Spirituality in Patient Care – Why, How, When and What

Professor Harold Koenig is perhaps the best known of a cohort of indefatigable researchers from the USA who, over the last ten years, have put spirituality in healthcare firmly on the map. Koenig founded the Duke's Center for the Study of Religion /Spirituality and holds a number of prestigious academic appointments. He has published extensively in the fields of mental health, geriatrics, and religion, with over 160 scientific peer-reviewed articles, 35 book chapters and 24 books in print or in preparation.

Koenig is by any standards an intellectual heavyweight and first author of the seminal textbook, Handbook of Religion and Health, published in 2001 by Oxford University Press (Koenig H, McCullough M. and Larson, D). Yet here he has favoured us with a book small enough to fit into a large pocket, and one that is redolent with good, practical and commonsensical advice. Koenig distils a vast amount of epidemiological and clinically based research correlating health and spirituality into this little book. He is so succinct and to the point that his outline summary cannot be bettered: Why address spirituality in patient care? Why identify spiritual needs? Why should this be a routine part of health care? Koenig discusses how religious beliefs and spiritual needs are common among medical patients and serve a distinct function; how religious beliefs influence medical decision making; the nature of the relationship between religion and both mental and physical health; why many patients would like their doctors to address these issues; and shows indeed that there is a historical precedent for doing so. The need for physician training in this area is outlined. How does a physician identify and address spiritual needs? Koenig explores the process of spiritual assessment; how to take a spiritual history and instruments for doing so; the role of the physician as orchestrator of resources, supporter of patients' spiritual beliefs, and participant in spiritual activities with patients (such as prayer); and the importance of physicians and healthcare systems linking together with religious organizations (through parish nurses or lay leaders) to address the present and future health needs of communities. When does one take a spiritual history during the course of medical evaluation? As part of the chief complaint, history of the present illness, family history, social history, or physical examination? Here Koenig examines the relevance of context. Are certain kinds of patients more appropriate than others (for example, a teenager in for a wart removal, a pregnant woman being seen for a prenatal exam, an older person in for a health maintenance visit, or someone being admitted to a hospital, nursing home, or hospice)? How often should a spiritual history be done: once and never repeated, every visit, only at selected times? When does a physician provide spiritual support and what kinds of support are permissible? What about praying with patients? Is this ever acceptable? What results can be expected from addressing patients' spiritual needs? Koenig considers the impact that spiritual assessment can have on the patient's ability to cope with illness, on the doctor-patient relationship, patient compliance, and more broadly, on the course of medical illness and response to treatment. Some of the practical benefits of communicating with, referring to, and interacting with clergy in hospital and community settings are illustrated. There are further chapters on: Boundaries and Barriers and the limitations in the role that physicians can play in this area. Are there ethical boundaries that should not be crossed? Does medical specialty make a difference? Are there gray areas that must be addressed on a case-by-case basis? What kinds of problems can arise when physicians attempt to address spiritual needs of patients? How can these problems be avoided? Are there other pitfalls and dangers to be aware of when addressing spiritual issues? What are some of the resistances, fears, and concerns of health professionals that prevent them from addressing religious or spiritual issues, and how valid are these concerns? When Religion Is Harmful: The negative effects that religion may exert on health. Are there times when spiritual beliefs can actually interfere with medical care, lead to health problems, or worsen disease outcomes? What are some examples and how often does this occur? How can clinicians handle these cases in a sensitive, thoughtful, and effective manner? Can physician inquiry about spiritual issues cause harm? Further Resources that clinicians can turn to for more information about spirituality and health. First, different assessment tools for taking a spiritual history are described and discussed. Second, thirty key original research studies are briefly summarized, on spirituality and mental health, physical health, and social health. Third, a number of academic texts on religion and health are reviewed. Finally, there is a listing of websites, newspapers, and popular magazines where health professionals can obtain up-to-date information about spirituality and health. In the United States, and in large measure due to the endeavours of Dr. Christina Puchalski of George Washington University, (generously supported by the John Templeton Foundation), over two thirds of medical schools now hold required or elective courses on religion, spirituality and medicine. In the UK, to date there are just two. However, a joint initiative is being headed by Professor John Swinton of the University of Aberdeen, who set up the first university-based course on spirituality and health in this country, and Christina Puchalski, to interest all medical schools in the UK in developing similar courses for medical students. The art is to be able to show that spirituality in medicine is not something split off from mainstream practice but underpins all compassionate and caring medicine. There is a subtle continuum, from the unspoken, which finds expression in a gesture, or even just the tone of voice, to the explicit, which may go as far as joining a patient in prayer. Koenig's book demonstrates a multitude of opportunities in daily clinical practice for recalling the spiritual dimension. Without this constant awareness, those moments rich with possibility slip away unnoticed. The allure of the technology of medicine is powerful indeed. There is a romance with cure that is irresistible to most young doctors. But we need just as much to have a romance with care. It is at first sight less dramatic and less thrilling. Yet it brings us close to our patients in that most privileged of settings, where a fellow human being, stripped naked in pain, fear, distress, appeals to us for help. In medicine, we can expect machines to give us a lot of answers. But the questions our patients ask us, the biggest ones, call for a response, not from machines but from ourselves as fellow human beings. What are our greatest fears? What of our mortality? How much of life remains? Why are we being afflicted? Are we being, or will we be, punished? Can we find comfort in the embrace of a greater, divine reality? Koenig shows in this small book that far from avoiding such questions, the doctor can readily engage with his/her patients with sensitivity and openness, and that whatever the clinical outcome, those is in need will have had the solace and encouragement of being recognised and valued in their personhood. Doctors, too, will find that they are by no means excluded from the spiritual replenishment that such soul-to-soul contact invariably brings.