Harold G. Koenig, MD, completed his undergraduate education at Stanford University, his medical school training at the University of California at San Francisco, and his geriatric medicine, psychiatry, and biostatistics training at Duke University Medical Center. He is on the faculty at Duke as professor of psychiatry and behavioral sciences and associate professor of medicine. Dr. Koenig is also director of the Center for Spirituality, Theology, and Health at Duke University Medical Center, and is Distinguished Adjunct Professor at King Abdulaziz University in Jeddah, Saudi Arabia. Dr. Koenig has published extensively in the fields of mental health, geriatrics, and religion, with over 400 scientific peer-reviewed articles and book chapters and 40 books in print or in preparation. He has given invited testimony to both the U.S. Senate and the U.S. House of Representatives on the role of religion in public health, and is the recipient of the 2012 Oskar Pfister Award from the American Psychiatric Association. 

Spirituality in Patient Care

WHY, HOW, WHEN, AND WHAT

By Harold G. Koenig

TEMPLETON PRESS

Copyright © 2013 Harold G. Koenig
All rights reserved.
ISBN: 978-1-59947-425-0

Contents

Introduction………………………………………………………3ONE. Why Include Spirituality?………………………………………23TWO. How to Include Spirituality…………………………………….51THREE. When to Include Spirituality………………………………….78FOUR. What Might Result?……………………………………………96FIVE. Boundaries and Barriers……………………………………….115SIX. When Religion (or Spirituality) Is Harmful……………………….135SEVEN. Chaplains and Pastoral Care…………………………………..151EIGHT. Spirituality in Nursing Care………………………………….173NINE. Spirituality in Social Work……………………………………191TEN. Spirituality in Rehabilitation………………………………….200ELEVEN. Spirituality in Mental Health Care……………………………213TWELVE. A Model Course Curriculum……………………………………230THIRTEEN. Information on Specific Religions…………………………..244FOURTEEN. Summary of Key Points……………………………………..281Notes…………………………………………………………….287Index…………………………………………………………….329
<br><h2>CHAPTER 1</h2><p><b><i>Why</i> Include Spirituality?</b></p><br><p>WHY INCLUDE SPIRITUALITY in patient care? Why would anHP take time to address spiritual needs or support a patient’sreligious beliefs? HPs need to be able to answer such questionsbefore tackling spiritual issues with patients. Here arenine reasons why HPs should do so:</p><p>1. Many patients are religious or spiritual, have spiritualneeds related to illness, and want their health professional toknow about them.</p><p>2. Religion influences the patient’s ability to cope withillness.</p><p>3. Patients when hospitalized are often isolated from theirreligious communities.</p><p>4. Religious beliefs affect patients’ medical decisions, mayconflict with medical treatments, and can influence compliancewith the treatment plan.</p><p>5. Physicians’ religious beliefs often affect their medicaldecisions and influence the care they provide.</p><p>6. Religious involvement is associated with both mentaland physical health, and likely affects the patient’s responseto medical and surgical treatments.</p><p>7. Religion influences the support and care that patients receive inthe community.</p><p>8. Failure to address patients’ spiritual needs increases health carecosts.</p><p>9. Standards for accreditation and payment require an awarenessof patients’ spiritual beliefs.</p><br><p><b>MANY PATIENTS ARE RELIGIOUS ANDHAVE SPIRITUAL NEEDS</b></p><p>Many people seen in health care settings in the United States (andmany other areas of the world) are religious and have spiritual needs.A series of Gallup polls that surveyed 327,244 persons between January2 and November 30, 2011, found that religious affiliations in theU.S. are diverse, with 78 percent of Americans identifying themselvesas Christian (95 percent of those indicating a religious affiliation),1.6 percent Jewish, 0.5 percent Muslim, and 2.4 percent othernon-Christian. Furthermore, 15 percent of those surveyed indicated”none, atheist, or agnostic,” and 2.5 percent did not give a response.That same survey found that 55 percent of Americans say that religionis very important to them, a figure that has remained relativelyconstant since 1976. Note also that a 2009 Gallup poll of 1,000 adultsin each of 114 nations around the world found that 84 percent ofrespondents (on average) said that religion is an important part ofdaily life. A Gallup poll conducted in May 2011 found that 92 percentof Americans believe in God (including 87 percent of those with apostgraduate education and 84 percent of those ages 18–29), whereas7 percent say they do not believe in God. In that same poll, 79 percentof Americans say they believe that the Bible is the actual or inspiredword of God (including 71 percent of those with a postgraduate education).Other religious activities are also common. According to Galluppolls of 800,000 Americans conducted between February 2008 andMay 2010, 43 percent reported attending religious services weeklyor almost weekly (regardless of education level). Finally, nine in tenAmericans say they pray (a proportion that has not changed duringthe past half-century based on Gallup polls), and three out of fourAmericans say that they pray on a daily basis.