Why is addressing spirituality in health care important?
"Doctor, you say that I have terminal cancer and there isn't any more that you can do for me. You say that I have two or three months left. What happens then? I'm afraid of the pain and suffering ahead. I'm afraid that I haven't been a good person. I'm afraid that God doesn't love me, since my prayers for healing have gone unanswered. I'm afraid of where I'm going after I die. I'm afraid of leaving my daughter and son, and never seeing them again. I'm afraid, doctor, I'm so afraid."
For people who face a serious illness, these are often the most pressing concerns. Increasingly, both health professionals and the medical system must tackle such personal inquiries. Furthermore, they will soon be confronted with a possible future health-care crisis, driven inexorably now by financial pressures and an aging population.
The research and policy questions abound. Should health professionals take more seriously the spiritual concerns of patients, and can this be a way to approach individual patients more compassionately as well as to strengthen and reform the health-care system? If these spiritual concerns are taken into account, what might health care look like thirty years from now? If health-care systems in the coming decades can no longer function as they have in the past, what are the options and how might faith communities be helpful?
Our approach to such policy questions will help determine the quality of care that patients receive in the future. This chapter will try to answer two policy questions in particular. First, does research confirm that health professionals should be looking at the spiritual needs of patients? And, second, how important might this be in responding to a health-care crisis should this develop in the future? To answer these, I will briefly describe the current situation of research on religion, spirituality, and health and discuss how this research is being applied to the clinical care of patients. Next, I will give an overview of medicine and health care in the twenty-first century, looking both at areas of crisis and also at new resources that may be found in religious organizations and faith communities.
The good news is that research on religion, spirituality, and health is advancing as never before, even though most doctors are still not trained to talk to patients about these issues. The bad news is in the headlines every day: the health-care systems of the world are headed for troubled times, unless we find innovative solutions.
By the year 2000, the number of studies examining the relationship between some aspect of religion, spirituality, and health or health care had ballooned to nearly 1,200 (about 70 percent were on mental health and 30 percent on physical health).1 Since then, hundreds more studies have been published. Thus, it is safe to say that over one thousand research studies have quantitatively examined relationships between religion, spirituality, and health, many reporting positive findings.
This research has prompted at least three consensus conferences partially supported by the National Institutes of Health (NIH) to review the research and come up with recommendations for methodological advances and future studies.2 William R. Miller, chair of the latest NIH working group, concluded, "Substantial empirical evidence points to links between spiritual/religious factors and health in U.S. populations. . . ."3 While it is clear that many of the hundreds of studies published in the scientific literature have serious methodological flaws, not all of the studies do, and the critique of earlier research may have been overstated.4 Furthermore, the quality of religion-health studies has increased substantially since the last NIH conference in 2002, with investigators responding to and correcting many of the concerns voiced about prior research.
While the field of religion, spirituality, and health is in its infancy and much research is needed to verify (or dispel) earlier findings, a lot of outstanding work has already been done. There is good reason to begin implementing some of what is already known in clinical practice.
Clinical Practice Applications
Not all of the reasons for addressing spiritual issues in clinical practice depend on research that definitively demonstrates that religion influences health. The application is for very practical reasons: Many patients are religious, have religious beliefs and traditions related to health, and have health problems that often give rise to spiritual needs. Religious beliefs will frequently influence the kind of health care that patients wish to receive. Those beliefs affect how patients cope with illness and derive meaning and purpose when feeling bad physically or unable to do the things they used to do that give them joy and pleasure. Such beliefs help patients maintain hope and motivation toward self-care in the midst of overwhelming circumstances. Patients, particularly when hospitalized, may be isolated from their religious communities, and, because spiritual needs often come up during this time, health-care providers must recognize and address those needs. Religious beliefs can also influence medical decisions, conflict with medical treatments, and influence patients' compliance with treatments prescribed. The patient's
involvement in a religious community can affect the support and monitoring he or she receives after discharge. In summary, there are many reasons for clinicians to discuss religious or spiritual issues with patients, learn to identify spiritual needs, and refer patients to health professionals trained to address those needs.5
The need for training to integrate spirituality into patient care has been increasingly recognized within medical education. In 1992, only three medical schools offered courses on religion, spirituality, and medicine. By 2006, over one hundred of the 141 medical schools in the U.S. and Canada had such courses (70 percent of which are required).6 Unfortunately, most physicians in practice today have no such training. In a recent nationwide survey of a random sample of over one thousand U.S. physicians of all specialties, only about 10 percent of physicians indicated they routinely talked to patients about these issues.7 Those data are consistent with reports by patients. Only 10 to 20 percent of patients report that a physician ever asked about spiritual issues.8 As leaders in health care, physicians ought to be responsible for ensuring that spiritual needs likely to affect medical decisions and health outcomes are addressed.
Evidence that even the spiritual needs of dying patients are often unmet and the adverse effect of this on quality of life has recently been reported. Balboni and colleagues surveyed 230 patients with advanced cancer who had failed to respond to first-line chemotherapy.9 These patients were being cared for at some of the best medical-care systems in the world, including Yale University Cancer Center in New Haven, Connecticut, and Memorial Sloan-Kettering Cancer Center in New York City. This study, conducted by Harvard Medical School researchers, had patients rate on a one to five scale to what extent either their religious community or the medical system supported their spiritual needs (from "not at all" to "completely supported"). One out of every two patients (47 percent) said that spiritual needs were minimally or not at all met by their religious community. Nearly three-quarters (72 percent) said that spiritual needs were minimally or not at all met by the medical system (i.e., doctors, nurses, or chaplains). Patients who indicated that their spiritual needs were being met reported significantly higher quality of life. In fact, of nine factors known to influence quality of life, degree of spiritual support was the second strongest predictor.
