174

with serious illness, such as cancer, depression, heart disease or disability

and many other chronic illnesses suffer not only physical pain but also a
The spiritual dimension: separation from self, from others and from God or the transcendent. Thus
the healing force for body and mind the individual’s sense of personhood is disrupted leading to suffering. It is
not until there is integration of self that a person can be healed.
* In the healthcare system, physicians and other healthcare providers
Christina M. Puchalski
encounter people who suffer deeply on many levels. Illness or trauma can
result in suffering in many dimensions – physical, emotional, social and
spiritual. Cancer, for example, results in physical pain from the tumor(s) as
Resumo
well as from the therapy. People experience associated symptoms such as
A espiritualidade é muitas vezes essencial para as pessoas que enfrentam nausea, vomiting, constipation or diarrhea, all of which greatly disrupt one’s
problemas de doença crónica e de saúde débil. Trata-se de um primeiro life. People need to miss days of work due to illness. Some people need to
recurso através do qual os pacientes encontram ajuda e significao para take short or even long-term disability leading to financial stress and burden.
os seus padecimentos. Um largo espectro de estudos vêm mostrando One’s social life is disrupted. Many people with cancer talk of the stress the
que a espiritualidade pode desempenhar um papel significativo na
illness puts on relationships with family and friends as well as colleagues.
melhoria da qualidade de vida dos pacientes afectados por problemas
cardíacos, cancro, em situações de convalescença, depressão e cuidados Fatigue from chronic illness can prevent one from doing the activities that
de saúde em geral. O respeito pelas crenças individuais e os valores previously gave meaning to a person’s life. One of my patients who eventually
envolvidos é condição essencial na relação clínica, podendo revelar-se died of metastatic breast cancer told me that the cancer had ravaged not
um aspecto essencial da cura. only her body but also her life and her soul. She struggled daily with the
severe fatigue that made lifting a cup of tea too difficult. When her daughter
jumped on her lap, my patient bit her lip to avoid crying out in pain and
Intoduction frightening her young daughter. Her relationship with her husband was
distant. He was frustrated because he could not take her pain away leading
Suffering is intrinsic to our human condition. We suffer in our mind; him to feel impotent in his ability to care for her. She perceived his frustration
we suffer in our bodies. Helping to bring healing to both mind and body is a as not understanding her pain and isolation. Her own sense of worth was
therapeutic endeavor that will bring healing to our being. Many people challenged. She had been a successful public health nurse with an active
suffer from a wide variety of causes — illness, poverty, loss of loved ones, career. She published numerous academic articles. Now, in the midst of her
disability, and war. Eric Cassell defines suffering as a state of severe distress illness she could no longer concentrate on a magazine article let alone write
associated with events that threaten the intactness of personhood—the a paper. She once told me “I am no longer a member of society, no longer a
interconnected physical, social, spiritual and psychological aspects of self.1 At good wife and mother—so who am I, doctor?”
the root of this suffering is a sense that “what ought to be whole is being Aging, while not an illness, also has its challenges. Many elderly people
split apart.”2 Suffering results from the perception of brokenness. People suffer deeply due to a number of factors. First, as people age, the likelihood
of chronic illness increases. Thus, all of the above conditions exist and may
*
even increase as the number of illnesses increase with age. Many people
M.D., George Washington University School of Medicine, Washington, D.C.;
have multiple conditions such as diabetes, hypertension, congestive heart
Founder and Director, The George Washington Institute for Spirituality and Health.
Email: hcsijw@[Link] failure and severe arthritis. This can result in physical debilitation and the
inability to continue with previous activities including work and hobbies.
