2 nd Annual Cultural Competence Seminar

1. 2nd Annual Cultural Competence Seminar Paul F. Foster School of Medicine Texas Tech University Health Sciences Center April 12, 2013 Religious Diversity, Spirituality & Implications for Clinical Practice Chaplain John W. Ehman University of Pennsylvania Medical Center – Penn Presbyterian Philadelphia, PA 4/1/13

2. Plan for the Presentation: 1) Review the significance of spirituality/religion for clinical practice in a diverse hospital setting 2) Provide a practical strategy for clinicians' support of diverse patients who engage their religion or spirituality in relation to their health and treatment 3) Suggest ways to manage potentially problematic aspects of interaction around spirituality/religion across lines of diversity

3. The challenges of diverse religious patients: A Catholic patient is distraught as she goes to surgery after her request for the Eucharist has been denied by both her physician and priest because she is NPO.

4. The challenges of diverse religious patients: A Catholic patient is distraught as she goes to surgery after her request for the Eucharist has been denied by both her physician and priest because she is NPO. A Muslim patient is found on the floor of his room, unable to get up. He had gotten out of bed in order to kneel and pray.

5. The challenges of diverse religious patients: A Catholic patient is distraught as she goes to surgery after her request for the Eucharist has been denied by both her physician and priest because she is NPO. A Muslim patient is found on the floor of his room, unable to get up. He had gotten out of bed in order to kneel and pray. A Buddhist patient refuses pain medication, because he is worried that it will cloud his mindful awareness.

6. The challenges of diverse religious patients: A Catholic patient is distraught as she goes to surgery after her request for the Eucharist has been denied by both her physician and priest because she is NPO. A Muslim patient is found on the floor of his room, unable to get up. He had gotten out of bed in order to kneel and pray. A Buddhist patient refuses pain medication, because he is worried that it will cloud his mindful awareness. A Jewish patient whose discharge paperwork was delayed until after sunset on Friday now refuses to leave the hospital because of religious restrictions on travel over the Sabbath.

7. The challenges of diverse religious patients: A Catholic patient is distraught as she goes to surgery after her request for the Eucharist has been denied by both her physician and priest because she is NPO. A Muslim patient is found on the floor of his room, unable to get up. He had gotten out of bed in order to kneel and pray. A Buddhist patient refuses pain medication, because he is worried that it will cloud his mindful awareness. A Jewish patient whose discharge paperwork was delayed until after sunset on Friday now refuses to leave the hospital because of religious restrictions on travel over the Sabbath. A very spiritual patient with Cystic Fibrosis experiences a breathing crisis. Her nurse knows that the patient usually prays to control her anxiety and regulate her breathing, but the patient says, “I can’t pray anymore to a God who is so uncaring.”

8. Number of Medline-Indexed English Articles by Year, with Keywords: RELIGION and SPIRITUALITY [ Includes the variations: religious, religiosity, religiousness, and spiritual ] John Ehman, 2012

9. Number of Medline-Indexed English Articles by Year, with Keywords: RELIGION and SPIRITUALITY [ Includes the variations: religious, religiosity, religiousness, and spiritual ] John Ehman, 2012

10. Number of Medline-Indexed English Articles by Year, with Keywords SPIRITUAL or SPIRITUALITY John Ehman, 6/30/09

11. Number of Medline-Indexed English Articles by Year, with Keywords SPIRITUAL or SPIRITUALITY John Ehman, 6/30/09

12. Among the factors in the mid-1990saffecting the study of spirituality/religion & health: • Greater attention paid to religious values, beliefs, and practices as key aspects of patient diversity (e.g., new emphasis by the Joint Commission) • Growing sense among health care providers and researchers of religion’s role in health-pertinent behaviors and health care decision-making -- important for “knowing your patient” • Research begins accumulating significant data that patients’ spirituality/religiosity may be important to medical outcomes and thus to the process of “healing your patient”

13. Two things to keep in mind about the modern field of Spirituality & Health: 1) It is still nascent in the current form 2) It has somewhat fluid terminology

14. In the health care literature, religion is associated with institutional systems of beliefs and practices, whereas spirituality is associated with personal experiences and an individual quest for meaning. Spirituality is generally seen as a broad concept, going beyond the “limits” of religion.