</p><p>Even if patients are not religious, there is a good chance that somewill describe themselves as spiritual, since about one in five Americansconsiders themselves “spiritual but not religious.” This is lesstrue for older adults, who tend to be more traditionally religious andoften equate spirituality with religion. A 2004 study of 838 medicalinpatients ages sixty or over found that 88 percent said that they wereboth religious and spiritual, 7 percent that they were spiritual butnot religious, 3 percent that they were religious but not spiritual, and3 percent that they were neither religious nor spiritual.</p><p>Many people use religious beliefs or practices for health reasons.In a national random sample of 31,044 U.S. adults (2002 NationalHealth Interview Survey), researchers found that of the ten mostcommon complementary and alternative medicine (CAM) therapiesthat Americans engage in, “prayer for health reasons” was the mostcommon (45.2 percent in the past twelve months and 55.3 percent intheir lifetime). This is especially true for ethnic minorities. Whileonly 41.5 percent of European Americans prayed for health reasons(either their own or someone else’s) in the past twelve months, 49.5percent of Hispanic Americans and 62.6 percent of African Americansdid so. In another national survey of 3,728 Latino Americans (PewCenter’s Latino Health Survey), 60 percent prayed for healing in thepast twelve months, 49 percent asked otheers to pray for healing, and69 percent considered spiritual healing very important.</p><p>Not only are the vast mmajority of patients religious and oftenuse it for health, but many have spiritual needs that they would likeaddressed as parrrrt of their health care. Being religious or spiritual ispart of who many people are—it forms the root of their identity ashuman beings and gives life meaning and purpose. This is especiallytrue when medical illness threatens life or way of life. For example,in a study of 101 psychiatric and medical/surgical inpatients at a Chicagohospital, investigators found that the vast majority of psychiatricpatients (88 percent) and medical/surgical patients (76 percent)reported three or more religious needs during hospitalization.</p><p>Most of the available data on patients’ attitudes toward HPsaddressing spiritual needs comes from studies asking about their physicians.Early studies (1994–1998) indicated that about three-quarters offamily practice patients said physicians should consider their spiritualneeds or know about their religious beliefs. In a latter study (2003),however, patients’ attitudes varied depending on the setting and severityof their illness, ranging from 33 percent wanting the physician toask about their religious beliefs during routine office visits to 84 percentif they were terminally ill. Admittedly, these studies took place inthe Southern and Southeastern U.S. and so may represent higher-endestimates. However, a study from the Northeastern U.S. found aboutone-half (53 percent) of HIV-positive inpatients felt that it was importantfor them to discuss spiritual needs with their physicians.</p><p>Research published more recently updates these earlier reports. Ina study of 3,141 general medical inpatients at the University of ChicagoMedical Center, patients were asked whether they would liketo discuss religious or spiritual concerns with someone while in thehospital. They were also asked whether someone had spoken withthem about religious or spiritual issues, and if so, who did so. Resultsindicated that 41 percent desired to discuss religious or spiritual concernswith someone; 32 percent indicated that such a discussion didtake place; and 8 percent said that the person with whom they discussedreligious or spiritual concerns was their physician, 61 percent achaplain, 12 percent a member of their own religious community, and12 percent someone else. Those who wished to discuss religious or spiritualconcerns were older, had less education, had experienced severepain, and were more religious. Satisfaction with care was significantlygreater among those who had such discussions. Interestingly, satisfactionwith care was significantly greater even among the 315 patientswho didn’t want such discussions but ended up having them anyway.