 175 176
There is also an increased dependence on care from others, which can the period of time over which a chronically ill patient dies. The end of life
affect both the senior person’s sense of independence and dignity as well as can now last several years. So people face the challenges, pain and suffering
result in financial strain. Medical expenses increase particularly for prescription of chronic illness over longer periods of time in their lives.
medications, which are not covered by Medicare and some other insurance While these technological advances have benefited people in many
plans. One of my patients once asked me what was more important – ways, they have failed to eliminate suffering. People still face tremendous
taking their medicine or eating three meals a day. Other aging friends and pain and suffering in their lives and some face even more because of the
family die which often leads to isolation and loneliness. Because most aging challenges of chronic illness. And unfortunately, while the medical system in
people deal with chronic illness and disability, there are fears of recurring the United States is advanced technologically, it is devoid of compassion.
physical or psychological pain that cause even more suffering and a sense of Consequently, while people are given the opportunity to live longer with
unrelenting hopelessness.3 In the United States, seniors (people over 65) chronic illness they are not given the support to address their spiritual
have the highest suicide rate of all age groups.4 While people 65 and over suffering. The scientific and technological advances have shaped the medical
comprise only 13 percent of the US population, they account for 19 percent system in the western world. While this is very positive in some ways, it has
of all suicides. The suicide rate in 1999 was 10.3 per 100,000 while among tended to focus care on the technological and curative aspects, diminishing
the aged it was 15.9 per 100,000 (almost 50 percent above the national the importance of the humanitarian and compassionate aspects of care. As
average). This fact has received little publicity, which may reflect the US Doka wrote, “Efforts to humanize patient care are essential if the integrity
society’s obsession with youth and its fear of aging and death. But because of the human being is not to be obscured by the system.”6 Thus many people,
of the denial of the predicament of our elderly, and the lack of adequate while having their physical pain attended to, fail to have their spiritual
support programs for the elderly, there is increased suffering and distress distress and suffering addressed.
that aging people face and unfortunately face in isolation.

2. Spiritual Suffering
1. Technological Advances
As mentioned above illness can result in physical, emotional, and social
While suffering has existed throughout all the ages of human existence suffering. It can also give rise to a less evident but perhaps more intense
it may be more prevalent due to illness, since the last century. The tech- suffering—spiritual suffering. Many physicians use the words pain and
nological advances of the last century have help find more effective suffering interchangeably, even when referring only to physical pain. But
treatments for disease even offering cure for many conditions that were physical and spiritual suffering are not the same.7 Most suffering in chronic
previously fatal. These advances also led to an increased life expectancy. illness and in dying is not related to the physical pain but to one’s inability to
People did not live as long as they do now. At the turn of the century, an answer some of the most fundamental questions of being:
average American’s life expectancy was 50 years. Now, 73% of deaths are
 Who am I?
among people at least 65 years old and 24% of deaths are among those at
least 85 years old. The causes of deaths in 1900 were influenza, tuberculosis,  What gives value to my life?
diphtheria, heart disease, cancer and stroke. Today, heart disease is the  What gives me meaning and purpose?
number one cause of death, followed by cancer and stroke.5 Infection
 What is my worth in this world today?
usually was not treatable in the early 1900’s and people frequently died
quickly from these causes. The time frame of dying from heart disease,  What is my ultimate destiny?
cancer and stroke is much longer. In effect, modern medicine has increased  What is my relationship to others and to God/the transcendent?
 177 178
These are existential questions which, if left unanswered can cause to do with the lack of control we ultimately have in our lives. Not all
distress and a sense of unconnected to self, God and others. This dis- illnesses and life conditions are curable and fixable. One reason may be that
connectedness then leads to the sense of fragmentation and brokenness. we need more research; that eventually answers will be found. But, if
Suffering is not a condition that can be cured by modern medicine. It is the history has any lessons for us, even with technological advances, death and
state of being characterized by shattered dreams, destroyed meaning, and suffering cannot be avoided.
lost hope. Any assumptions one had about the world and about one self can There simply are no answers to existential questions. Part of com-
be obliterated. passionate care is recognizing when to simply sit in silence as the person
My patients who face the diagnosis of a serious illness or the real grapples with his or her own quest for meaning. Honoring the mystery is
prospect of dying want answers to major questions about life. sitting in silence, being present to another’s grief as well as our own grief
and sadness while surrounded by unanswerable questions. Life and death
 Why is this happening to me?
become more precious when we unlearn our need to fix and control and
 Will I have time to finish my life’s work and achieve my goals? simply learn to be present to another, to ourselves, to the mystery.
