What’s Faith Got to do with it? Spirituality and the Art of Medicine

1. What’s Faith Got to do with it?Spirituality and the Art of Medicine Dr. Julian Hsu Dr. Calvin Wilson

4. Objectives • By the conclusion of this discussion, participants will be able to: • Understand the significance of the spiritual dimension in health and illness • Define the difference between spirituality and religion • Describe some of the studies correlating spiritual belief and specific health issues • Use a simple screening tool to explore a patient’s spiritual beliefs related to health

6. Gallup Poll 2008

7. Gallup Poll 2008

8. Gallup Poll 2008

10. But…spirituality is increasing

11. Definitions: Spirituality and Religion • Spirituality • Cognitive, experiential, behavioral • Cognitive • Internalized search for meaning, purpose truth – beliefs and values by which an individual lives • Experiential and emotional • Involves feelings of hope, love, connection, inner peace, comfort and support. • Behavioral • The external manifestation of individual spiritual beliefs and inner spiritual state

12. Definitions: Spirituality and Religion • Religion • Typically defined as the external practices of a person • Attendance at public religious services (church, mosque, synagogue, etc) • Prayer • Fasting • Others • More easily measured • Many research studies on health and religion use this type of marker

13. Importance of Spirituality in Health • Religious beliefs influence medical decisions, especially when patients are seriously ill • Religious beliefs/activities are related to improved health & quality of life • Many patients would like physicians to consider spiritual issues in their care • Spiritual aspects of health and illness are openly discussed in most parts of the world (except the Western world) • (Case Presentation)

14. Physicians and Patient’s Religious Commitment • Most past studies show that patients are more religious than doctors • They attend religious meetings more often than doctors • They pray more than doctors • They engage in religious activities and functions more than doctors • They are more interested in including spiritual elements in their health care than are doctors • They are more interested in praying for their health with their doctor than doctors are

15. Barriers for Physicians • Lack of knowledge of relationship between spirituality and health • Lack of training: how & when to address spiritual issues • Perceived lack of time • Personal discomfort with spiritual issues • Lack of clarity of one’s own spiritual/religious beliefs • Too personal • Too soft – un-scientific • Fear of perception of proselytizing or imposing religious views on patients

16. Cultural Sensitivity and Spiritual Sensitivity • Cultural sensitivity includes spiritual sensitivity • True cultural sensitivity requires knowledge of and incorporation of a patient’s cultural beliefs that affect health • All cultures have a spiritual component, and in some cases this forms a major determinant of their attitudes toward health and illness • Spiritual and religious beliefs should be included in the understanding and incorporation of the patient’s cultural beliefs • Religious/Spiritual beliefs are considered an ethical and cultural issue

17. AAFP Curriculum Guidelines for Family Medicine Residents in Medical Ethics • Competencies • At the completion of residency training, a family medicine resident should provide care that is sensitive to the belief systems of the patient and family • Attitudes • An appreciation for the value and dignity of human life • An understanding of cultural, social and religious customs and beliefs that may differ from his or her own • An understanding of individual, cultural, institutional and societal biases that may affect ethical decision-making • A self-awareness regarding personal ethical strengths and vulnerabilities as they affect one’s own professional practice.

18. AAFP Curriculum Guidelines for Family Medicine Residents in Medical Ethics • Knowledge • In the appropriate setting, the resident should demonstrate the ability to apply knowledge of: • Belief systems about right and wrong, meaning and purpose, and religious and spiritual values and biases, and how they affect decision-making regarding: • The physician and other care providers • The patient • The family • Health care systems and society at large

19. AAFP Curriculum Guidelines in Culturally Sensitive Care Attitudes • Awareness of the impact of socio-cultural factors • Acceptance of the physician's responsibility to understand the cultural dimensions of health and illness • Appreciation of the heterogeneity within and across cultural groups • Recognition of their own personal biases and reactions, and how one's personal cultural values, assumptions, and beliefs influence clinical care • Expressing respect and tolerance for cultural and social differences

20. AAFP Curriculum Guidelines in Culturally Sensitive Care Knowledge • Sociocultural issues relating to health care • Multiculturalism in the United States, including vulnerable or "at-risk" groups • Cultural perspectives on medicine and public health • Cultural assumptions and their influence on the US health care system • The ethnosensitive (cultural) epidemiology of health and illness

