Spirituality can be defined as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose, and the way they experience their connectedness to the moment, to self, to others, to nature and to the significant or sacred” (1).

Studies have shown that spirituality and religious beliefs and practices have an impact on how people cope with serious illness and life stresses (2, 3). Spirituality often gives people a sense of wellbeing, improves quality of life, and provides social support (4, 5). As clinicians we know that spiritual beliefs can also affect healthcare decision making (6). Surveys have indicated that patients want their clinicians to talk with them about their spiritual needs and integrate spirituality into their treatment plans (7, 8, 9).

We all know that the patient’s wishes, beliefs, and values have a role in decision making and in the treatment plan. The clinician’s ability to form a compassionate relationship with the patient is as important as that clinician’s ability to diagnose and treat the patient scientifically. Central to this healing relationship is recognition of and attention to the support that is available to patients in the midst of their illness. To support patients in their suffering requires healthcare professionals to know how to be a compassionate presence, convey dignity, and attend to spiritual needs of families (10).

In addressing our patients spiritual needs it is important for us to be able to take a spiritual history. The FICA method (see below) by Puchalski (11) is one way of doing this. The US medical schools have incorporated this into their curriculum in taking a medical history and so are the UK medical schools. The General Medical Council’s, Tomorrow’s Doctors (12) sets out recommendations for medical schools to ensure that they produce doctors who meet the standards set out in the GMC’s Good Medical Practice. Tomorrow’s Doctors does not address spirituality or religion directly anywhere but does so on the section on “The individual in society.” This mentions the need for students to be aware of a number of cultural factors influencing patients’ experience of illness. The General Medical Council’s Good Medical Practice (13) is more explicit in stating outlining in that when we treat patients we need to take into account the patient’s spiritual and cultural factors. Perhaps we need to do more work on this front to ensure that we really do address this in the patient sitting in front of us.

The NHS produced a document that responds to changes in the NHS, society, and the widening understanding of spiritual, religious, and pastoral care (14).The guidance draws on evidence from practice to recommend the resources needed for chaplaincy staffing across a range of contexts in the NHS. Implementation of the guidance will improve support for patients, carers, family members, volunteers, and other people accessing NHS services and staff across the health service. It is intended to include the pastoral and spiritual care provided to patients, family, and staff, whatever it is called in practice, and to include religious care provided by and to religious people. We should be familiar with what is offered in our work practice to give to our patients as we care for them.

As professionals it is important for our therapeutic relationships with patients and families to adhere to boundaries. Recognizing the professional boundary allows the physician to focus on the clinical issue rather than on the patient’s potentially distracting words or emotions, so the encounter can continue. Respect for boundaries, on the other hand, allows for compassionate presence in the healing encounter. As clinicians we are more vulnerable to crossing boundaries when we are overworked, stressed, or have experienced losses or grief, so it is essential for us to have avenues for self care and reflection.

In conclusion, spiritual care supports the relationship-centred model of healthcare. Clinicians who are able to ask spiritual questions of meaning and purpose, suffering, and particularly issues at the boundaries of life and death gain intimate relationships within the clinical context. Importantly, clinicians are then able to afford compassion and clinical care and thereby holistic wellbeing for our patients.

The FICA method of taking a spiritual history

F Faith and belief. Ask: Are there spiritual beliefs that help you cope with stress or difficult times? What gives your life meaning?
I Importance and influence. Ask: Is spirituality important in your life? What influence does it have on how you take care of yourself? Are there any particular decisions regarding your health that might be affected by these beliefs?
C Community. Ask: Are you part of a spiritual or religious community?
A Address/action. Think about what you as the healthcare provider need to do with the information the patient shared—e.g. refer to a chaplain, meditation or yoga classes, or another spiritual resource. It helps to talk with the chaplain in your hospital to familiarize yourself with available resources.

References:

1.Puchalski CM, Ferrell B, Virani R, et al. Improving the spiritual domain of palliative care. J Palliat Med. In press.
2.Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health. New York, NY: Oxford University Press; 2001.
3.Roberts JA, Brown D, Elkins T, Larson DB. Factors influencing views of patients with gynecologic cancer about end-of-life decisions. Am J Obstet Gynecol. 1997;176(1 Pt 1):166-172.
4.Cohen SR, Mount BM, Tomas JJ, Mount LF. Existential well-being is an important determinant of quality of life. Evidence from the McGill Quality of Life Questionnaire. Cancer. 1996;77(3):576-586.
5.Burgener SC. Predicting quality of life in caregivers of Alzheimer’s patients: the role of support from and involvement with the religious community. J Pastoral Care. 1999;53(4):433-446.
6.Silvestri GA, Knittig S, Zoller JS, Nietert PJ. Importance of faith on medical decisions regarding cancer care. J Clin Oncol. 2003;21(7):1379-1382.
7.Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med.1999;159(15):1803-1806.
8.McCord G, Gilchrist VJ, Grossman SD, et al. Discussing spirituality with patients: a rational and ethical approach. Ann Fam Med.2004;2(4):356-361.
9. Best M, Butow P, Olver I. Creating a safe space: A qualitative inquiry into the way doctors discuss spirituality. Palliat Support Care. 2015 Nov 3:1-13. [Epub ahead of print]
10. Puchalski CM, Lunsford B, Harris MH, Miller RT. Interdisciplinary spiritual care for seriously ill and dying patients: a collaborative model. Cancer J. 2006;12(5):398-416.
11. Puchalski CM. The role of spirituality in health care. Proc (Bayl Univ Med Cent). 2001t; 14(4): 352–357.
12. http://www.gmc-uk.org/Tomorrow_s_Doctors_1214.pdf_48905759.pdf
13. http://www.gmc-uk.org/guidance/good_medical_practice.asp
14. https://www.england.nhs.uk/wp-content/uploads/2015/03/nhs-chaplaincy-guidelines-2015.pdf

Beryl De Souza is an honorary clinical lecturer in plastic surgery, Imperial College and honorary secretary Medical Women’s Federation.

Competing interests: Associate Editor BMJ Case Reports and member of BMA Community Care and Ethics Committee.