</p><p>Adult patients are not the only ones who want physicians to knowabout their spiritual beliefs and concerns. In a study of 151 adolescentoutpatients with asthma, participants were asked about their preferencesregarding the clinical encounter. Nearly one-half (42 percent)indicated their provider should play a role in their spiritual or religiouslife. In addition, 52 percent felt their provider should be aware oftheir spiritual/religious beliefs. Of the latter, 71 percent said providerawareness of their beliefs was important in order for the provider tounderstand how those beliefs helped them to cope with their asthma.</p><p>Studies outside the U.S. have also found that patients often desirethat physicians know about their religious beliefs and spiritual needs.For example, a survey of patients and families in a public teachinghospital in Sydney, Australia, found that the majority felt it wouldbe helpful for health staff to know about their religious beliefs andthey were willing to be asked about those beliefs. Australia is ranked135 out of 147 countries in terms of religiosity (twelfth from the bottom),according to the World Gallup Poll conducted in 2006–2008.Also, in a small German study of 30 medical patients, researchersasked the question: “How should physicians deal with spiritual questions?”Responses were 13 percent “not at all,” 70 percent “talk aboutit,” 3 percent “refer to chaplain,” and 17 percent “other/do not know.”When asked whether they wanted to continue the dialogue aboutspirituality, 60 percent (n = 18) wanted to continue the interview withthe physician. In another German study of 580 patients with chronicpain, 37 percent said that it was important to talk with the medicaldoctor about their spiritual needs. Germany was ranked 120 out of147 countries in religiosity based on the Gallup poll above (twenty-seventhfrom the bottom). Thus, patients in the U.S. are not the onlyones who wish to discuss these issues with their medical providers.Even in countries whose populations are not particularly religious,many patients feel similarly.</p><p>Feeling that health care providers should know about theirspiritual concerns is especially common among patients with severeillness such as advanced cancer. In a multisite study, Harvard investigatorssurveyed 230 patients with advanced cancer. Most (88 percent)considered religion to be at least somewhat important. However, 47percent reported that their spiritual needs were minimally or not atall supported by their religious community. Furthermore, 72 percentsaid their spiritual needs were minimally or not at all supported bythe medical system (doctors, nurses, or chaplains). However, whenthe medical team or religious community did provide spiritual supportto patients, this was associated with significantly higher qualityof life (p = 0.0003). Another study by this research group involved 69patients with advanced cancer receiving palliative radiation therapyrecruited from four hospital sites in Boston. Most of these patientssaid that attention to their spiritual concerns should be an importantpart of cancer care by physicians (87 percent) and nurses (85 percent).Investigators also found that patient spirituality and religiouscoping were associated with overall better quality of life (p < 0.001and p < 0.01, respectively), independent of other predictors of qualityof life. Almost all of these patients (86 percent) voiced one ormore spiritual concerns, with a median of four spiritual concerns perpatient. Spiritual concerns/struggles were associated with worsepsychological health and poorer adaptation to illness.</p><p>Not only are spiritual needs important to patients, but 66 to 81 percentof general medical patients say they would have greater trust in theirphysician if he or she asked about their religious/spiritual beliefs. Furthermore,research has shown a significant improvement in the doctor-patientrelationship when a physician has done so. Religious patientsare not only more likely to want their doctor to ask about religious/spiritual beliefs, but also are more likely to receive regular medical care,undergo regular disease screening, and comply with prescribed treatments.They are also more likely to leave medical decisions up to theirdoctors (vs. making their own decisions about their care). Even amongpsychiatric patients with schizophrenia, research shows that thoserandomly assigned to receive a spiritual assessment by their physicianwere significantly more likely to attend future appointments. Thus,while addressing religious patients’ spiritual needs may take some additionaltime, it is worth it in the long run.