Pastoral Care Services

Physicians

RESOURCES ON SPIRITUALITY AND HEALTH

Source: SPIRITUALITY IN PATIENT CARE, Harold G. Koenig, M.D.

www.templetonpress.org

TAKING A SPIRITUAL HISTORY

Kuhn's Spiritual Inventory. Clifford Kuhn, associate professor and associate chairman of the University of Louisville’s department of psychiatry, provides one of the earliest spiritual inventories that taps into seven areas: meaning or purpose, belief and faith, love, forgiveness, prayer, meditation, and worship. Each area is explored with five questions, resulting in a total of thirty-five questions. This instrument probably takes about thirty minutes to administer, and is therefore way too long. However, if one considers only the following five belief and faith questions, it becomes more manageable.

	What things do you believe in or have faith in?
	Has this illness influenced your faith?
	How do you exercise faith in your life?
	How has your faith influenced your behavior during this illness?
	What role does your faith play in regaining your health?

This instrument is relatively brief, elicits considerable content with regard to religious beliefs that influence health, is patient-centered, and has a credible source (published in a peer-reviewed professional journal). It is a bit tedious, however, to remember.

Matthews' Spiritual History. Dale Matthews, an associate professor of medicine at Georgetown University, suggests that physicians ask patients three fundamental questions as part of their initial (intake) evaluation.

	Is religion or spirituality important to you?
	Do your religious or spiritual beliefs influence the way you look at your medical problems and the way you think about your health?
	Would you like me to address your religious or spiritual beliefs and practices with you?

This instrument is brief, easy to remember (I I I = Importance, Influence, Interaction), and elicits good content. The source is a popular book and therefore not as reliable as if published in a medical journal and the final question is a bit personal, suggesting a more active physician role. Matthews has further shortened this history to just two questions in a more recent peer-reviewed journal publication: "Is your religion (or faith) helpful to you in handling your illness?" and "What can I do to support our faith or religious commitment?"

FICA Spiritual Assessment Tool. Christina Puchalski, assistant professor of medicine at George Washington University Medical Center and director of the George Washington Institute for Spirituality and Health, has developed the following five questions that are easily remembered using the income tax mnemonic FICA:

	F – faith: What is your faith tradition?
	I – important: How important is your faith to you?
	C – church: What is your church or community of faith?
	A – apply: How do your religious and spiritual beliefs apply health?
	A - address: How might we address your spiritual needs?

This instrument is also brief, has reasonably good content, it patient-centered, has been published in a peer-reviewed medical journal, and is easy to remember, meeting all five qualities needed in an assessment tool.

Maugans’ SPIRITual History. Todd Maugans, in the Department of Family Medicine at the University of Virginia, Charlottesville, has developed a spiritual history that covers six areas (SPIRIT). The six areas are listed below, with illustrative questions suggested by Maugans.

	Spiritual belief system What is your formal religious affiliations? Name or describe your spiritual belief system.
	Personal spirituality Describe the beliefs and practices of your spiritual belief system that you personally accept. Describe the beliefs and practices you do not accept. Do you accept or believe . . . [specific tenet or practice]? What does your spirituality/religion mean to you? What is the importance of your spirituality/religion in your daily life?
	Integration within a spiritual community Do you belong to any spiritual or religious group or community? What is your position or role? What importance does this group have to you? Is it a source of support? In what ways? Does or could this group provide help in dealing with health issues?
	Ritualized practices and restrictions Are there specific practices that you carry out as part of your religion/spirituality (e.g., prayer or meditation)? Are there certain lifestyle activities or practices that your religion/spirituality encourages or forbids?/ Do you comply? What significance to these practices and restrictions have to you? Are there specific elements of medical care that you forbid on the basis of religious/spiritual grounds?
	Implications for medical care What aspects of your religion/spirituality would you like me to keep in mind as I care for you? Would you like to discuss religious or spiritual implications of health care? What knowledge or understanding would strengthen our relationship as physician and patient? Are there any barriers to our relationship based on religious or spiritual issues?
	Terminal events planning As we plan for your care near the end of life, how does your faith impact your decisions?

Are there particular aspects of care that you wish to forego or have withheld because of your faith? This spiritual inventory is perhaps one of the most comprehensive, hitting on virtually all important content areas. The questions illustrate the ways that different parts of the spiritual history can be explored. Of course, such an extensive exploration is likely to take considerable time, making it necessary to adapt the instrument to the individual patient. Different clinical situations might prompt the administration of part of the history at one time and the remaining parts at other times. The mnemonic SPIRIT, however, makes the six basic areas relatively easy to remember. The instrument has been published in a peer-reviewed medical journal.

HOPE Questionnaire. Gowri Anandarajah and Ellen Hight, assistant professors in the Department of Family Medicine at Brown University, suggest that a spiritual assessment cover four areas that can be remembered with the mnemonic HOPE. Below is a description of each of these areas and a couple of sample questions for each category.

	H - Sources of hope, meaning, comfort, strength, peace, love, and connection. What are your sources of hope, strength, comfort, and peace? What do you hold onto during difficult times? What sustains you and keeps you going?
	O - Organized religion Are you part of a religious or spiritual community? Does it help you? How? What aspects of your religion are helpful and not so helpful to you?
	P - Personal spirituality and practices Do you have any personal spiritual beliefs that are independent of organized religion? What aspects of your spirituality or spiritual practices do you find most helpful to you personally?
	E - Effects on medical care and end-of-life issues Has being sick affected your ability to do things that usually help you spiritually? As a doctor, is there anything that I can do to help you access the resources that usually help you? Are there any specific practices or restrictions I should know about in providing your medical care?

This assessment tool is relatively brief, easy to remember with the mnemonic, covers lots of excellent content areas, is patient-centered (and applicable to patients with different types of spirituality), and has been published in a peer-reviewed journal, again meeting all five criteria.

ACP Spiritual History. A consensus panel of the American College of Physicians and American Society of Internal Medicine has suggested that the following four simple questions be asked of patients with serious medical illness.

	Is faith (religion, spirituality) important to you in this illness?
	Has faith been important to you at other times in your life?
	Do you have someone to talk to about religious matters?
	Would you like to explore religious matters with someone?

This is one of the strongest of all the spiritual histories, largely because of the credibility of the medical body and journal that are its source. The instrument is brief and easy to remember, although no mnemonic exists to aid memory. It is also patient-centered and does not get too personal by having the physician offer to address the patient’s spiritual needs. This tool was published in the Annals of Internal Medicine in an article authored by a trio of academic giants (Bernard Lo, a medical ethicist at the University of California at San Francisco; Timothy Quill, a highly respected and widely known physician-author; and James Tulsky, a prominent medical internist and ethicist at Duke). A major weakness, however, is that the questions fail to gather information in several key content areas (identifying spiritual needs, connections with spiritual community, and beliefs affecting medical decision making).

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