 Will I see my children grow up? Probably, one of the greatest stressors around illness and dying for
both patient and caregivers is created by the ambiguity regarding the patient’s
 Is God there for me? Why is he letting me suffer?
health, including the prognosis, capacity of family to provide support and
 Will I be remembered when I die? care and financial concerns.9 10 11 There is a tremendous amount of uncer-
There are no answers for questions such as these. Patients grapple tainty with any illness and in life in general. While science and medicine may
with these questions daily. Western medicine trains physicians to diagnose, have some answers to many of the physical aspects of disease and illness,
treat and provide answers. For treatment of the disease there may be there are so many aspects of being ill for which there are no answers. Some
answers; for the existential questions that arise for our patients, there are of the questions both patients, professional and family caregivers ask are:
none. On teaching rounds when my patients ask the “Why is this happening  When will my loved one or I and how?
to me” question of my students or residents, most young physicians either
 How long can I or my loved one function like this?
freeze in discomfort or attempt to answer in a biological way – you have a
genetic predisposition to breast cancer which is why this is happening. But  Why can’t this illness be cured?
this question is not about answers. It is a plea for an opportunity to be heard  Why am I or is she or he suffering?
about the deep pain and suffering that the patient is experiencing. Our
 Why do I feel angry, sad, and afraid?
model of western medicine is based in a “fix-it” model. In this model there
is no room for uncertainty. Yet, spiritual suffering is all about uncertainty.  How will I cope with my or his or her death?
Acceptance of the uncertainty or the mystery is what may lead to healing.  What is the meaning and purpose of my life in the midst of this
experience and stress?
 Why can’t I do and be everything to another person? Why can’t I
3. Mystery
be what I use to be?
Life presents us with mystery all the time. Rabbi Lawrence Kushner These questions of uncertainty, limitations, meaning and purpose are
writes, “The first mystery is simply that there is a mystery. A mystery that essentially existential or spiritual questions.12 Larry Burton writes, “Spirituality
can never be explained or understood. Only encountered from time to is the expression of self-in- relation, incorporating both material and non-
time…”8 The mystery that confronts us in situations of death and illness has -material realities, and reflecting the tension between the possibilities and
 179 180
limitations of human existence in history.” Henry and Henry suggest that attentive to their needs. Viktor Frankl wrote of his experiences that “People
people need mystery. They write, “If there is no wonder there is no holy.”13 are not destroyed by suffering; they are destroyed by suffering without
Uncertainty may trigger those spiritual questions that lead to an awareness meaning.”18 The most common sources of meaning provide connections
of mystery. It is then the struggle of the spiritual journey that may lead to an with something larger than the individual’s own life. This could be work,
honoring or acceptance of the mystery. family, religious belief, or other spiritual belief. To be satisfying, meaning
needs to provide as sense of purpose and value to one’s life. What gives
people meaning changes over one’s lifetime? Illness, as Foglio and Brody
4. Superfino and Illness noted, causes people to question that sense of meaning. Usually people
search for a deeper meaning that can give them value, purpose and self-
What can the physicians and other healthcare providers do to help -worth.19 It is not uncommon for people to turn to religion or the
people in the midst of their suffering? Is it even the role of physicians to transcendent realm for that source of meaning. Spiritual beliefs, however
address existential or spiritual suffering? These are questions that are at the they are expressed, become critical for patients in coping with suffering. In
heart of the debate about the role of physicians in addressing spiritual issues one study of women with gynecological cancers, ninety-three percent of
of patients.14 The American College of Physicians consensus panel on end- these patients noted that their spiritual beliefs helped them cope with their
-of-life care concluded that it is the responsibility of physicians to address all illness.20 In that same study, forty-nine percent noted becoming more
dimensions of patients’ suffering—the physical, psychosocial, existential and spiritual after their diagnosis. In studies of patients with terminal illness,
spiritual suffering.15 Patients experience deep suffering in the midst of illness. three items correlate with good quality of life for patients with advanced
The existential questions often come up for the first time in the clinical disease: If the patient’s personal existence is meaningful; if the patient
setting in the presence of the physician and other healthcare provider. finds fulfillment in achieving life goals; and if life to this point has been
Foglio and Brody wrote: meaningful.21 This supports the importance of addressing meaning and
purpose in a dying person’s life.
