Faith and Medicine at the Bedside: Caring for the Patient - @drbrowncares

Faith & Medicine At The Bedside:
Caring For The Patient
SHERRY-ANN BROWN, MD, PHD
NARDIA MCFARLANE, MD
MARK NYMAN, MD
Painting from www3.stcamilluscenter.org
@drbrowncares
drbrowncares@gmail.com brown.sherryann@mayo.edu

Outline
 Faith in America
 Faith and Culture
 Need for a Spiritual component
 Case: Supporting spiritual need
 The Biopsychosociospiritual Model
 Barriers to a Spiritual component
 Tools for your Toolbox
brown.sherryann@mayo.edu
@drbrowncares
drbrowncares@gmail.com

Faith in America
 According to an online poll of 2,455 U.S. adults by
Harris Interactive in November 2007:
 82% of adult Americans believe in God.
 79% of the public believe in miracles.
 75% believe in the existence of heaven.
brown.sherryann@mayo.edu@drbrowncares

Faith and Culture
 It is well known that spirituality, faith, and culture
are intimately connected with each other.
 In the Hispanic world, faith plays a significant role
in day to day life.
 Faith and spirituality are known to be very
important to individuals of African and Caribbean
descent.
 “Religion is not only a way of life in the African-American
community, it is a part of an identity that has been
molded over centuries of experiences.”
(http://home.wlu.edu/~connerm/AfAmStudies/Contemporary%20Culture%20Project/Religion&Culture/conclusion.html)

Faith and Culture
 Patients - particularly ethnic minorities - rely upon
religion and spirituality as an important means to
interpret and cope with illness…improve quality of
life, and impact medical decision-making near
death.
 Patients largely desire medical caregivers to take
an active role in providing spiritual care, and
patients likewise frequently experience multiple
spiritual needs arising in the face of life-
threatening illness.
El Nawawi et al, Curr Opin Support Palliat Care 2012 6(2):269-74

The Need for a Spiritual
Component
 Medical illness can often trigger spiritual distress in patients and their
family members:
 Why is this happening to me?
 Why is God allowing this?
 Is it something I’ve done?
 Spiritual distress may worsen the medical illness.

Component
 Religious beliefs can affect decision making:
 A patient believing God will heal them and not adhering to medication
regiments
 Jehovah Witnesses’ do not accept transfusions

Component
 According to Anandarajah et al up to 77% of patients would like
spiritual issues considered as part of their medical care but only
10-20% of physicians discuss this issue with their patients.
Anandarajah et al, Am Fam Physician 2001;63:81-89

Component
 A study by King et al found that:
 94% of patients admitted to hospitals regarded
spiritual health as important as physical health.
 77% believed that physicians should consider their
patient’s spiritual needs as part of their medical
history.
 70% reported physicians never or rarely discuss
spiritual or religious issues with them.
King et al, J Fam Pract. 1994 39(4):349-52.

Component
 In patients at the Dana-Faber Cancer Institute:
 68% felt religion was very important to them
 89% felt religion was at least somewhat important
 Spiritual support by medical team resulted in OR:
 Better quality of life near death
 3x times more likely - final days in hospice
 3x times less likely - need for aggressive care
 5x times less likely - death in the ICU
In the last week of life.
Balboni et al, JAMA Intern Med 2013 173(12):1109-17 brown.sherryann@mayo.edu@drbrowncares

Component
 In another study at the Dana-Faber Cancer Institute:
 80% patients/nurses/physicians felt providing spiritual care was important
AND appropriate
 15% patients frequency of spiritual care provided
 100% patients positive impact of spiritual care
 Spiritual care training for physicians, OR:
 7x more likely to provide spiritual care
 14% had received prior training
J Balboni et al, J Clin Oncol 2013 1;31(4):461-7 brown.sherryann@mayo.edu@drbrowncares

Case Presentation
 69 year old female with small cell lung cancer metastatic to the
brain, bone, and liver
 Presents with pain, nausea, vomiting, anorexia, constipation,
generalized fatigue
 PMH: Hypothyroidism, depression, hypertension; s/p radiation
and chemotherapy
 SH: Widowed, grandson recently moved in

HOW WOULD YOU support this patient’s
SPIRITUAL needs?
1. I would offer to call the patient’s spiritual leader
2. I would connect the patient with Chaplain Services
3. If I am part of the patient’s greater faith community,
I would pray with the patient
4. Spiritual needs have no role in health care

Component
 The National Center for Complementary and
Alternative Medicine report that prayer is by far the
most popular alternative form of therapy in
comparison with yoga, tai chi, gigong, and reiki.
 Religious people are physically healthier, lead healthier
lives and require fewer health services.