15. The Two Most Common Views of the Relationship of Spirituality to Religion in the Current Health Care Literature Spirituality Spirituality Religion Religion

16. Terminology pairings in Medline articles, 1998-2011

17. ...And, how terms may be defined and used by researchers or providers, in academic articles or in clinical documentation systems, may not be in sync with how the public or an individual patient may relate to those terms.

18. Americans and Religious Affiliation A 2012 Pew Research Center survey found that one-fifth of the U.S. public – and a third of adults under 30 years old – now describe themselves as “religiously unaffiliated.” This is partly due to an increasing trend to drop all sense of connection to a specific religious tradition when there is not an active social involvement in a congregation. Moreover, 18% of American adults describe themselves now as “spiritual but not religious.” Pew Research Center’s Forum on Religion & Public Life, "'Nones' on the Rise…,” report issued October 9, 2012

19. I. What is the significance of spirituality/religion and of spiritual/religious diversity for clinical practice?

20. Polls re: Spirituality/Religion in the US • 90-96% of adults in the US say they “believe in God” • over 40% say they attend religious services regularly, usually at least once a week • 50-75% say religion is “very important” in their lives • 90% say they pray, and most (54-75%) say they pray at least once a day • over 80% say that “God answers prayers” • 79-84% say they believe in “miracles” and that “God answers prayers for healing someone with an incurable illness” --These percentages are summary characterizations of numerous national surveys showing fairly consistent results across time

21. Recent health care literature largely addresses spirituality/religion as… … a ground for “religious” social support … a value basis for personal meaning-making (and therefore understanding illness and coping with crises) and decision-making … a context for behavior that can influence the way the body works (e.g., meditation that can affect physiological reactions to stress)

22. Research increasingly indicates that health-positive effects of spirituality/religion far outweigh concerns about health-negative effects. For example: •fewer dangerous behaviors (e.g., less substance abuse, unsafe sex, or neglect of health screenings) • less suicide and generally greater aversion to suicide • less depression and faster recovery from depression • greater sense of meaning/purpose in life, hopefulness --See: Koenig, H.G, et al., Handbook of Religion and Health, 2001/2011; and Koenig, H.G., Testimony to the US House of Representatives Subcommittee on Research and Science Education, 9/18/08

23. • lower rates of coronary artery disease • lower cardiovascular reactivity • greater heart rate variability • lower blood pressure and generally less hypertension • tendency for better outcomes after cardiac surgery • better endocrine function • better immune function • lower cancer rate and better outcomes • lower mortality and longer survival generally --ibid.

24. Theoretical Model of How Religion Affects Physical Health --adapted from Koenig, et al., Hand- book ofReligion and Health, 2001 Religion also affects Childhood Training, Adult Decisions, and Values & Character; which then in turn affect mental health, social support, and health behaviors. Stress Hormones Infection Mental Health Cancer Immune System R E L I G I O N Heart Disease Hyper- tension Social Support Autonomic Nervous System Stroke Stomach & Bowel Disease Detection and Treatment Compliance Health Behaviors Liver & Lung High Risk Behaviors (smoking, drugs) Accidents & STDs

25. A Caution about Expectations of “Dramatic” Effects of Spirituality/Religion on Medical Outcomes We should be prepared to appreciate how empirical findings may indicate significant -- but not “dramatic” or “sensational” -- effects of spirituality/religion on medical outcomes.

26. Spirituality, the Brain, and Cell Life Studies using MRI indicate not only that certain kinds of religious/spiritual meditative practices can influence blood flow and activity in the brain but can even have a lasting effect on brain function and perhaps structure. --Newberg, A. B., et al., "Cerebral blood flow differences between long-term meditators and non-meditators,“ Consciousness & Cognition 19, no. 4 (Dec 2010): 899-905. Some forms of mindfulness meditation, practiced over time, appear to control cognitive stress reactions like threat appraisal and rumination to such a degree as to protect against the cellular process of the deterioration of telomeres, affecting cell life. --See: Epel, E., et al., "Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres," Annals of the New York Academy of Sciences 1172 (Aug 2009): 34-53.

