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 health care 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 Association of Professional Chaplains. "It needs to be done in a sensitive and caring way as one looks for clues about what is spiritually significant."

And it is not something that should wait until the patient is at the end of life.

"A spiritual assessment is not just for the end of life, even though our sense of ultimate concern certainly comes to the fore at such a time," Guss says. "But the holistic approach to health care certainly does include attending to the spiritual needs in treating all people at all levels — even in promoting wellness."

Spirituality not always religion

Guss says sometimes a patient will respond to questions of spirituality less than enthusiastically, particularly if the patient does not consider himself 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 doctor-patient relationship, and physicians who hold strong feelings of being very religious or very non-religious should exercise care with patients whose feelings are the opposite.

The involvement of a clinically trained chaplain — either as the lead person making the spiritual assessment or as a member of the team that gathers the information from the patient and family — can be key to a successful assessment, Guss suggests.

"A clinically trained chaplain, with the background training to not confuse religion with spirituality, should be part of the health care team to help nurses, doctors, and social workers in making those assessments," he says.

A spiritual assessment is a search for clues about a patient's spiritual needs and preferences; it might be done by a physician, nurse, or chaplain. 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, particularly if the patient has a relationship of trust with someone on the health care team. 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 doctor 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 use 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.)

"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.

The Joint Commission, the nation's leading provider of accreditation to health care facilities, says patients should receive a spiritual assessment that, at a minimum, determines their denomination, beliefs, and what spiritual practices are important to them. Topics to cover include sources of strength and hope, the use of prayer, the patient's philosophy of life, whether there is a clergy/minister/rabbi who the patient would like to be in contact with, and the role spirituality plays in the patient's view of health and medicine.


  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.


For more information, contact:

  • J. Vincent Guss Jr., MDiv, pastoral care and bioethics consultant, Alexandria, VA; advocacy commissioner, Association of Professional Chaplains. Phone: (703) 404-5215.