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Will the expectation of care vary based on the faith base of the patient involved

April 2014 Article Write Us Religious and spiritual beliefs and practices are important in the lives of many patients, yet medical students, residents and physicians are often uncertain about whether, when, or how, to address spiritual or religious issues.

Physicians in previous times were trained to diagnose and treat disease and had little or no training in how to relate to the spiritual side of the patient. In addition, professional ethics requires physicians to not impinge their beliefs on patients who are particularly vulnerable when seeking health care. No physician could be expected to understand the beliefs and practices of so many differing faith communities. At first glance, the simplest solution suggests that physicians avoid religious or spiritual content in the doctor-patient interaction.

As with many issues, however, the simple solution may not be the best. Research indicates that the religious beliefs and spiritual practices of patients are powerful factors for many in coping with serious illnesses and in making ethical choices about their treatment options and in decisions about end-of-life care Puchalski, 2001; McCormick et al.

This article inquires into the possibility that within the boundaries of medical ethics and empowered with sensitive listening skills, physicians-in-training and physicians-in-practice may find ways to engage the spiritual beliefs of patients in the healing process, and come to a clearer understanding of ways in which their own belief systems can be accounted for in transactions with patients.

Research shows that religion and spirituality are associated positively with better health and psychological wellbeing Puchalski, 2001; Koenig, 2004; Pargament et al. How pervasive is religiosity in the United States? Religious belief and practice is pervasive in this country, although less pervasive within the medical profession.

In 2010, approximately 43. These surveys remind us that there is a high incidence of belief in God in the US public. It also appears that physicians as a group are somewhat less inclined to believe in God.

Clearly, physicians are not inquiring about spirituality to nearly the degree that patients prefer Puchalski, 2001; King et al. Why is it important to attend to spirituality in medicine? Religion and spiritual beliefs play an important role for many patients. When illness threatens the health, and possibly the life of an individual, that person is likely to come to the physician with both physical symptoms and spiritual issues in mind. Religion is generally understood as a set of beliefs, rituals and practices, usually embodied within an institution or an organization.

Persons may hold powerful spiritual beliefs, and may or may not be active in any institutional religion. Spirituality can be defined as "a belief system focusing on intangible elements that impart vitality and meaning to life's events" Maugans, 1996. Many physicians and nurses have intuitive and anecdotal impressions that the beliefs and religious practices of patients have a profound effect upon their existential experiences with illness and the threat of dying.

Recent research supports this notion.

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When patients face a terminal illness, religious and spiritual factors often figure into their coping strategies and influence important decisions such as the employment of advance directives, the living will and the Durable Power of Attorney for Health Care.

Considerations of the meaning, purpose and value of human life are used to make choices about the desirability of CPR and aggressive life-support, or whether and when to forego life support and accept death as appropriate and natural under the circumstances Puchalski et al.

He identifies specific forms of religious struggle that are predictive of mortality. A study of religious coping in patients undergoing autologous stem cell transplants also will the expectation of care vary based on the faith base of the patient involved that religious struggle may contribute to adverse changes in health outcomes for transplant patients Sherman et al.

Referral of these patients to the chaplain, or appropriate clergy, to help them work through these issues may ultimately improve clinical outcomes Pargament, et al. How should I take a "spiritual history"? Medical students are usually introduced to the concept of spiritual inquiry in courses such as "Introduction to Clinical Medicine. Students-in-training are often hesitant to ask questions that they regard as intrusive into the personal life of the patient until they understand there are valid reasons for asking about sexual practices, alcohol, the use of tobacco, guns, or non-prescription drugs.

Religious belief and practice often fall into that "personal" category that students-in-training sometimes avoid, yet when valid reasons are offered by teachers and mentors for obtaining a spiritual history, students readily learn to incorporate this line of questioning into the patient interview. Often, the spiritual history can be incorporated into what we may now want to call the "bio-psycho-social-spiritual" patient history. Students are taught to make a transition by simply stating something like the following: If you are comfortable discussing this with me, I would like to hear from you of any beliefs or practices that you would want me to know about as your care giver.

If the patient says "no" or "none" it is a clear signal to move on to the next topic, although it is often productive to ask before leaving this topic if other family members have spiritual beliefs or practices in order to better understand the family context and anticipate concerns of the immediate family.

From years as a clinical tutor, I have observed students returning to my office to de-brief a recent patient interview with a sense of excitement and gratification in discovering that this line of questioning opened a discussion that disclosed the patient's faith in God as a major comforting factor in the face of a life-threatening illness.

One patient-family described gratitude for their church community who brought meals to their home in a period when one will the expectation of care vary based on the faith base of the patient involved was at work and the other was at the hospital with a sick child, leaving no one to cook for the other siblings. Others spoke of a visit from a priest, a rabbi, or a minister during their hospitalization as a major source of comfort and reassurance.

One patient, self-described as a "non-church-goer," described his initial surprise at a visit from the hospital chaplain which turned into gratitude as he found in the chaplain a skilled listener with a deep sense of caring to whom he could pour out his feelings about being sick, away from home, separated from his family, frightened by the prospect of invasive diagnostic procedures and the possibility of a painful treatment regimen.

Some find it helpful to have a clear approach or structure in mind when opening a discussion on spirituality with a patient or taking a spiritual history. A group at Brown University School of Medicine has developed a teaching tool to help begin the process of incorporating a spiritual assessment into the patient interview which they call the HOPE questions: Sources of hope, meaning, comfort, strength, peace, love and connection. Personal spirituality and practices E: When things are tough, what keeps you going?