For many people religion [spirituality] forms a basis of meaning and
purpose in life. The profoundly disturbing effects of illness can call into
question a person’s purpose in life and work; responsibilities to spouse,
children, and parents…Healing, the restoration of wholeness (as
5. New Meaning
opposed to merely technical healing) requires answers to these
questions. 16 Many patients are able to transcend their suffering and find new
meaning which they describe as deeper and more fulfilling than the meaning
Healing, then, is not synonymous with recovery. Indeed, healing may they had in their lives before their illness. They describe being more present
occur at any time, independent of recovery from illness. In dying, for to others, to the beauty around them and to the transcendent or God.
example, restoration of wholeness may be manifested by a transcendent set One patient of mine reveled in the warmth and beauty of the sunrises each
of meaningful experiences while very ill. It may be reflected by a peaceful morning with an intensity she never experienced before. In a study of the
death. In chronic illness, healing may be experienced as the acceptance of effect of spirituality on the will to live in HIV patients, we are finding that
limitations.17 Spirituality is that aspect of human beings that seeks to heal or greater than one-third of patients with HIV find that there lives are better
be whole. after being diagnosed with the illness than before. Spirituality and non-
The questions that arise for our patients as they face serious illness do organized religious measures (relationship with God) have a positive impact
not have answers. Patients need to find those answers for themselves. But, on patients feeling that their life is better after diagnosis than before.
as our patients struggle with their suffering we need to be supportive and Organized religious measures (church attendance, frequency of prayer) have
 181 182
no effect.22 23 24This supports what I have observed in my clinical practice; the caregiver…an intimacy with formality. The caregiver feels the pain
spirituality has a strong influence on how patients come to understand their and suffering of the other by being empathic, is able to help the other by
suffering and illness. Furthermore, patients may find deeper and more fulfilling understanding that suffering at an intuitive and felt level but then is able to
meaning in their lives in the midst of suffering. It is critical that our systems detach enough to be able to help guide the patient toward a self-healing of
of healthcare afford patients the opportunities to find this meaning for that suffering.
themselves.
6.2. Healing Partnerships

6. Spiritual Care How can we help our patients find meaning for themselves in the midst
of their suffering? Physicians and other healthcare providers need to re-frame
There are four key elements of spiritual care their roles not as fixers but as servers. Dr. Rachel Naomi Remen writes:

 Compassion and Love for Another “Helping, fixing and serving represent there different ways of seeing life.
When you help you see life as weak. When you fix you see life as
 Healing Partnerships
broken. When you serve you see life as whole. Fixing and helping may
 Reverence of Mystery be the work of the ego; and service the work of the soul.”27
 Self-care of the Caregiver; Having a Spiritual Practice By serving others we enable them to feel connected and supported in
the midst of their suffering and distress. In serving, the physician and
6.1. Compassion and Love for Another healthcare provider becomes a partner to the patient rather than an expert
that fixes or solves. Patients will find solace in the process of exploring
Compassion comes from two Latin words: from the Latin, ‘cum’ which spiritual questions of meaning with caring and supportive physicians and
means with, and ‘pati’ which means to suffer.25 So the act of compassion is other healthcare providers. By being present to our patients in the midst of
to suffer with another. The Dalai Lama talks of compassion as “defined in suffering we can help them feel less isolated and alone; we can listen to their
terms of a state of mind that is nonviolent, nonharming, and non-aggressive. fears, their dreams and their hopes. We can hold them in the midst of their
It is a mental attitude based on the wish for others to be free of their
pain and acknowledge their suffering without ignoring it. This provides the
suffering and is associated with a sense of commitment, responsibility and
support patients need to find a sense of meaning for themselves, to become
respect towards the other.”26 In being compassionate with others, we, in
whole again, and to heal. Thus, the partnership between physician and
essence, love them unselfishly and without demand or expectation. We love
patient or healthcare provider and patient becomes healing in and of itself.
them for who they are at their very core. Many of my patients suffer deeply
Dr. Francis Peabody wrote in his 1927 medical classic, The Care of
and often in the midst of that suffering, they feel alone and unloved. By
The Patient, “One of the essential qualities of the clinician is interest in
loving them, I see myself as holding them in a type of love that eventually
humanity, for the secret care of the patient is in caring for the patient.”28
allows them to heal and see themselves as loving beings in the midst of their
This relationship can have potential positive impact on healthcare outcomes,
brokenness. It is then that they can see how others in their lives love them.
