss spiritual matters with a physician. Respondents were least likely to want to discuss their beliefs during routine examinations.

Even though 83% of those who participated in the study wanted at least some kind of physician interest in their spiritual beliefs, only 9% of the respondents said that a physician has ever asked about their beliefs. However, 18% said they have initiated discussions of their spiritual beliefs with physicians.

The 83% who said they want to discuss spirituality with their doctors gave several reasons for wanting to share that information with their physicians, so that:

  • The doctor will understand how their beliefs help them deal with their illness or injury.
  • The doctor will understand how their beliefs influence their decisions about their care.
  • They think that, if their doctors know their beliefs, they will use that information to determine how to take care of the patients.
  • They believe that, if their doctors know their spiritual beliefs, the physicians will be more compassionate and encourage hope.

How should clinicians respond?

Whether they find any scientific merit to prayer or spiritual discussion in the recovery of patients, researchers generally find no harm in the discussion. This leaves the question of the individual physician or nurse should handle prayer requests from patients.

Initiating prayer or a discussion of spiritual beliefs by the clinician, however, could carry ethical problems because there may be implied pressure on the patient, who may be not inclined to pray but feels it necessary because the physician responsible for his care has suggested it.

Some authors blame physicians’ reluctance to deal with patients’ spiritual lives on lack of training and guidance. They don’t know what to do because they might never have been taught what to do.

"Part of the challenge is finding the time, but it’s also getting providers comfortable with doing it," says Lehmann. "There’s a lot of controversy among physicians as to how that kind of information is going to be incorporated into a patient’s treatment plan, and whether it even should be incorporated into the plan."

Guidelines developed by the Association of American Medical Colleges are partially responsible for about 70% of U.S. medical schools that now offer courses relating to spirituality and health. Many also include sections on taking a spiritual history — that is, including questions about a patient’s beliefs during the patient history which is completed at the initial contact (well visit or emergency intake) with that patient.

"There’s increasing emphasis or awareness amongst medical educators on incorporating a spiritual history along with the usual physical history," Lehmann says. She points out that simple question formats, such as the HOPE and FICA models, are popular methods for incorporating spiritual history with physical history for a patient. The HOPE mnemonic has long been used in medical schools, and the FICA questions, which were developed by a physician, have become widely used since they were first published in 2000. (See Models.)

The fact that most medical schools are adding at least one session on spirituality is a sign that the medical community is more sensitive to patients’ spiritual needs, Lehmann says.

"But even though they’re devoting the time to it now, it will be years before we see the effects of it," she points out. "It will take a long time to get the full effect."

References

1. Harris WS, et al. A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Arch Intern Med 1999; 159:2,273-2,278.

2. Aviles JM, et al. Intercessory prayer and cardiovascular disease progression in a coronary care unit population: A randomized controlled trial. Mayo Clin Proc 2001; 76:1,192-1,198.

3. Krucoff MW, et al. Integrative noetic therapies as adjuncts to percutaneous intervention during unstable coronary syndromes: The Monitoring & Actualization of Noetic TRAinings (MANTRA) feasibility pilot. Am Heart J 2001; 142:760-769.

Sources

  • End-of-Life Physician Education Resource Center, www.eperc.mcw.edu
  • Lisa Lehmann, MD, Assistant Professor of Medical Ethics, Department of Social Medicine, Harvard Medical School; Instructor, Brigham and Women’s Hospital, Boston. Phone: (617) 732-5500. E-mail: ethics@harvard.edu