Critics Review - Spirituality in Patient Care

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September/October 2002

Spirituality in Patient Care is intended as a guide for physicians, medical students, nurses, and health practitioners. As emerging research demonstrates the effect of one's spiritual beliefs on a person's health, it's important to perform a spiritual profile on a patient in addition to physical and lifestyle assessments. This book is a valuable resource to anyone in the healthcare profession.

Journal of the National Medical Association
September 25, 2002

There is much I like in this book. Harold Koenig, MD, in a short and eminently readable style, outlines how important spirituality can be in treating the whole person. He gives clear definitions of religious coping, spiritual assessment, transference and counter-transference, and boundaries to care. Dr. Koenig has a deep respect for people's religiosity and a belief, buttressed by rigorous research studies, that religion is good for your health. Koenig also has a deep respect for chaplains, whom he considers "experts" in spirituality.

My disappointment with this book is that it appears to be based on the old physician-centered philosophy of care. The physician has the duty to take a spiritual history. He or she has the responsibility to identify "spiritual needs" and "orchestrate resources to meet those needs," including community clergy. Other caregivers are ancillary providers, to be called in as consultants whenever the physician has determined such to be appropriate and only after the physician has obtained "consent from the patient" to ask "a chaplain or pastoral counselor to see the patient."

Koenig has a great section on the history of medicine. He remembers that, before the mid-19th century, "many of the physicians...were monks or priests, addressing physical and spiritual needs hand in hand." He notes, "The profession of nursing came directly out of the church," and even psychiatry got its start in the United States as "moral treatment...based on the idea that insanity was a disruption of both mind and spirit." It appears that Koenig might advocate a return to the time when clergy and physicians were one and the same. Concerning the physician's "asking about the patient's religious beliefs," he writes:

"In fact, the physician's medical authority may even begin to take on an aspect of spiritual authority. The doctor has now become both physician and priest, capable of fully utilizing not only the power of medical therapies but also the power of the patient's belief and trust."

Koenig describes the doctor managing the patient's care even out into the community: "Patients and healthcare systems need to consider linking with religious communities through 'parish nurses' (or lay leaders) to more fully address the health needs of patients and the families that care for them."

A reader might ask, where is the multidisciplinary team? Where is the patient-centered care, shared decision-making, and a total plan of care fashioned by a variety of disciplines in constant communication with the patient and each other? Must the physician be the only one to inquire into the spiritual and social history of the patient? Koenig writes that "delegating the questions to others [the nurse, social worker, or chaplain] is not sufficient."

Koenig has a high regard for chaplains, writing that "chaplains are the true experts in this area [spirituality] and should be fully utilized whenever possible." He believes that, "for all but the most simple of spiritual needs that arise during such assessments, referral to chaplains and pastoral counselors should be considered." But it appears that chaplains, nurses, and social workers are ancillary services.

Yet, there is much in this book to admire. "Spiritual Assessments" are reviewed on pages 89 through 94. They vary from short "spiritual screens" to extensive spiritual histories. A reader might ask, what benefits might accrue from having the physician, nurse, or social worker ask a few spiritual screen questions, then having the chaplain ("the expert") do the full spiritual assessment? Such an approach appears to be the direction that the Joint Commission on Accreditation of Health Care Facilities (JCAHO) is heading in its Long Term Care Standards. Those standards mandate that a registered nurse coordinate the completion of the patient's assessment carried out by "qualified individuals" within the organization, including chaplain, social worker, nurse, physician (Care of the Patient PE1.1). One of the areas to be assessed, according to those standards (PE2.1.5.1), is the "resident's spiritual status and needs, including spiritual orientation and the dying individual's concerns related to hope, despair, guilt, or forgiveness." JCAHO's substance abuse protocol suggests a similar interdisciplinary approach and includes spiritual assessment as an important part of the rehabilitation program.

Dr. Koenig vacillates over whether physicians should pray with patients. He raises the issue, gives some guidelines, but allows a lot of room for discussion.