compliance and patient satisfaction.29 30 31 32 33 34Vailoot suggests that it is
They can then be open to healing the spiritual woundedness that they feel
the relationship between the caregiver and the patient, which sustains the
by finding some hope in the midst of despair. Compassionate care involves
presence of hope.35
the caregivers ability to share the patients’ pain and suffering without
becoming overwhelmed and disabled by that suffering. So the love stems “Who is there in all the world who listens to us? Here I am—this is me
from an intimacy in which boundaries are respected for both the patient and in my nakedness, with my wounds, my secret grief, my despair, my
 183 184
betrayal, my pain, which I can’t express, my terror, my abandonment. In being compassionate, as described above, you allow the person’s
Oh listen to me for a day, an hour, a moment least I expire in my suffering to touch you and affect you but not debilitate you. What allows
terrible wilderness, my lonely silence. Oh God, is there no one to you to do this is the intent with which you open yourself up to another’s
listen?”36 suffering. As a caregiver you love another out of the intent to serve and do
The essence of spiritual care is therefore about listening and being something for the higher good of another person. A compassionate partner-
present to another in their time of need. Medicine is therefore not just ship with the patient results in a sense of connection and commitment to
science and technology. The art of Medicine is about service to another. In the good of another. The positive aspect of service to another overrides the
that way, Medicine is a spiritual practice since it is routed in altruism for negative experience of suffering. The spiritual nature of the work and the
another. commitment that comes from that gives one the strength to be able to
support another’s pain. Many physicians talk of being called to the profession
of medicine. Many physicians and other healthcare providers find meaning in
6.3. Reverence of Mystery
their work in the context of their spiritual beliefs and values. In the Jewish
By accepting and even honoring the mystery of life, the physician tradition for example it is written in the Talmud, “Who hath compassion for
acknowledges that he/she is not all knowing. It helps the physician become others receives compassion from Heaven.”37
humble in the face of something greater than science can explain— the Another pre-requisite of doing spiritual care is having a spiritual
unknown, the answerable questions. But it also helps humanize the physician practice. For the religious physician or healthcare provider, it may be a
and the medical profession as a whole and allow physicians to become more practice in that tradition such as prayer or service attendance. For others,
attainable to patients. In this way, compassionate partnerships becomes more their practice may be meditation, yoga, rituals, relationship with others or
of a model of care than distant stances of expertise. It is well established the divine, or art and music. A spiritual practice can help one encounter the
that physicians who have warm and caring relationships with patients are transcendent and realize a higher value or meaning in life and enable one to
less likely to be sued. That may be because they are honest about their be truly compassionate to another. Most mystics, such as Teresa of Avila,
limitations as physicians and as human beings. While patients need physicians’ see spiritual practices as leading them beyond themselves to the practice of
expertise in technical matters, they also need honest appraisals of what is charity and love of neighbour. 38
not possible to fix or answer. And more importantly, they need the assurance It is essential that when we care for others we also care for ourselves.
of support especially in the face of confusion and ambiguity. So in addition to a spiritual practice, exercise, proper nutrition and sleep are
critical. It is also important to have as support system for the caregivers.
Working with the ill and dying can be enriching and that often gives meaning
6.4. Self-Care
to our lives. But it can be draining as well. It is important to have people
The process of caring for or being compassionate to another who is with whom you as the caregiver can share your feelings—grief as well as joy
suffering, means opening oneself up to another’s suffering. In order to do and awe.
this, it is critical that one is first honest with oneself about his or her own
experience with suffering as well as an awareness of our own mortality.