21. AAFP Curriculum Guidelines in Culturally Sensitive Care Skills • Recognizing and appropriately responding to verbal and nonverbal communication • Performing an H & P and prescribing in a culturally sensitive fashion • Using the biopsychosocial model in all health interactions • Appropriate use of family members, community gatekeepers, translators, and other community resources • Working with alternative/complementary medicine practitioners when professionally, ethically, and legally appropriate • Identifying how one's cultural values, assumptions, and beliefs affect patient care and clinical decision making

22. Ethical Boundaries • Spiritual and religious beliefs are intensely emotional & deeply personal, more so than even sexual issues • Yet, spiritual and religious issues influence both health and healing • Well within medical mandate: • Inquiry into general and health-related aspects of the patient’s spiritual belief • Incorporation of a faith community that could support patient • Incorporation of patient’s spiritual beliefs into healing process.

23. Ethical Boundaries • NOT within the medical mandate: • Proselytizing (trying to convince patient to convert to your religion or faith) • Discussing spiritual issues without patient’s express consent and collaboration • Spiritual interventions (ie, praying with patient) apart from patient’s specific request and collaboration

24. Research • Before 2000 over 1200 studies looked at the relationship between health and religious practice • The general and strong trend was that there is a positive correlation between a person’s religiousness and better health • Since 2000 many new studies have been conducted that confirm these findings • Some criticism of earlier studies for being cross-sectional rather than being prospective or randomized controlled trials • However, many prospective cohort studies and randomized trials since then support findings from cross-sectional studies

25. Google Review Spirituality + Health = 30,700,000 hits!!

26. Cochrane Review • Spirituality + Health = 1 hit • Coruh B, Ayele H, Pugh M, Mulligan T. Does religious activity improve health outcomes: a critical review of the recent literature. Explore: Journal of Science and Healing.2005;1(3):186-191

27. Randomized Controlled Trials One double-blind RCT (219 women undergoing in vitro fertilisation) reported that women allocated to distant IP had significantly higher pregnancy rates (50% versus 26%, p=0.0013) and implantation rates (16% versus 8%, p=0.0005) than non IP women.One RCT (approximately 4,000 adults with bloodstream infections) reported that retrospective distant IP was associated with a significant decrease in hospital stay (p=0.01) and duration of fever (p=0.04); the reviewers also reported that there was no difference in the median duration of fever.One double-blind RCT (799 patients discharged from a coronary care unit) reported no significant differences between distant IP and no IP in death, revascularisation, emergency department visits or cardiac arrest. One RCT (150 patients undergoing percutaneous coronary intervention) reported that noetic therapy plus standard treatment was associated with a statistically non significant reduction in adverse periprocedural outcomes. The only deaths occurred in patients allocated to noetic therapy (9.2% over 6 months).One RCT (95 adults with end-stage renal disease) evaluated expectation, IP, nonreligious positive visualisation and no intervention in a 2x3 factorial trial. It reported no significant difference in medical or psychological outcomes between IP and positive visualization, but found that patients who expected to receive IP reported significantly improved well-being (p<0.02).

28. Clinical Trials Four studies described as clinical trials were included. These examined disease activity in rheumatoid arthritis patients, immunological indicators in metastatic breast cancer patients, anxiety in students, and health and social outcomes in healthy individuals. All reported positive effects of religious activity.

29. Faith-Based Partnerships • Six studies described as faith-based partnerships were included. These assessed fruit and vegetable consumption, cardiovascular risk factors and mammography uptake. All reported positive effects of the (often multi-component) interventions • Author’s conclusions - Religious activity may improve health outcomes.

30. Religious Activity and Death • Strawbridge and colleagues: 28 year prospective assessment of more than 5000 adults • Weekly attendance of religious services decreased risk of dying during follow up by 36%, 24% when adjusted for social connections • The effect in women is as great as quitting smoking cigarettes • Frequent attendance was predictive of better health behaviors, improved mental health, increased social connection • Findings replicated in a 6 year study with sample of 4000 older adults • Similar effects and was strongest in women

31. Religious Activity and Death • Lutgendorf and colleagues: 557 older adults • Frequent attendance at religious services reduced risk of dying in a six year follow up study by 78% compared with nonattendance • Serum interleukin 6 (Il-6) levels less in frequent attenders than in non-attenders • Stimulates increased acute phase reactant production (C-reactive protein, ESR, fibrinogen, alpha-1 antitrypsin, ferritin and others) as part of generalized inflammatory processes