Dr. Koenig should be commended for writing a concise yet meaty book on spirituality in patient care. I hope it is widely read and discussed. Even the book's flaws can be useful in raising the issue of spirituality and encouraging physicians and other care providers to find ways to relate the patient's spirituality to the holistic plan of care.

August 2002

It is refreshing to read an excellent resource authored by a well-informed, well-read, committed, academician with ties to clinical medicine. Dr. Koenig's book is small enough to read in two sessions, and packed with enough information to whet the appetite of any clinician irrespective of spiritual persuasion.

I was excited to review this book because I have been involved with this subject for the past 15 years, both as a Pastor, and in my private practice of Medicine. I was curious to see how he would capsulate what I had been practicing into a book of 110 pages. To say the least, I was not disappointed.

Dr. Koenig's introduction is succinct wasting no time preparing the reader for the book's contents. I have only one warning; if you read the introduction you will purchase the book. The Introduction is so well written that the reader is not left straddling the fence.

The Book is divided into seven chapters, namely:

&bullWhy include spirituality?
&bullHow to include spirituality
&bullWhen to include spirituality
&bullWhat might result?
&bullBoundaries and barriers
&bullWhen religion is harmful
&bullResources on spirituality and health

From the outset it is important to understand that this author comes from a background rich in this subject. He has authored many clinical studies and authored several textbooks, two this year alone.

The first chapter necessarily asks "why include spirituality?" Dr. Koenig's answer is patient centered. He presents data supporting the positive health care outcomes of people as a result of their spirituality while supplying the necessary caution in one's approach. I agree with his statement; "religious beliefs and practices, then, are used to regulate emotion during times of illness, change, and circumstances that are out of patients' personal control." Dr. Koenig also gave a historical perspective in this chapter. He traced the development of health care institutions and professions relating to spirituality in medicine. As early as AD 370 a large hospital was set up in Turkey as a response to Matthew 25:36-40; the profession of nursing came from the Catholic church, first by the Daughters of Charity of St. Vincent de Paul, in 1617. A Lutheran Pastor set up a nursing school in France in 1830 and Florence Nightingale, after receiving a calling from God, sought and received training from the Daughters of Charity and the Protestant deaconesses for nursing training. She is credited with establishing the modern principles of nursing. Dr. Koenig continues by showing the progress made in Psychiatry as a result of recognizing the importance of spirituality in patient care. He concludes this chapter with both a summary statement and an introduction to his next chapter. "Addressing spiritual needs of patients is not new, either in the practice of medicine or in psychiatry. How one goes about doing that in this day and age is the subject of the next chapter."

Chapter two addresses the issue of information gathering. Dr. Koenig introduces several tools to assist the Physician. With each segment he discusses the importance of recognizing two issues, namely: the patient's sensitivity to the issue, and the physician's comfort zone. The tools serve as a method to carefully weave between the two, enabling the Physician to obtain the history necessary to improve the care of the patient. The Koenig, as well as all Physicians, recognize that patient's private lives are being invaded and perhaps limits are in order; however, certain patient's health outcomes are improved when the physician has knowledge of their spirituality. Dr. Koenig makes it clear that spiritual inventories must be individualized to patient condition and the depth of that inventory may vary from patient to patient.

Recognizing the truth of the last statement the next chapter offers several caveats that address the statement, when to include spirituality. This chapter offers some useful tools that will assist the physician in initiating a spiritual history. For the physician who wants to be sensitive to the patient's needs, without appearing "too religious," this chapter offers help. Dr. Koenig lists the various points in the patient encounter where a history can be obtained without appearing to be intrusive. Within the social history of a new patient encounter, upon hospital admission, during a health maintenance visit, within a hospice setting, are but a few places where this can be done. For the Physician concerned with praying with patients and for the one that routinely prays with patients this chapter discusses both the advantages and pitfalls of prayer. Physicians are result conscious and it is this motivation that drives decisions in therapeutic intervention.