Once we face our own issues we can then recognize and help another with 7. Spirituality in Clinical Practice
theirs. So in spiritual care, a pre-requisite is to reflect on what suffering and
loss you have encountered in your life and how you handled it, to recognize Medical professionals are recognizing that there are inadequacies in
that you too will die and what that means to you, and to ponder what values the healthcare system in terms of care of chronically ill and dying patients.
you have in your life that give you meaning. Several national organizations have also supported the inclusion of spirituality
 185 186
in the clinical setting. The Joint Commission on Accreditation of Healthcare humanism, and the arts. All of these factors can influence how patients
Organizations (JCAHO) has a policy that states that: Pastoral Counseling and health care professionals perceive health and illness and how the
and other spiritual services are often an integral part of the patient’s interact with one another.”43
daily life. When requested the hospital provides, or provides for, pastoral Spirituality, or that which gives us meaning, can be expressed in many
counselling services.39 ways. When approaching patient’s spiritual issues, it is important to recognize
The interest in spirituality in medicine among medical educators has that the definition of spirituality is broad and all encompassing. It is critical to
been growing exponentially. Medical schools are now teaching courses in allow the patient to inform the physician and other care providers what
end-of-life care and in spirituality and medicine. Only one school had a formal spirituality means to that patient. The outcome goals stated in MSOP III are
course in spirituality and medicine in 1992. Now, over seventy medical that students will:
schools are teaching such courses.40 41The key elements of these courses
have to do with listening to what is important to the patient, being present  Be aware that spirituality, and cultural beliefs and practices, are
to their suffering, respecting their spiritual beliefs, and being able to com- important elements of the health and well being of many patients.
municate effectively with patients about their spiritual beliefs and values.  Be aware of the need to incorporate awareness of spirituality, and
In 1998, the Association of American Medical Colleges (AAMC), culture beliefs and practices, into the care of patients in a variety of
responding to concerns by the medical professional community that young clinical contexts.
doctors lacked these humanitarian skills, undertook a major initiative – The
Medical School Objectives Project (MSOP) – to assist medical schools in  Recognize that their own spirituality, and cultural beliefs and
their efforts to respond to these concerns. The report notes that: practices, might affect the ways they relate to, and provide care to,
patients.
“Physicians must be compassionate and empathetic in caring for
patients...they must act with integrity, honesty, respect for patients’  Be aware of the range of end-of-life care issues and when such
privacy and respect for the dignity of patients as persons. In all of their issues have or should become a focus for the patient, the patient’s
interactions with patients they must seek to understand the meaning of family, and members of the health care team involved in the care
the patients’ stories in the context of the patients’, and family and of the patient.
42
cultural values.”
 Be aware of the need to respond not only to the physical needs
In recognition of the importance of teaching students how to respect that occur at the end of life, but also the emotional, socio-cultural,
patients’ beliefs, AAMC has supported the development of courses in spiri- and spiritual needs that occur.44
tuality and medicine.
As mentioned above, more than half of U.S. medical schools have
In 1999, a consensus conference with AAMC was convened to deter-
courses in spirituality and medicine, many of which are required and
mine learning objectives and methods of teaching courses on spirituality,
integrated into the curriculum. The response to these courses has been
cultural issues and end-of-life care. The findings of the conference were
positive. Students and practicing physicians find their relationships with their
published as Report III of the Medical School Objectives Project (MSOP).
patients are warmer, more meaningful, and deeper once they talk with their
This report included a clinically relevant definition of spirituality:
patients about their spiritual beliefs. Medical students and residents are
“Spirituality is recognized as a factor that contributes to health in many finding it easier to address issues of suffering and meaning in the context of
persons. The concept of spirituality is found in all cultures and societies. a spiritual history. Doctors who felt burned out by the hectic schedules
It is expressed in an individual’s search for ultimate meaning through of managed care now feel a way to reconnect with their patients and
participation in religion and/or belief in God, family, naturalism, rationalism, bring compassionate care giving back into the practice of medicine. Most
 187 188
importantly, the patients are happier because their whole person is treated or a group of like-minded friends can serve as strong support systems for
(body, mind and spirit) and not just their illness. Thus, by educating physicians some patients.
about spirituality in patients’ lives, we are hoping to develop more compas-
sionate and caring models of healthcare. A – Address/Action in Care
The physician and other healthcare providers can think about what
needs to be done with the information the patient shared – referral to
8. Spiritual History chaplain, other spiritual care provider, or other resource such as yoga,
meditation, spiritual direction, or pastoral counselling. Some patients use
One way to address suffering and issues of meaning and purpose is by rituals or journaling as a spiritual intervention. Others will talk about prayer,
doing a spiritual history. The main elements of a spiritual history that has walking in nature or other person rituals as important in coping. Listening
been developed for physicians and other healthcare providers can be recalled to the concerns, feelings and beliefs of the patient as well as providing a
by using the acronym, “FICA.”45 46 47The spiritual history is that part of the safe environment so that the patient can express feelings and experiences
patient encounter where the patient can tell his or her story and share his associated with illness and suffering is one of the most important parts of
or her values. It is that part of the exam that is less technical. Many people the action plan.