Component
 Beneficial relationship with:
 Recovery from illness.
 Prevention of heart disease and high blood pressure.
 Recovery from Cardiac surgery.
 Adjustment to disability.
 Substance abuse prevention and recovery.
 Stress reduction.
 Anxiety.
 Depression.
 Mitigation of Pain.
 Sense of well-being.

Component
 Random, national sample of 340 patients
 Avanced illness
 Ranked highest in importance:
 Pain control
 Being at peace with God
Steinhauser et al, JAMA 2000 284(19):2476-82

Case Resolution
 Patient’s spiritual leader visited with her
 Shared faith experience with patient
 Provided songs, Scriptures, and quotes
 Impacted:
 Patient and her healthcare providers
 “We need more like you…”
 Developed need for pain meds escalation
 Passed away 2 months later at home with hospice

Easing Patient Suffering
 “To cure sometimes, relieve often, comfort always”
 Spiritual strength: strength which gives the ability to
face difficulties & overcome adversities
 Meaning of life: a sense of purpose to life or that life is
part of a greater plan or mission
O’Connor and Skevington, Br J Health Psychology 2005 10 (pt 3):379-398
Wessel MA ,Conn Med 1980 44(2):111-2

The Biopsychosociospiritual Model
 WHO definition of health:
“a state of complete physical, mental
and social well-being and not merely
the absence of disease or infirmity”
 Patients as whole persons with physical, emotional, social &
spiritual needs

 Towards the end of the 20th century
 Shift from purely Biomedical view of health to a more holistic
approach
 Biopsychosocial Model of illness formulated in 1970’s by George
Engel, professor of psychiatry & medicine at the University of
Rochester NY

 Biopsychosocial Model
 Illness results from interaction of biological, psychological, & social
causal factors
 Biopsychosociospiritual Model
 Religion and spirituality important to health
 Onarecker and Sterling proposed revision to include spirituality
Katerndahl, Ann Fam Med 2008 6(5):412-20

#11 Spiritual Care
- Offer biopsychosociospiritual support and Chaplain
Services as needed
#12 FEN
#13 Prophylaxis
#14 Disposition
#15 Code status

Mandate to incorporate a
Spiritual Component
 The Joint Council for Accreditation of Healthcare
Organizations (JCAHO, 1999) has recognized the
influence of spirituality on hospitalized patients and
has mandated that
a spiritual assessment should be performed on every
patient.

Barriers to incorporating a Spiritual
Component
 Uncertainty about how to address spiritual needs.
 Lack of experience or formal training.
 Not wanting to offend anyone.
 The belief that the role of a physician is separate and apart from that
of a pastor/priest.
 Inability to correctly identify patients who desire such discussions.

Tools
 HOPE
 Hope (sources of hope, meaning or comfort)
 Organized religion (church attendance/commitment)
 Personal spirituality and practice (prayer, meditation)
 Effects of medical care and end-of-life issues
 FAITH
 Faith (importance of faith/religion)
 Apply (how do beliefs apply to health)
 Involvement (church, community etc)
 Treatment (spiritual views affecting Tx)
 Help (how can I help address your concerns)
Anandarajah et al, Am Fam Physician 2001;63:81-89
King, Spirituality And medicine 2002 (pp. 651-669)

Tools
 FICA
 Faith/Beliefs (Spiritual vs. religious)
 Importance (emphasis placed on faith/belief)
 Community (belonging to a church etc.)
 Address needs (what concerns can the dr. address)
Puchalski et al, J Of Palliative Medicine 2000 3(1):129-137

Developing Your Toolbox
1. What are your sources of hope, strength
and comfort?
2. Are you at peace?
3. What helps to get you through the difficult
times in your life?
4. What practices do you find helpful when
you are ill (example prayer, meditation,
etc)?
5. Do you hold faith/religious beliefs that can
affect your health care decisions?
6. Would you like someone to pray with
you?