P Are there spiritual practices or beliefs that are important to you personally? E Are there ways that your personal beliefs affect your health care choices or might provide guidance as we discuss decisions about your care near the end of your life? How can respect for persons involve a spiritual perspective? The principle of respect for persons undergirds our duties as health care professionals to treat all persons fairly, to safeguard the autonomy of patients, and to limit the risks of harm by calculating the burdens and benefits of the care plan.

Likewise, it is reinforced in religious hospitals whose mission is to care for persons as "children of God," regardless of socio-economic standing. Such caring implies care for the whole person, physically, emotionally, socially and spiritually. How should I work with hospital chaplains? It is heartening to know that the physician is not alone in relating to the spiritual needs of the patient, but can enjoy the team work of well trained hospital chaplains who are prepared to help when the spiritual needs of the patient are outside the competence of the physician.

Board Certification Objective Requirements: Stephen King, personal communication, Need date Chaplains play an important role in a team approach to caring for patients. The onset of serious illness or accident often induces spiritual reflection as patients wonder, "what is the meaning of my life now?

Practical questions concerning the permissibility of procedures such as an autopsy, in vitro fertilization, pregnancy termination, blood transfusion, organ donation, the removal of life supports such as ventilators, dialysis, or artificially administered nutrition and hydration, or employment of the Death with Dignity Act, arise regularly for persons of faith.

In many cases, the chaplain will have specialized knowledge of how medical procedures are viewed by various religious bodies. In each case, the chaplain will first attempt to elicit the patient's current understanding or belief about the permissibility of the procedure in question. The chaplain is also prepared to respond to patients experiencing religious struggle through expert listening and communication skills. The chaplain is a helpful resource in providing or arranging for rituals that are important to patients under particular circumstances.

Some patients may wish to hear the assurances of Scripture, others may want the chaplain to lead them in prayer, and still others may wish for the sacraments of communion, baptism, anointing, formerly, the last ritesdepending upon their faith system. The chaplain may provide these direct services for the patient, or may act as liaison with the patient's clergy person.

In one case, a surgeon called for the chaplain to consult with a patient who was inexplicably refusing a life-saving surgical procedure.

The chaplain gently probed the patient's story in an empathic manner, leading the patient to "confess" to a belief that her current illness was God's punishment for a previous sin.

The ensuing discussion revolved around notions of God's forgiveness and the patient's request for prayer. In this case, the chaplain became the "embodiment" of God's forgiveness as he heard the patient's confession, provided reassurance of God's forgiving nature, and offered a prayer acknowledging her penitence and desire for forgiveness and healing. The conference with the chaplain opened the door for this patient to accept the care plan that she had refused earlier.

In another case, a neonatologist summoned the chaplain to the NICU when it became apparent that a newly born premature infant was not going to live and the parents were distraught at the notion that their baby would die without the sacrament of baptism.

“Patient-centred” – what does it mean and how achievable is it?

Sometimes, in the fast moving delivery of health care, the chaplain, by his or her job description, is the only one on the team with sufficient time to follow up on these important patient needs and concerns.

What role should my personal beliefs play in the physician-patient relationship? Whether you are religious, or nonreligious, your beliefs may affect the physician-patient relationship. Care must be taken that the nonreligious physician does not underestimate the importance of the patient's belief system. Care must be taken that the religious physician who believes differently than the patient, does not impose his or her beliefs onto the patient at this vulnerable time.

In both cases, the principle of respect for the patient should transcend the ideology of the physician. Our first concern is to listen to the patient.

Physicians are autonomous agents who are free to hold their own beliefs and to follow their consciences.

They may be atheists, agnostics, or believers. It is clear that religious beliefs are important to the lives of many physicians. Medicine is a secular vocation for some, while some physicians attest to a sense of being "called" by God to the profession of medicine.

For example, the opening line from the Oath of Maimonides, a scholar of Torah and a physician 1135-1204 incorporates this concept: In a much earlier time in the history of the world, the priest and the medicine man were one and the same in most cultures, until the development of scientific medicine led to a division between the professions.

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After Descartes and the French Revolution it was said that the body belongs to the physician and the soul to the priest. In our current culture of medicine, some physicians wonder whether, when and how to express themselves to patients regarding their own faith. The general consensus is that physicians should take their cues from the patient, with care not to impose their own beliefs.

In one study reported in the Southern Medical Journal in 1995, physicians from a variety of religious backgrounds reported they would be comfortable discussing their beliefs if asked about them by patients Olive, 1995. The study shows that physicians with spiritual beliefs that are important to them integrate their beliefs into their interactions with patients in a variety of ways. These interactions were more likely in the face of a serious or life-threatening illness and religious discussions did not take place with the majority of their patients ibid.

Obstacles to discussing Spirituality with Patients Some physicians find a number of reasons to avoid discussions revolving around the spiritual beliefs, needs and interests of their patients. Reasons for not opening this subject include the scarcity of time in office visits, lack of familiarity with the subject matter of spirituality, or the lack of knowledge and experience with the varieties of religious expressions in our pluralistic culture.

Many admit to having had no training in managing such discussions. Others are wary of violating ethical and professional boundaries by appearing to impose their views on patients. Nonreligious physicians have expressed anxiety that a religious patient may ask them to pray. In such instances, one could invite the patient to speak the prayer while the physician joins in reverent silence.

On the other hand, some physicians regularly incorporate spiritual history taking into the bio-psycho-social-spiritual interview, and others find opportunities where sharing their own beliefs or praying with a particular patient in special circumstances has a unique value to that patient. These and a myriad of other questions have religious and spiritual significance for a wide spectrum of our society and deserve a sensitive dialogue with physicians who attend to patients facing these troubling issues.

Often, such questions are initiated in doctor-patient discussions and may trigger a referral to the chaplain. How can we approach spirituality in medicine with physicians-in-training?

The UW School of Medicine was an early leader among medical schools in addressing the topic of patient-spirituality.