feel it is the place where compassionate care can be a felt experience. It is
FICA is not meant to be used as a checklist, but rather as a guide on
also the place that helps reveal what sources of strength, hope and meaning
how to start the spiritual history and what to listen for as the patient talks
and what kind of coping mechanisms the patient has. Spirituality may enhance
about his or her beliefs. Mostly, FICA is a tool to help physicians and other
well being in a person’ s life by providing one with the language of hope and healthcare providers know how to open a conversation to spiritual issues and
meaning and purpose, through social support and integration within a issues of meaning and value. In the context of the spiritual history, patients
religious or other community or through enhanced coping mechanisms. may relate those fears, dreams, and hopes to their care provider. The spiritual
Thus the assessment tool asks the person about these areas of their life. history can be done in the context of a routine history or at any time in
the patient interview, usually as a part of the social history. In addition to
F – Faith and Belief religious or spiritual beliefs and values and other aspects of the spiritual
“Do you consider yourself spiritual or religious?” or “Do you have history, the social history should address: lifestyle, home situation and primary
spiritual beliefs that help you cope with stress?” If the patient responds “no,” relationships; other important relationships and social environment; work
the physician might ask, “What gives your life meaning?” Sometimes patients situation and employment; social interests/avocation; life stresses; and life-
respond with answers such as family, career, or nature. styles risk factors: tobacco, alcohol/illicit drugs. As with any part of the history
sometimes issues come up that require more attention. If a patient shares
I – Importance symptoms of depression, it is likely the visit will center on that and therefore
“What importance does your faith or belief have in your life? Have the depression assessment will take longer. For some patients the spiritual
your beliefs influenced how you take care of yourself in this illness? What history may take a brief amount of time; for others, spiritual issues may be
role do your beliefs play in regaining your health?” the predominant part of the discussion for that visit. In patient care, spirituality
is part of ongoing spiritual care both in the context of the caring relationship
C – Community as well as active conversation about spiritual issues. As part of the history
“Are you a part of a spiritual or religious community? Is this a support the conversation might be lengthy or be something the patient shares at the
to you and how? Is there a group of people you really love or who are first visit and then brings up only at subsequent visits as appropriate to the
important to you?” Communities such as churches, temples, and mosques circumstance.
 189 190
The spiritual history is patient-centered and family-centered. One Physicians and other healthcare providers should strive to discuss patients’
should always respect patient’s and families’ wishes and understand appro- spiritual concerns in a respectful manner and as directed by the patient.
priate boundaries. Physicians and other healthcare providers must respect A physician or other care provider should always respect patients’ privacy
patients’ privacy regarding matters of spirituality and religion and should regarding matters of spirituality and religion, and must be vigilant in avoiding
avoid imposing their own beliefs onto the patient.48 imposing his or her beliefs onto the patients. The relationship between
The following case illustrates how FICA can be used. A patient who physician and patient is not an equal one and in the professional setting
died of metastatic malignant melanoma was an Episcopalian. Her religious neither is the relationship between other professional caregivers with their
beliefs were central to her life and, in fact, the way she came to be at peace patients. There is an intimacy in the relationship but it is intimacy with
with dying. During her last hospitalization, the house officers caring for her formality. The patient comes to the physician/healthcare provider in a vul-
were apprehensive about discussing advance directives and dying. However, nerable time of his or her life, often looking to the physician as a person of
during the spiritual history, the patient told them how her religious beliefs authority. The physician/healthcare provider should not abuse that authority
helped her come to terms with dying and how she was ready to die naturally. by imposing his or her own beliefs, or lack of beliefs, onto patients. A vul-
She handed them her living will. She also asked that her church members nerable patient may adopt a physician’s/healthcare provider’s belief simply
be allowed to visit her often. She later told me that being asked about her because the patient is fearful and assumes the physician/healthcare provider
beliefs helped her feel respected and valued by the physicians and she felt knows more. In terms of spiritual intervention, physicians/healthcare pro-
that she could trust them more. The physicians stated that once they asked viders can recommend a variety of interventions: chaplain referral, meditation,
a spiritual history, the nature of the interaction between themselves and this yoga, prayer or other spiritual practice, but, the decision to recommend
patient was changed. It felt “more natural, more comfortable, warmer and these comes from the patient. For example, the physician/healthcare provider
more honest.” can recommend religious and spiritual practices to their patient if these
Another case illustrates the variability encountered in practice. When practices are already part of that patient’s belief system. However, an
asked “if you have any spiritual beliefs that help you with stress,” a patient agnostic patient should not be told to engage in worship anymore than a
undergoing a routine examination answered that she found meaning and highly religious patient should be criticized for frequent church attendance.