32. Religious Observance and Acute Coronary Syndrome in Predominantly Muslim Albania • A Population-based Case-Control Study in Tirana (Genc Burazeri, Artan Goda, AND Jeremy D. Kark, Ann Epidemiol 2008;18:937–945) • “Our study is consistent with a protective effect of higher levels of religious observance on coronary health in both Muslims and Christians in a largely nonobservant population.” • “The findings, particularly among Muslims, withstood adjustment for potential confounding and mediating variables, suggesting that some quality associated with religious observance (e.g., stress amelioration) may be protective in a transitional society.”

33. Health Associations with Religious Activity • Improved mental health • Decreased substance abuse • Better social health • Improved overall quality of life • Positive health behaviors • Disease screening • Decreased surgical complications • Diminished hypertension • Less coronary artery obstruction • Less carotid atherosclerosis • Improved longevity • Positive human traits (forgiveness, gratitude, meaning and purpose, optimism, hope, altruism)

34. How to Prepare to be Spiritually Sensitive • Introspection • What do you believe? • Understand your own philosophy regarding religion and prayer • Will help guide the professional response to a request for prayer or other religious activity • Understand personal spiritual beliefs, values and biases in order to remain patient-centered and nonjudgmental • Especially true when the beliefs of the patient differ from those of the physician. • Study • Develop a basic understanding of existing research on religion and health • Develop a basic knowledge of religious practices and belief systems present in your community and patient population.

35. How to Incorporate Spirituality/Faith/Religion into Medical Practice • Ask – take a spiritual history • “What role does religion/spirituality/faith have in your life?” • “Is your religion (faith) helpful to you in handling your illness?” • “What can I do to support your faith or religious commitment?” • Encourage patients to use the potentially health promoting religious resources from the patients’ own religious traditions • Refer patients to clergy or chaplain as an important resource and support

36. Why Take a Spiritual History? • In a recent multicenter survey of 476 physicians' attitudes toward spirituality in clinical practice, 85% said physicians should be aware of a patient's religious and spiritual beliefs.1 This finding was consistent with a 1992 survey of 594 family physicians, of whom 93% agreed or strongly agreed that physicians should consider patients' spiritual needs.2 • However, only 31% and 39% of physicians believed that physicians should ask patients about their spiritual beliefs in outpatient and inpatient settings, respectively • .1 It has been reported, however, that fewer than 10% of physicians actually do so,3 even among dying patients.4

37. When to include a spiritual history • New patient evaluation: as part of the social history section • Admission to the Hospital • Life crisis: • Life or limb threatening conditions • Great personal loss, grief, fear • Health Maintenance Visit • Discussing end of life issues, DNR orders • Before referral to chaplain or clergy

38. Spiritual History • “What role does spirituality or religion play in your life?” • FICA (Puchalski)  • F: Faith and beliefs  • I: Importance of spirituality in the patient's life • C: Spiritual community of support  • A: How does the patient wish spiritual issues to be addressed in his or her care? • SPIRIT (Maugans)  • S: Spiritual belief system  • P: Personal spirituality  • I: Integration with a spiritual community  • R: Ritualized practices and restrictions  • I: Implications for medical care  • T: Terminal events planning

39. Spiritual History • Sample questions to ask your patient • Is religion or spirituality important to you? • What is your faith tradition? • Do your religious or spiritual beliefs influence the way you look at your medical problems / health? • What role does your faith play in regaining your health? • How would you like me to address your religious or spiritual beliefs & practices with you? Matthew’s Spiritual History Modified

40. Case #2

41. Resources • Duke University’s Center for the Study of Religion / Spirituality & Health www.geri.duke.edu • Int’l Center for Integration of Health & Spirituality www.hihr.org • George Washington Institute for Spirituality & Health www.gwish.org/index.htm • John Templeton Foundation www.templeton.org • Mind-Body Medical Institute www.mbmi.org • Spirituality in Patient Care: Why, How, When, and WhatTaking a Spiritual History, Harold Koenig, M.D., Associate Prof. of Psychiatry & Medicine, Duke University Medical Center • Spirituality, Religion, and Clinical Care Sulmasy DP - Chest - 01-JUN-2009; 135(6): 1634-42