High Yield Points
 Patients desire integration of their faith in their care
 Obtain a meaningful spiritual history: Develop toolbox
 Interest in patient as a whole person
 Patient care should reflect impact of spirituality
 Caring respectable manner
 Assess and meet patients’ spiritual needs
 Ease patient suffering

Quotes to consider
 “To exclude God from a consultation with a patient is a
form of malpractice. Spirituality is a wonder and joy
and shouldn’t be left in the clinical closet.”
Kornhaber (psychotherapist), Newsweek 1992 119:40

Quotes to consider
 “Science without religion is lame, but religion without
science is blind.” (Albert Einstein)

Addressing
Spiritual/Religious Conflicts
 Assessing Capacity
 “I believe in Miracles”
 Chaplain Services; Spiritual Leader
 Treating Patients As Whole Persons
 Ethics Consultation

References
 Anandarajah et al. Spirituality and Medical Practice: Using the HOPE Questions
as a Practical Tool for Spiritual Assessment. Am Fam Physician. 2001;63:81-89.
 Balboni et al. Provision of spiritual support to patients with advanced cancer by religious communities and
associations with medical care at the end of life. JAMA Intern Med. 2013 173(12):1109-17.
 Balboni et al. Why is spiritual care infrequent at the end of life? Spiritual care perceptions among patients, nurses,
and physicians and the role of training. J Clin Oncol. 2013 1;31(4):461-7.
 Borrell-Carrio et al. The Biopsychosocial Model 25 years later: Principles Practice and Scientific Inquiry. Ann Fam
Med. 2004; 2:576-582.
 El Nawawi et al. Palliative care and spiritual care: the crucial role of spiritual care in the care of patients with
advanced illness. Curr Opin Support Palliat Care. 2012 Jun;6(2):269-74.
 Katerndahl. Impact of spiritual symptoms and their interactions on health services and life satisfaction. Ann Fam
Med. 2008 6(5):412-20.
 King et al. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994 39(4):349-52.
 King. Spirituality And medicine, In Fundamentals Of Clinical Practice: A Text Book On The Patient, Doctor, And
Society. Mengel, M. B., Holleman, W. L., & Fields, S. A. (Eds.). New York, NY: Plenum. 2002 (pp. 651--669).
 MacLean et al. Patient Preference for Physician Discussion and Practice of Spirituality. J Gen Inter Med. 2003; 18:38-
43.
 McCord et al. Discussing Spirituality with Patients: A rational and Ethical Approach. Ann Fam Med. 2004; 2:356-361.
 Phelps et al. Addressing spirituality within the care of patients at the end of life: perspectives of patients with
advanced cancer, oncologists, and oncology nurses. J Clin Oncol. 2012 30(20):2538-44.
 Post et al. Physician and Patient Spirituality: Professional Boundaries Competency and Ethics. Ann Intern Med.
2000;132: 578-583.
 Puchalski et al. Taking Spiritual History Allows Clinicians To Understand Patients More Fully. Journal Of Palliative
Medicine 2000 3(1):129-137.
 Rumbold. A Review of Spiritual Assessment in health care practice. MJA. 2007;186:S60-62.
 Steinhauser et al. Factors considered important at the end of life by patients, family, physicians, and other care
providers. JAMA. 2000 284(19):2476-82.
 Wessel. To cure sometimes, to relieve often, to comfort always. Conn Med. 1980 44(2):111-2.

Faith & Medicine At The Bedside:
Caring For The Patient
SHERRY-ANN BROWN, MD, PHD
NARDIA MCFARLANE, MD
MARK NYMAN, MD
Painting from www3.stcamilluscenter.org

Questions?

Organized Religious Preferences in
the Study Participants, 2013
Balboni et al, J Clin Oncol. 2013 1;31(4):461-7. Balboni et al, JAMA Intern Med 2013 173(12):1109-17

http://www.gallup.com
Organized Religious Preferences in the
United States, 2012 (Gallup poll)

http://www.gallup.com
Global Religiosity, 2012
(Gallup poll)

Example of Spiritual Ethics
Conflict/Uncertainty
drbrowncares@gmail.com@drbrowncares

Ethics Consultation

Faith and Medicine at the Bedside: Caring for the Patient - @drbrowncares

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