27. Frontal Lobe Activity of Buddhists Meditating --see Newberg, et al., "The measurement of regional cerebral blood flow…,” Psychiatry Research: Neuroimaging 106, no, 2 (April 10, 2001): 113-122.

28. Parietal Lobe Activity of Buddhists Meditating --see Newberg, et al., "The measurement of regional cerebral blood flow…,” Psychiatry Research: Neuroimaging 106, no, 2 (April 10, 2001): 113-122.

29. Non-Meditators and Long-Term Meditators --Newberg, A. B., et al., "Cerebral blood flow differences between long-term meditators and non-meditators,“ Consciousness & Cognition 19, no. 4 (Dec 2010): 899-905.

30. Patients’ Spiritual Beliefs, Health Care Decision-Making, and Physician Inquiry • A University of Pennsylvania study (n=177) indicated that nearly half of patients may have spiritual/religious beliefs that would influence their health care decision-making if they became gravely ill. • Two-thirds of patients would welcome a carefully worded exploratory question about spiritual or religious beliefs. (E.g., “Do you have spiritual or religious beliefs that may affect your medical decisions?”) • Two-thirds of patients think that such an inquiry by a physician would make them trust the physician more. -- Ehman, J.W., et al., “Do patients want physicians to inquire…,” Archives of Internal Medicine 159, no. 15 (1999): 1803-1806

31. Spiritual/Religious Support & Medical Costs • A multisite study by a Harvard group found that medical costs for cancer patients in the last week of life (n=339) were higher for those who reported not receiving sufficient spiritual/religious support from the care team as a whole. • On average, care cost $2441 more than for those who received spiritual/religious support from the team, but $4060 for “high religious coping” patients and $4206 among racial/ethnic minorities • Costs centered around ICU care and hospice care in the last week of life. -- Balboni, T., et al., “Support of cancer patients’ spiritual needs and associations with medical care costs at the end of life,” Cancer 117, no. 23 (Dec 1, 2011): 5383-5391

32. The picture emerging from spirituality/religion & health research is promising, but application to the clinical setting remains complex. Causal relationships/mechanisms are not well understood. The nascency of the field means that few findings have been tested across diverse populations. Application of the findings relates not only to questions of health but to patients’ rights regarding spirituality/religion. The role or function of spirituality/religion in the life of any patient is notoriously hard to predict.

33. Spirituality  Grave Illness & Treatment ● Congregational connections may bring social support and practical assistance ● Patients’ own clergy may bring “authoritative” support and guidance for coping ● Scriptures may help patients find focus and direction amid crisis ● Religious rituals may bring a sense of assurance and “deepening” ● Prayer/meditation may bring peace and encouragement

34. Spirituality  Grave Illness & Treatment ● Congregational connections may bring social support and practical assistance (or constrict the patient by the imposition of the group’s norms) ● Patients’ own clergy may bring “authoritative” support and guidance for coping (or may give “simple” answers, poor guidance, or even shaming chastisement) ● Scriptures may help patients find focus and direction amid crisis (or, as complex documents, scriptures may be confusing or disturbing) ● Religious rituals may bring a sense of assurance and “deepening” (but are often disrupted by illness and treatment, causing stress) ● Prayer/meditation may bring peace and encouragement (but some patients find prayer/meditation practice difficult during illness)

35. → Spirituality → Illness & Treatment

36. Grave Illness & Treatment  Spirituality ● Patients may experience “stress-related growth” that is spiritual in nature or is spiritually enriching ● Questions of “what really matters” can open some gravely ill patients to affirm who they are “at the core,” spiritually ● Patients may find in their self-experience of resilience an affirmation of their spirituality ● The experience of loss of control can shift a patient’s sense of locus of control from himself/herself to a “higher power”

37. Grave Illness & Treatment  Spirituality ● Patients may experience “stress-related growth” that is spiritual in nature or is spiritually enriching (or they may feel diminished, cut off, and beaten by illness/treatment and spiritually withered) ● Questions of “what really matters” can open some gravely ill patients to affirm who they are “at the core,” spiritually (or can lead them to question long-held spiritual/religious beliefs) ● Patients may find in their self-experience of resilience an affirmation of their spirituality (or may see in their self-perceived weaknesses, such as feelings of fearfulness, a spiritual “failure”) ● The experience of loss of control can shift a patient’s sense of locus of control from himself/herself to a “higher power” (or can create a sense of sheer vulnerability and “abandonment by God”)

38. II. What are practical strategies to recognize the potential importance of spirituality/religion in the clinical setting while working with diverse patients?

