There is 'increasing emphasis on spirituality as a factor contributing to wellbeing and coping strategies' said Speck and colleagues in a recent BMJ editorial. A team from the Royal Free Hospital, London, has also discovered in a study of acute admissions to that hospital that 71% of people have an important spiritual belief even though many do not express it in a religious way. Further, spiritual needs are an issue for trust managers. Sarah Mullally, Chief Nursing Officer and the Department of Health's lead director on public and patient involvement, argues that faced with a choice between a trust geared up to caring for patients in a holistic way and another which treats them like a series of clinical episodes, patients will vote with their feet. She goes on to say that healthcare professionals and the organisations in which they work 'need to recognise that in healthcare we join people on their life journey and for a time we travel with them. We need to understand better who they are and how we can work with them as partners on that journey. Central to this is understanding them as individuals who have many dimensions including a spiritual one'.
Many doctors, even Christians, are surprised by these recent developments in our NHS and do not know how to respond. Most of us are completely untrained in taking a spiritual history and many are unaware of the substantial evidence demonstrating that faith has a positive impact on illness prevention, coping with illness, recovering from surgery and treatment outcomes.[4,5] As clinicians we will want to do our part in helping our patients and their families deal with their presenting complaints and associated issues. However as Christians we may also long that our lives would express the Gospel in such a way that those we meet may be drawn to know God personally. Paul writes to the Colossians: 'Be wise in the way you act toward outsiders; make the most of every opportunity. Let your conversation be always full of grace, seasoned with salt, so that you may know how to answer everyone.'
How do we find appropriate words to get started in conversation, particularly in the clinical context? Taking a spiritual history may be one way of opening a door for further conversation and it can certainly help the medical team manage patients more appropriately. It is encouraging to see that in a medical school in New South Wales, Australia, which serves a population of mixed ethnic origin and religious belief, spiritual history-taking has been integrated into the regular student curriculum, through the influence of one palliative care physician. As in taking any medical history, we will need to approach our patients with 'gentleness and respect' in the spirit of 1 Peter 3:15.
Various models for spiritual history-taking have evolved and all contain three key components:
Belief, Practice and Faith Community. Many of us are afraid that time constraints will prevent us from getting involved in this area, but it only takes three simple questions to gain the basic information. The words used may depend on the style of the individual questioner and whether the questions are part of a formal history for admission/health maintenance or coming up naturally in the course of conversation. Typical questions which may be asked are:
- Belief: 'Do you have a faith which helps you (in a time like this)?' 'Do you have a personal faith?' 'What is important to you?'
- Practice: 'How does it affect your life?' 'Have you ever prayed about your situation?'
- Faith Community: 'Do you belong to a faith community?' 'Who gives you support?' 'What keeps you going?'
There may be a particularly good opportunity to take a spiritual history:
- When someone is suffering from major illness, terminal disease or dying
- In the perioperative period
- At registration or health maintenance check
- In a social crisis or time of loss
It may be best to ask only one question at a time and to gather the information incrementally over several consultations, or it may even be possible for an assistant to take a history at routine registration. It is not necessary to follow up the information immediately, but it is available when required for a subsequent occasion. Working in the context of General Practice I have found the questions 'Do you have a faith that helps you?', 'Have you ever prayed about your situation?' and 'Who gives you support?' can often be asked quite naturally during the consultation. Elizabeth Croton has helpfully written in a similar vein from the hospital context, in previous editions of Triple Helix.[7,8]
It is surprising how often a door to further conversation or an opportunity to pray with a patient may develop. However, even if a patient appears to respond negatively, that in itself is valuable information. A positive response of allegiance to another faith such as Judaism, Islam or Jehovah's Witnesses (or the knowledge that our patient's main support comes from fellow-members of the local amateur dramatic society), will help us in providing appropriate care to our patients.
Nowadays many people struggle to know where to turn for help on spiritual issues as they have no regular contact with the church and may feel it is not accessible or relevant. On the other hand, most people do have contact with healthcare professionals at some time, but again they may feel that this is not the right arena to raise spiritual issues as the professionals are busy coping with 'a series of clinical episodes'. However those professionals who are willing to take a small initiative in asking a gentle question may have great opportunities to offer help. A recent research article in Palliative Medicine which states that spiritual care is about helping people whose sense of meaning, purpose and worth is challenged by illness, found, after conducting 149 in-depth interviews, that 'Many patients and carers were uneasy about turning to health and social services for spiritual support, although if they did find professionals who were able and willing to discuss such needs, this was much valued'. Let us pray that with courage and the help of God, we professionals may be able to help our patients in this area and so fulfill a vital element in our vocation.
A CMF member who has recently started taking spiritual histories writes:
'I have come to realise that even on a bad day and despite time constraints, there are simple things that you can do and say which may have quite an impact. One of the things that I've found most helpful is the simple question, 'Do you have a faith that helps you?' It's a nonthreatening question that can be slipped into a consultation quite easily.
Two weeks ago, I was seeing one of my regular patients, who has recently lost her husband and is suffering with profound depression. I asked her this question and she looked rather taken aback and then said 'I used to be a Catholic'. I didn't feel it was right to go any further and so left it there. She came back today and quite spontaneously said, 'I believe in God. Do you think he can help me?'. We then went on to have a wonderful conversation about the power of prayer and how helpful it can be in times of need. She then expressed concern that she was under pressure from her neighbour and her sister to become a Jehovah's Witness and she thought their religion might not be true. I agreed with her and we briefly discussed some of the differences between Christianity and the Jehovah's Witnesses. I also suggested that she try the local Anglican church.
This lady had come in with her head down, looking deeply unhappy, but as she left, she had a big smile on her face and said, 'I'm going to start praying!' I've been caring for this lady for two years and this topic of conversation has never come up before, so I can only assume that it was the result of my initial question two weeks ago that opened the door. I was really encouraged and look forward to exploring all this further with her in future consultations!