</p><p>Besides wanting their physicians to know about their religiousbeliefs and spiritual concerns, some patients even want to pray withtheir health care providers. Some physicians are quite open to this andbelieve it is beneficial (see address given by president Dr. Donn Schroderof the Midwest Surgical Association). The percentage of patientswho would like their physician to pray with them ranges widely from19 percent to 78 percent, depending on the setting, severity of illness,and the religiousness of the patient. For example, in a Yale study ofHIV/AIDS patients, 46 percent indicated that it would be helpful topray with their physicians. In general, patients who are sicker andmore religious are more likely to want to pray with their HPs. However,only 10–20 percent of patients report that a physician <i>ever</i> askedthem about spiritual issues or prayed with them.</p><p>Although many patients want HPs to know about their religiousor spiritual beliefs, many patients (from one-quarter to one-half)don’t want to discuss these matters with physicians. When a sampleof healthy people (nonpatients) were surveyed, over two-thirds saidthey would want to discuss spiritual concerns with someone, particularlyif they were seriously ill. Most, however, wanted to discussspiritual concerns with their minister, not a physician. Unfortunately,ministers may not be available in medical settings when patientsneed to discuss these issues. Also, “discussing” religious beliefs withphysicians is not the same as a health care provider simply inquiringabout a patient’s religious or spiritual beliefs, which I suspect patientswould be more receptive to. Of course, most patients do not want HPsinquiring or discussing spiritual matters until after they have competentlydealt with medical issues.</p><br><p><b>MANY PATIENTS DEPEND ON RELIGION TO COPE</b></p><p>Not only is religion vital to the personal identity of many people, it isoften used to cope with loss, fear, medical problems, and other stressfullife circumstances. Consider a report published in the <i>New EnglandJournal of Medicine</i>, which involved a random survey of the U.S. populationone week after the terrorist attacks on September 11, 2001.Investigators found that 90 percent of Americans turned to religionin order to cope with the stress of these events. Likewise, in certainparts of the United States, over 90 percent of medical patients indicatethat religious beliefs and practices are ways they cope with and makesense of physical illness, and over 40 percent say that religion is <i>themost important</i> factor that keeps them going. Research shows that religiouscoping is widespread among patients with heart disease, stroke,Parkinson’s disease, spinal cord injury, emphysema, kidney disease,cystic fibrosis, diabetes, cancer, gynecologic cancer, HIV/AIDS, arthritis,chronic pain, terminal illness, schizophrenia, and in nursing homepatients and dementia caregivers—i.e., almost every type of medicalcondition, psychiatric disorder, or stressful situation studied.</p><p>What exactly is “religious coping”? Religious coping is the use ofreligious beliefs or practices to reduce the emotional distress causedby loss or change. Patients may ask God to heal their health problemsor to give them the strength to cope with them. They may “turn over”their problems to God, trusting God to handle them so that they don’thave to ruminate or worry about those problems. They may believethat God has a purpose in allowing them to experience pain or suffering,which gives their suffering meaning and makes it more bearable.A host of religious beliefs and behaviors like these may be mobilizedto reduce anxiety, increase hope, or convey a sense of control. Withregard to religious practices that facilitate coping, patients will pray,meditate, read religious scriptures, worship at religious services, go ona pilgrimage, perform religious rituals (light a candle, receive the sacraments,or be anointed with oil, for example), or rely on support fromclergy or members of their church, synagogue, mosque, or temple.Religious beliefs and practices are often used in these ways to <i>regulateemotion</i> during times of illness, change, and circumstances that areout of their personal control.
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