39. -- John Ehman

40. Need for a strategy for health care providers to support patients spiritually... …that can work across lines of religious diversity …that takes very little time in the clinical encounter, while potentially bringing clinically significant benefits …that does not necessitate a large knowledge base regarding spiritual/religious traditions and issues …that does not blur professional roles/boundaries, and especially does not ask health care providers to act as spiritual counselors

41. A Pastoral Care Approach …with Implications Chaplains often work across lines of religious diversity by focusing on the experiential and emotional issues or dynamics that affect the patient’s sense of meaning, quest, and relationship. Chaplains try to follow the lead of the patient, to help him/her feel heard, connected, and safe to venture wherever he/she feels distress or otherwise has need. The chaplain expresses an openness to spiritual concerns and keeps in mind that identified needs which are not explicitly religious/spiritual may still be spiritually relevant for the patient. Also, non-religious or non-theistic patients may have “spiritual” needs. This approach may have implications for the general spiritual support of patients by physicians, nurses, and others.

42. Health care providers can support diverse patients spiritually by: ● acknowledging patients’ statements of meaning, quest, and relationship ● affirming the emotional nature of our humanity ● looking/listening for indications of possible spiritual distress ● expressing interest in the patient’s spirituality per se: particular spiritual resources & issues pertinent to the provider-patient relationship

43. MEDS

44. Supporting Patients Spiritually with MEDS M = acknowledge statements of meaning/quest/relationship E= affirm the emotional nature of our humanity D = look/listen for indications of possible spiritual distress S = express an interest in the patient’s spiritualityper se: particular resources and issues pertinent to the provider-patient relationship; and consider options for explicit inquiry

45. MEDS M = acknowledge statements of meaning/quest/relationship E = affirm the emotional nature of our humanity D = look/listen for indications of possible spiritual distress S = express an interest in the patient’s spirituality per se: particular resources and issues pertinent to the provider-patient relationship; and consider options for explicit inquiry

46. Acknowledging Patients’ Statements of Meaning, Quest, and Relationship Patients may make overtly religious/spiritual statements of meaning, quest, and relationship, but often the expression is more subtle and indirect. E.g.: “God has a plan,” “I know God’s with me,” or “God didn’t bring me this far to let me down now”; but also, “I'm sure learning a lot,” “Something like this changes your priorities,” or “I'm so thankful for my family.” Acknowledgement can be made as simply as reflecting or paraphrasing the patient's statement or by saying, for instance: “I appreciate your perspective,” “You're finding your way ahead through this,” “You're in touch with what's important,” or “This is a journey.” --Such statements generally open up communication

47. Responding to a patient is these ways might seem a matter of general courtesy and sensitivity, but at the right moment can be experienced very much as a spiritual support.

48. MEDS M = acknowledge statements of meaning/quest/relationship E= affirm the emotional nature of our humanity D = look/listen for indications of possible spiritual distress S = express an interest in the patient’s spirituality per se: particular resources and issues pertinent to the provider-patient relationship; and consider options for explicit inquiry

49. Emotion and Spirituality Emotion may be said to be the “heart” of spirituality, and an affirmation of emotion can help patients express spiritual need. E.g.: patients who are ashamed of their anxiousness or tears may be blocked from expressing or exploring spiritual issues, or emotional lability may be experienced as a spiritual problem. Affirmation of emotion can occur through acknowledgement and normalization. For instance: ● “Your tears show how deeply you feel, how important things are to you.” ● “There's so much about what’s happening that’s scary.” ● “Illness and treatment can be such an emotional rollercoaster.” ● “Your spirit feels heavy. I want to affirm how well you are managing in all of this.” --Listen for spiritual content in patients’ responses.

50. MEDS M = acknowledge statements of meaning/quest/relationship E = affirm the emotional nature of our humanity D = look/listen for indications of possible spiritual distress S = express an interest in the patient’s spirituality per se: particular resources and issues pertinent to the provider-patient relationship; and consider options for explicit inquiry