Spirituality an Important Component of Patient Care

An Expert Interview With Christina M. Puchalski, MD

Jim Kling

March 02, 2011

March 2, 2011 — Editor's note: Until recent years, spirituality has been an oft-overlooked element of patient care. Numerous studies have suggested that having a spiritual community is helpful to people coping with illness and recovering from surgery. A discussion of improving spiritual care was featured at the American Academy of Hospice and Palliative Medicine/Hospice and Palliative Nurses Association Annual Assembly, held February 16 to 19 in Vancouver, British Columbia.

To find out more about spirituality and healthcare, Medscape Medical News interviewed Christina M. Puchalski, MD, executive director of The George Washington Institute for Spirituality and Health in Washington, DC, and professor of medicine and health sciences at The George Washington University School of Medicine. Dr. Puchalski helped develop the Faith and Belief, Importance, Community, and Address in Care (FICA) tool to help healthcare professionals address spiritual issues with their patients. Spiritual distress is also an important factor in healthcare, and can be monitored as part of an overall screening plan. It is designed to be taken as part of the regular history during an annual exam or at an initial visit with a new patient. It consists of a series of questions addressing faith and belief, importance of that belief in the patient's life, the presence or absence of a spiritual community, and how spirituality should be addressed in care by the physician.

Medscape: How do you define spirituality?

Dr. Puchalski: Spirituality [refers to the way] people understand meaning and purpose in their lives. It can be affected by illness or loss, and it can be experienced in many ways — not just religion, but nature, arts, humanities, and rational thinking. Some say it is God, some say it is family, and some find it in nature. It's a very personal thing for people.

It's also important for physicians. Spirituality is about relationships. We talk about providing compassionate care. If you go into any hospital, it says its mission is to provide compassionate care. Compassion means you're present with another human being, and unless a physician knows what gives his life meaning, the source of the call to serve others, it is very hard to be compassionate. Our profession is really a spiritual profession.

Medscape: How does spirituality come into play in common medical practice?

Dr. Puchalski: It's so important in palliative care because you're dealing with the possibility of dying. It's staring you in the face.

But aging is another aspect. I have a patient who is a bicyclist. Her community comes out of her biking group; she raises money for charities, she bikes internationally. She's healthy right now, but one thing we talked about was, if there [comes] a time when [she's] not able to do this, what is going to give [her] meaning then. She kind of shrugged it off, but the next year she came back and said that she had given thought to it. It would have been really hard for her to become inactive, but now she has other resources.

I had another who patient who had a mild stroke, which caused her to slow down. She later broke her elbow. The question the family had to deal with was whether or not to let the elbow heal as it was or to have surgery done. She probably would not have been able to straighten it without surgery. A key question was: What gives meaning to the patient? She is religious, but what was really important to her was her sense of dignity and independence. So we needed to fix her elbow and do the surgery. These questions can affect healthcare decision making.

The issues aren't just for end-of-life care. It's about conversations, about recognizing that conversations are important in clinical care and not just end-of-life care. Every single visit I have with a patient includes a conversation about spirituality, about what's important to them. Every time we come to a crossroads that requires a decision, I want to know: 'Where are you today, what's important to you, what gives your life meaning and value, and how does this affect your decisions?'

Medscape: Tell me about the FICA tool.

Dr. Puchalski: I recommend that for every new patient, part of the social history should be a spiritual history. It should be used in annual exams as part of risk assessment, like anything else. . . We did a validation study comparing it to the City of Hope Quality of Life tool, which is more of a research-based tool, but we identified the same types of spiritual issues, so we know that FICA works.

If people aren't exercising, that's a problem. If people don't have a sense of meaning and purpose, that's another problem. People should also think about a spiritual history when there's a change in clinical status. When you're breaking bad news, I think it's important to ask about support systems and what might work for people. Spirituality is one of those things.

It gives people the tools to talk about and diagnose spiritual distress and to integrate it into a treatment plan. What we've done at The George Washington Institute for Spirituality and Health is develop tools and practical ways to integrate that into healthcare.

Medscape: What do you recommend that clinicians do if they see a spiritual problem developing in a patient?

Dr. Puchalski: It depends on what the issue is. If it's spiritual distress, ideally a board-certified chaplain might be the best referral, but in reality, there aren't that many available in an outpatient setting.

Let's say the issue is meaninglessness. There are a variety of options. Maybe it's talking to a pastoral counselor, or there are some therapists that are really good at dealing with these types of spiritual and emotional issues together. Art therapy might work for some.

If they want to deepen their relationship with God, however they understand that, then a spiritual director might be ideal.

Medscape: How do you distinguish between spiritual suffering and other issues, such as depression or social isolation?

Dr. Puchalski: It overlaps. Let's take depression. There's something called demoralization, which is a lack of meaning and purpose in life. Some would say that's psychological, but if you're talking about a sense of ultimate meaning, an inner sense of coherence of who you are — regardless of what's happening around you — you can be depressed and demoralized, you can be depressed and have no hope, you can be depressed and isolated from God.

What is important to do is to identify depression, meaning typically the patient has physical symptoms, like a change in appetite, feelings of worthlessness, inability to sleep, change of weight, or thoughts of suicide. Someone could be clinically depressed but not necessarily have a really active spiritual issue, and once you get the depression stabilized, they're fine.

People can have spiritual issues, but not be clinically depressed. You have to dig deeper. This is a relatively new field, and we're just beginning to identify these different arenas. It's just like social and emotional issues — they overlap with physical pain. Many people tell me, 'my back really hurts, but stress really exacerbates it.' Maybe there's something physical there, but an emotional thing can exacerbate it.

Medscape: Is spirituality often overlooked in healthcare?

Dr. Puchalski: In 1992, I started a course at The George Washington School of Medicine on spirituality and health. It was the first such course then, but today more than 75% of medical schools in the United States teach content in spirituality and health. Some Canadian schools are doing it as well, and there's a growing interest in Europe.

I would say interest has certainly increased, as evidenced by the number of people asking me to use the FICA tool. It's now in medical textbooks, and it's been integrated into many electronic records in the hospital setting.

Religion has been on [healthcare assessment] forms, but that is not a spiritual history. It could be a part of it, but it misses the aspect of meaning, purpose, and connection. Increasingly, hospitals have deleted the question [of religion], or still have it but in addition ask something about spirituality.

We're really calling for a system change. We need something far more holistic than what we have right now, and that's what I think has been important about this work.

Dr. Puchalski has disclosed no financial conflicts of interest.


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