Unfortunately, there are not enough chaplains employed by hospital organizations to screen all patients or address the spiritual needs that are present, nor do community clergy have the time or expertise to meet those needs. Chaplains see only about 20 percent of hospitalized patients in the U.S. today.10 In the current environment of intense competition among hospitals to survive financially, chaplain services are often the first to be downsized or eliminated.11 The results of a survey on patient satisfaction that involved 1,732,562 patients representing 33 percent of all hospitals in the United States and 44 percent of all hospitals with more than one hundred beds found that satisfaction with the emotional and spiritual aspects of care received one of the lowest ratings of all clinical-care indicators. At the same time, it was one of the areas rated the highest for need of quality improvement.12 This is a major reason why physicians, nurses, social workers, and other health professionals need to get more involved. There are not enough chaplains in hospital settings to see all the patients, so health professionals need to identify patients with the most pressing spiritual needs and get them connected to the few chaplains that are available to address them. However, there is resistance to doing so, particularly among physicians.
- H. G. Koenig, M. M. McCullough, and D. B. Larson, Handbook of Religion and Health (New York: Oxford University Press, 2001), 514-89.
- For information on the recommendations of these conferences, see: National Institute on Aging and Fetzer Institute, Conference on Methodological Approaches to the Study of Religion, Aging, and Health, Bethesda, MD, 1995; National Institute on Aging and Fetzer Institute, Working Group on Measurement of Religion/Spirituality for Healthcare Research, Bethesda, MD, 1997 (in particular, see E. L. Idler, M. A. Musick, C. G. Ellison, et al., "Measuring Multiple Dimensions of Religion and Spirituality for Health Research: Conceptual Background and Findings from the 1998 General Social Survey," Research on Aging 25 (2003): 327-65; and National Institutes of Health Working Group on Spirituality, Religion, and Health, Office of Behavioral and Social Sciences Research, Bethesda, MD, 2001. This last report resulted in a special section on spirituality, religion, and health published in the January 2003 issue of the American Psychologist 58, no. 1.
- W. R. Miller and C. E. Thorsen, "Spirituality, Religion and Health: An Emerging Research Field," American Psychologist 38 (2003): 33.
- For questions on methodology, see R. P. Sloan, E. Bagiella, and T. Powell, "Religion, Spirituality, and Medicine," Lancet 353 (1999): 664-67. For a rebuttal, see H. G. Koenig, E. Idler, S. Kasl, et al., "Religion, Spirituality, and Medicine: A Rebuttal to Skeptics," International Journal of Psychiatry in Medicine 29 (1999): 123-31.
- H. G. Koenig, Spirituality in Patient Care, 2nd ed. (Philadelphia, PA: Templeton Foundation Press, 2007).
- Regarding these statistics, see C. M. Puchalski, "Spirituality and Medicine: Curricula in Medical Education," Journal of Cancer Education 21, no. 1 (2006): 14-18; and John Templeton Foundation Capabilities Report (West Conshohocken, PA: Templeton Foundation, 2006), 68.
- F. A. Curlin, M. H. Chin, S. A. Sellergren, C. J. Roach, and J. D. Lantos, "The
Association of Physicians "Religious Characteristics with Their Attitudes and Self-Reported Behaviors Regarding Religion and Spirituality in the Clinical Encounter," Medical Care 44 (2006): 446-53.
- See T. McNichol, "The New Faith in Medicine," USA Weekend, April 5-7, 1996, 5; J. Ehman, B. Ott, T. Short, R. Ciampa, and J. Hansen-Flaschen, "Do Patients Want Physicians to Inquire about Their Spiritual or Religious Beliefs If They Become Gravely Ill?" Archives of Internal Medicine 159 (1999): 1803-06; and D. E. King and B. Bushwick, "Beliefs and Attitudes of Hospital Inpatients about Faith Healing and Prayer," Journal of Family Practice 39 (1994): 349-52.
- T. A. Balboni, L. C. Vanderwerker, S. D. Block, et al., "Religiousness and Spiritual Support among Advanced Cancer Patients and Associations with End-of-Life Treatment Preferences and Quality of Life," Journal of Clinical Oncology 25 (2007): 555-60.
- K. J. Flannelly, K. Galek, and G. F. Handzo, "To What Extent Are the Spiritual Needs of Hospital Patients Being Met?" International Journal of Psychiatry in Medicine 35, no. 3 (2005): 319-23.
- L. VandeCreek, "How Has Health Care Reform Affected Professional Chaplaincy Programs and How Are Department Directors Responding?" Journal of Health Care Chaplaincy 10, no. 1 (2000): 7-17.
- P. A. Clark, M. Drain, and M. P. Malone, "Addressing Patients" Emotional andSpiritual Needs," Joint Commission Journal on Quality and Safety 29 (2003):659-70.
From Harold G. Koenig, M.D., Medicine, Religion, and Health: Where Science and Spirituality Meet (West Conshohocken, PA: Templeton Foundation Press, 2008) 21-25.