This next chapter discusses the results of spiritual intervention. The results of studies that deal with patient coping, compliance, and doctor-patient relationship are presented. I was impressed with these statements:
"By asking about the patient's religious beliefs in a respectful manner, the doctor indicates a desire to understand an important part of who that person is. If the physician then supports and encourages those beliefs, the patient's trust in the doctor may be amplified. If the physician goes so far as to actually pray with the patient, then this will confirm even more that the physician can be trusted."

Though this statement is a realistic outcome of such activity Dr. Koenig states that caution must be made to avoid patient transference from a Physician-Patient relation to a Physician-Priest, Patient relationship. There is only one situation where a Physician-Priest, Patient relationship may be construed as acceptable. I Pastor a Baptist Church within the city where I practice and several of my members have chosen me as their primary physician. These patients call me Pastor whether it is in the church or within the office setting. In my office setting I represent their Physician-Pastor and in the church, Pastor. This unique circumstance is the only one that I can site where transference has not occurred; the relationship is already multifaceted.
Dr. Koenig discusses the negative consequences of spiritual intervention, summarizing them in six bulleted points and presenting four legal case examples.
At this point I wrote another note in the margin. "I have discovered that the physician must get to know the patient first. A Physician -Patient rapport must be firmly established before initiating more probing interventions. As physicians we invade people's private lives enough. It is easy to treat the biological aspects but tricky to get at the rest. Some patient's complain that we do not treat the whole patient; some like distance. The art is to distinguish between the two!"

To distinguish between the two is to recognize those boundaries and barriers to the process. This represents the purpose of chapter five. Dr. Koenig presents the text of Hippocrates' original oath, its amended version published in the New England Journal of Medicine, the oath of Moses Maimonides, and of Pelligrino. Each of these oaths represent the same principle; "do no harm" to the patient. This chapter not only offers extensive explanations into those boundaries and barriers that should be respected and broached with caution, but also discusses methods by which the physician can overcome those barriers that impede initiating a discussion into the spiritual aspects of patient care. This chapter peaked my curiosity. I really wonder whether medical students are being taught this aspect of patient care and if so actually using it. A survey given to medical students each year of their schooling, through graduation, and if possible residency, would prove to be a very interesting barometer of physician comfort in this area. As physicians we are taught to know our limits and not intervene where limited. Dr. Koenig's recognition of this fact is the background for the information presented in the next chapter.

Both sides of the argument are presented well. There are legitimate concerns that intervention may introduce harm and there are concerns that the lack of intervention may affect patient health outcome. As an academician Dr. Koenig recognizes the need for further, evidence-based research in this area.
After reading this chapter I left with the realization that no randomized, placebo-controlled study exists that evaluates the health status outcome of a large group of patients in a community based setting where the intervention was spiritual and the placebo was usual care. The chapter gives anecdotal information and the sources of negative outcomes came from the media. I recognize that many studies have been done in a variety of physical and psychiatric states; however it was not the purpose of this chapter to introduce. It is my point of view that this chapter served as an excellent spot to introduce the information. The lack of it's introduction indicates to this reader that research in this area would answer the question, When is religion harmful?

If the reader has read the first six chapters he is hooked. Chapter seven will be a welcomed delight. This chapter is pregnant with the synopsis of several spiritual history taking tools. He summarizes the top research studies that address spiritual intervention in mental, physical and social health. Next Dr. Koenig gives an annotated bibliography of the major academic and nonacademic books on the subject and concludes with websites where further information can be obtained. The last section of the book lists the reference citations for each chapter heading.

Summary

This book represents an excellent summary and springboard for any person interested in the subject. In a matter of just a very few hours a wealth of information can be gleaned from the book and the resources listed and summarized will only peak the interest of the more interested. I highly recommend this book as reading for all physicians and would certainly recommend it as part of any course on medical ethics and/or required reading for any medical student.

© American Psychiatric Association Press