Principles to make a spiritual assessment work in your practice

Journal of Family Practice, August, 2004 by Robert T. Lawrence, Dwight W. Smith

Practice recommendations

* Consider the research showing that spiritual faith is an ally to health and positive health behaviors, and that many patients rely on their spiritual beliefs in times of illness (C).

* Regardless of personal ethic, physicians need a set of principles to guide decisions concerning the appropriateness of addressing spiritual issues when such issues arise in the clinical setting (C).

* The EBQT (Evidence-Belief-Quality Care-Time) paradigm provides a natural set of principles for consistent clinical decision-making regarding spiritual or alternative adjuncts to medical therapy (C).

In recent years, physicians have been encouraged to assess their patient's spiritual sources of strength or stress when taking a medical history. However, the decision to act on such information can be ethically complex. Physicians may feel apprehensive about delving into spiritual issues in clinical practice without clear ethical guidelines as to which actions may, or may not, be taken in response to information gained from such an inquiry. This paper introduces the EBQT paradigm, a set of 4 principles designed to guide physicians who wish to address clinically relevant spiritual issues in their practice.

* NEED FOR GUIDELINES

The contribution of a patient's personal faith to the success or failure of medical care has long been a subject of interest to physicians. Sir William Osler, contrasting the beneficial and harmful effects of various expressions of faith, called it "an essential factor in the practice of medicine." (1) Research highlights both the beneficial aspects of a patient's spiritual faith, (2-7) and the harmful effects of religious struggle in regard to illness (8) or lack of strength and comfort from religion. (4)

Due to the potential relevance of spiritual beliefs and practices, many authors (9-13) recommend that physicians include a brief spiritual assessment when taking a patient's medical history. A decision to act on such information, however, can prove ethically complex. Should physicians have a referral relationship with local clergy? Is it ethical to pray with patients who make such a request? Can a physician express support for faith-based activities? When is it appropriate to confront a patient's harmful religious beliefs?

Some authors argue against addressing spiritual issues, calling the activity premature and ethically questionable. (14) Others acknowledge a connection between spiritual faith and health, yet do not agree on the extent to which physicians should address spiritual issues. (15) We elect not to discuss the details of each point of view here, but do emphasize that, despite holding divergent viewpoints, authors seem to agree that guidelines for behavior are lacking. Richard Sloan and colleagues conclude their critique by stating "between the extremes of rejecting the idea that religion and faith can bring comfort to some people coping with illness and endorsing the view that physicians should actively promote religious activity among patients lies a vast uncharted territory in which guidelines for appropriate behavior are needed urgently." (16)

This paper introduces such guidelines in the form of what we call the EBQT Paradigm. With the principles of this paradigm, physicians may personally evaluate or openly debate the ethics of certain spiritual adjuncts to therapy using consistent parameters on which to base their conclusions. Previous authors have developed principles for accommodating the religious beliefs of patients. (17) Others have provided recommendations for the discussion of spiritual issues with patients. (18) However, guidelines for acting on a patient's spiritual history were not found in a Medline search of the medical literature, including articles and letters from peer-reviewed publications from the last 15 years that refer to or assess the clinical relevance of spirituality, prayer, clergy, religion, or faith.

* THE EBQT PARADIGM FOR SPIRITUAL ASSESSMENT

The EBQT paradigm (Table 1) involves 4 principles: Evidence, Belief, Quality Care, and Time. Used in concert with a spiritual assessment, these principles provide an ethical model with which physicians may evaluate the benefit or harm in addressing spiritual sources of strength or stress in the clinical setting.

Principle of evidence

Before considering a spiritual adjunct to therapy, evaluate the evidence that supports a therapeutic advantage to such action. Two questions must be answered: 1) does sufficient evidence exist to recommend the action, and 2) what is the quality of that evidence?

One might logically question whether evidence exists at all to support a physician addressing spiritual issues. Several authors have thoroughly reviewed the evidence for a connection between spiritual commitment and health outcomes. (19-21) It is not our intent to repeat their effort here. However, in reviewing their findings, we were struck by the varying quality of evidence found in the medical literature. In some cases, spiritually related actions are supported by abundant evidence; other spiritual practices lack sufficient data for recommendation in the clinical setting. As empirical evidence accumulates, physicians will be increasingly able to discern the therapeutic benefit of certain faith-based practices. Evidence alone, however, does not establish an ethical imperative to address a patient's spiritual or faith-based practices. The physician's belief, medical and patient values, and available time must also be taken into account.