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Am Fam Physician. 2022;106(4):415-419

Related Letter to the Editor: The Importance of Inclusivity During the Spiritual Assessment

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

The spiritual assessment offers the opportunity to enhance the patient-physician relationship and incorporate patient views that may have a significant impact on clinical decision-making. Multiple studies have demonstrated that patients' expectations of spiritual discussions in the health care setting are not being met. Perceived barriers reported by physicians include lack of time, training, and experience. There is a variety of physician approaches to assess and incorporate spirituality in the health care setting. A spiritual assessment is recommended when a patient is admitted to the hospital, has a significant clinical decline while in the hospital, is receiving psychosocial services for the treatment of substance use disorder, or when addressing palliative care. Tools for spiritual assessment include the Open Invite mnemonic, which initiates the topic and relies on a conversational approach, and the HOPE questions, which offer a structured approach to determine the relevance of spirituality to the patient's overall health and assist with the development of an individualized care plan. Although physicians should respect the right of patients who do not want to discuss this topic, multiple studies demonstrate significant relationships between spiritual interventions and improved mental and physical health outcomes.

The physician-patient relationship is at the foundation of every interaction in family medicine. Understanding a patient's spirituality significantly impacts this relationship as well as clinical decision-making. Patients often view their health care with spirituality in mind, particularly at the end of life. Spiritual assessment is a component of the holistic or biopsychosocial-spiritual approach of caring for the patient.1

Defining Spirituality

Although religion is the beliefs and practices with which one approaches the sacred, spirituality is broader and involves seeking meaning and connectedness behind human life.2,3 Here the term spirituality is used as opposed to religion to convey greater inclusivity in the context of the diverse views patients may have.4 A 2017 Gallup Poll showed that 87% of Americans believe in God or a universal spirit and this has remained between 86% and 92% since 2011.5 Spirituality may be expressed as a belief in God, but it can also include beliefs that give patients a sense of greater purpose in life through connection with nature, energy, art, music, and humankind.6

Scope of Spirituality

The scope of spirituality in medical practice is typically addressed during the discussion of end-of-life care. The COVID-19 pandemic has highlighted the importance of advance care planning and spiritual assessment as necessary elements to consider when discussing end-of-life issues with patients.3,7 The Joint Commission requires accommodation of spiritual issues in end-of-life care and for patients who receive psychosocial services for substance use disorders.810 The Association of American Medical Colleges has established learning goals for medical students regarding spirituality, including the ability to elicit a spiritual history.11

Multiple studies demonstrate that physicians are not meeting the expectations of patients to discuss spirituality. One outpatient survey showed that most family medicine patients desired spiritual discussions during challenging life events, including 70% of patients who indicated they desired spiritual discussions for loss of a loved one, 74% for serious medical conditions, and 77% for life-threatening illnesses.12 In the same study, patients identified the most important reasons for these discussions as desire for physician-patient understanding and the belief that spiritual needs would affect medical advice and treatment.12 A recent cross-sectional study showed that nearly one-half of patients in the outpatient setting wanted to partake in a spiritual assessment, but 90% of participants reported that they were never asked about their beliefs.13

Physicians may view spirituality and its role in medicine differently. A qualitative study of general practitioners in Scotland demonstrated four major actions that physicians can take based on a patient's spiritual beliefs.14 Some physicians may choose not to explore a patient's spiritual beliefs.14 Other physicians use the spiritual assessment to provide relevant cultural information or clinical background and to understand patients' belief systems. In this action, physicians do not view spirituality as a shared experience with the patient, but as a data point in providing comprehensive care.14 Some physicians use the spiritual assessment to refer or recommend the patient to a spiritual advisor or member of the patient's faith community. In this situation, physicians may acknowledge the importance of the spiritual needs of the patient but do not view themselves as the person to address those needs.14 Some physicians choose to actively engage patients in a discussion about spirituality and how it affects their health, and may offer to pray with or for them.14

Although studies demonstrate that physicians see themselves as supportive of patients' spiritual well-being, there are multiple perceived barriers. These barriers include lack of time and training for, and experience with the spiritual assessment.15 Given the time constraints of office visits and lack of experience in conducting spiritual assessments, physicians report feeling uncertain or uncomfortable in initiating spiritual discussions.15 A quality improvement project in the palliative care setting that focused on encouraging physicians to perform spiritual assessments shows that barriers can be addressed. By integrating chaplains who joined physicians for the interview, documentation of completed spiritual assessments increased from 49% to 72%.16

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