purpose while sitting in the woods near her house – that nature brought her Thus, if a patient states that prayer helps with stress, the physician/health-
peace. This was very important to her, as she noted that on days when she care providers could suggest that prayer might help in dealing with a serious
did not meditate there in the morning, her day would be scattered and diagnosis. Or if a patient finds meaning and purpose in nature, a physician/
tense. Her community was a group of like-minded friends who shared her healthcare provider might suggest meditation techniques focused on nature.
beliefs. She asked that her medical records indicate that when she became Patients often ask physicians/healthcare providers to pray with them.
seriously ill or dying, that the room in her hospice overlook trees. She It is not inappropriate to allow a moment of silence or a prayer if the patient
also asked to learn basic meditation techniques. In a subsequent visit, many requests this. In fact, walking away and not showing respect for the request
months later she reported that she had stopped meditating, with negative may leave the patient with a sense of abandonment by the physician/health-
results; resuming meditation helped her cope better with her stress. care provider. If the physician/healthcare provider feels conflicted about
praying with patients, he or she need only stand by quietly as the patient
prays in his or her own tradition. Or, alternatively, the physician/healthcare
9. Ethical Issues provider could suggest calling in the chaplain or the patient’s clergy person
to lead a prayer. Physician-led prayer or healthcare provider-led prayer
In discussing spiritual issues with patients it is important to recognize is generally not recommended, as that is usually the role of a clergy or
that the spiritual history is patient-centered not physician centered.49 50 chaplain. In addition, having the physician/healthcare provider lead a prayer
 191 192
opens the possibility of having the prayer be of the physician’s/healthcare Conclusion
provider’s belief, not of the patient’s. Furthermore, clergy and chaplains are
trained specifically in techniques of leading prayer in ecumenical and health- As people encounter serious illness they often face profound questions
care contexts. However there is disagreement amongst experts in this area. of meaning and purpose in their lives. If left unattended, people can experi-
Some say that physician-led or healthcare provider-led prayer may be permis- ence tremendous isolation and suffering. Spirituality is at the core of who
sible if the physician/healthcare provider and patient share a long-standing we are as human beings. It is that part of us that helps us find meaning
relationship, have similar beliefs or religious background or if the patient especially in the midst of confusion and suffering. It is the connections we
requests it. It is still recommended however to be mindful of respecting the form with each other in a profound sense of community that helps all of us
patient’s belief system. survive in an often isolating and dehumanizing world. It is the responsibility
of the physicians, other healthcare providers and healthcare systems to
provide the opportunities for patients to be supported in the midst of their
10. The Interdisciplinary Team pain and suffering. By addressing spiritual issues and by being compassionate
and loving to patients, physicians and other healthcare professionals will be
Addressing suffering and spiritual issues of patients does not belong in able to help people heal and find new meaning in their lives. Patients may
any one person’s domain. It is the responsibility of all members of the health- then be able to find a sense of wholeness, wonder and grace. The healing
care team – physicians, nurses, social workers, psychologists, therapists and force for both body, mind and soul is the spiritual dimension. By facing this
others – to be sensitive and caring to the spiritual needs of patients. One of dimension patients and caregivers alike will be able to achieve a therapy for
the members of that team, the chaplain, is the trained spiritual care provider. being.
One of the most important elements of the courses on spirituality and health
is the recognition of trained spiritual care providers—chaplains, pastoral
counselors, spiritual directors and clergy. We are not training physicians to
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