Nature and setting of discussions
Respondents reported specific patient illnesses and stressors that are likely to prompt spiritual discussions. These included terminal illness; chronic illness; specific conditions, such as heart disease, cancer, or miscarriage; depression, anxiety, or other psychiatric illness; pregnancy; and life stressors, including traumatic illness in the family. Other patient situations associated with spiritual discussions included the presence of symptoms without an explanation (eg, pain, insomnia, anorexia), loss of a bodily function, role change within the family, or an illness that erodes one’s self-concept.
Physician respondents also reported factors that often prompt them to ask spiritual questions. These included intensive care unit admission, new diagnosis of terminal illness, treatment failures, patients’ dissatisfaction with progress of treatment, and discussion of advanced care directives. The respondents who regularly address spiritual issues use screening questions that they tend to ask in response to a patient’s cues or crisis (Table 1).
Some respondents asserted that patients’ spiritual questions arise from their unique reactions to life stress and illness. One physician stated that patients’ questions have “more to do with their view of their illness than what the illness really is.” Spiritual questions commonly asked by patients covered a wide range of spiritual themes (Table 1).
TABLE 1
SELECTED SPIRITUAL QUESTIONS OF PATIENTS AND PHYSICIANS
| Questions PATIENTS’ QUESTIONS | Spiritual Dimension* |
|---|---|
| How do others cope with this? | Coping with illness |
| What do you think death is like? | Death and dying |
| I just wonder what my life is supposed to be about now. | Life’s meaning and purpose |
| What did I do to deserve this? God must be angry with me. | Role of God in illness |
| PHYSICIANS’ SCREENING QUESTIONS | |
| Have you had stress or changes in your life recently? | Screening |
| What is important to you? | Belief system |
| Has faith been important to you? | Beliefs |
| How have you dealt with difficult times in the past? | |
| From what do you draw your strength? | Resources |
| Do you hold any spiritual beliefs that might help you at this time? | |
| *With the exception of “screening” and “resources,” items under the Spiritual Dimension heading are found in Kuhn CC.9 | |
| For the complete table, see Table W1. | |
Manner of addressing spiritual health issues
The physicians in our study believed that in most circumstances, patients should initiate spiritual discussions. One said, “It’s one of those areas where you need a small amount of the patient’s permission to get started and a lot more of the patient’s permission to finish.”
Those who regularly address spiritual issues reported using a variety of techniques and approaches (Table 2). These physicians allow for an inclusive definition of spirituality; they try to normalize spiritual discussions and to integrate spiritual discussions into the ongoing doctor–patient relationship. One said that “bringing [spirituality] to the table” along with other potentially sensitive issues helps patients know “what you’re interested in and gives them the option of deciding to pursue it or not.”
The physicians who address spiritual issues follow principles of spiritual assessment (Table 2). All respondents affirmed that spiritual discussions should be approached with sensitivity and integrity to avoid imposing their own belief systems on their patients. One said, “I can’t even describe how negative it [would be] for me to impose my spiritual beliefs on [my] patients.” Another respondent agreed, but also described a tension between faith-based and profession-based thoughts: “[Discussing one’s faith with a patient risks being] an abuse of power; yet if a patient dies tonight and I haven’t shared the Good News that I have . . . I’m neglecting something that’s very important. . . . How do we do this . . . with both gentleness toward the patient and reverence toward God?”
Respondents expressed divergent viewpoints concerning routine spiritual history taking. Although some considered this to be an essential skill, those who seldom addressed spiritual issues found it less pressing and more time consuming than medical concerns. None reported the routine use of currently available spiritual assessment tools. A respondent opposed to initiating spiritual discussions noted a Judeo-Christian bias in these tools, calling their use “cultural imperialism.”
TABLE 2
PHYSICIANS’ APPROACHES TO ADDRESSING SPIRITUAL ISSUES
| Techniques |
| Spiritual discussion in context of broad issues |
| Asking spiritual questions at onset of relationship and again during crises |
| Assessing and affirming patients’ spiritual resources |
| Diagnostic Approach |
| Active attention to patient cues or questions |
| Consideration of questions in context of patient’s known spiritual background |
| Processing of questions to look for deeper spiritual questions or issues |
| Asking clarifying questions to assure accurate identification of spiritual issues |
| Offering therapies (answers, suggestions, or exercises) related to patient’s questions and appropriate to patient’s beliefs and values |
| Principles |
| Sitting and listening has value |
| Use patient-centered reflection rather than providing answers to spiritual questions |
| Approach spiritual discussions with gentleness and reverence |
| Do not impose spiritual or religious views on patients |
| For the complete table, see Table W2. |