Spirituality and Health Care

1
Spirituality and Health Care

• Anita S. Kablinger MDAssociate Professor
• Psychiatry and Pharmacology

2
Audience Participation

• What percentage of Americans says that they would
  welcome a conversation with their doctor about
  faith?
• What do people pray for the most (give the top
  three)?
• Scientific evidence for the following has been
  rated as WEAK, INADEQUATE, MODERATE or
  PERSUASIVE. Match the evidence to the following-
• religion or spirituality slows the progression of
  cancer
• religion or spirituality protects against
  disability
• religion or spirituality improves recovery from
  acute illness
• religion or spirituality protects against cancer
  mortality
• being prayed for improves physical recovery from
  acute illness
• religion or spirituality protects against
  cardiovascular disease
• church attendance promotes longer life

3
Definitions

• Religion means to bind together and a belief in
  and reverence for a supernatural power regarded
  as creator and governor of the universe.
• Spirituality, on the other hand, is defined as a
  dynamic, personal, and experiential process of
  belief.

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Religion/Spirituality Involvement in Medicine

• -JCAHO requires routine assessment of
  spirituality needs
• -APA issued Guidelines Regarding Possible
  Conflict Between Psychiatrys Religious
  Commitment and Psychiatrys Practice
• -DSM-IV includes Religion or Spirituality
  Problem section
• -instruction in religion-spiritual issues is a
  curricular requirement of accredited psychiatric
  residencies
• -APA recommends that doctors inquire about
  religion and spiritual orientation of patients

5
Background

• The percentage of those who believe in God has
  changed little over the past 50 years (96 in
  1944 and 95 in 1993).
• Eighty-nine percent of the population state that
  they pray to God on a regular basis.
• Ninety-four percent of people regard their
  spiritual and physical health as equally
  important and the majority of physicians believe
  spirituality is an important factor in health
  care.
• In fact, one-third of the population regards
  religion as the most important dimension in their
  life.

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Scientist and Clinician Beliefs Rates of
Atheism and Agnosticism
U.S. Population 6 American Men and Women
of Science 1916 and 1996 55 Vermont Family
Practitioners 36 Psychologists 28 Psychiatr
ists 21 Bergin and Jensen, Psychotherapy,
1990, 273-7. Maugans and Wadland, Journal of
Family Practice, 1991, 32210-213.
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Myths about religion and health care

• What research does NOT show
• -religious people do not get sick
• -illness is due to lack of faith
• -spirituality is the most important factor
• -doctors should prescribe religious activities
• -other factors explain the association between
  religion and spirituality and better health
  outcomes

8
Benefits to clinicians of religious/spirituality
focus

• -communicates to patient that their life
  experience is of interest and value to them
• -increases understanding of clinical conditions
  association with a religious-spiritual problem
• -allows the development of a case formulation of
  interpersonal responses and psychiatric patterns
• -identifies areas of support and community
  involvement that may be helpful adjuncts to
  treatment

9
Reasons to acknowledge and support a patients
spirituality

• -people regard spiritual and physical health as
  equally important
• -enhances coping and quality of life during
  illness
• -enhances cultural sensitivity
• -enriches the doctor/patient relationship

10
Barriers (reasons doctors have problems assessing
religion/ spirituality)

• -doctors practice in biomedical model
• -fewer doctors regard themselves as religious or
  spiritual as compared to patients
• -taught infrequently in medical training
• -patients regarded as having complex or daunting
  needs
• -not addressed due to time constraints, lack of
  confidence, and role uncertainty

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Illness PreventionSpirituality and Life
Satisfaction

• Study sample reviewing findings from three
  national surveys totaling more than 5,600 older
  Americans
• Study results Attending religious services was
  linked with improved physical health or personal
  well-being.
• Other studies 12 other studies published since
  1980 found persons in organized religious
  activity had higher levels of life satisfaction.
• Levin JS, Chatters LM. Religion, health, and
  psychological well-being in older adults
  findings from three national surveys. J Aging
  Health 199810(4)504-531.

12
Patient NeedPatient Views Regarding
Spirituality When Seriously Ill

• Pulmonary
• Patients
• Consider self religious 51
• Welcome religious questions in medical history
  66
• Not welcome religious questions
  16
• Physician asking about their spiritual or
  religious
• beliefs would increase trust in the
  physician 66
• Ehman JW, Ott BB, Short TH. Archives of Internal
  Medicine 1999159 (15)1803-1806.

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Recovery from SurgeryHip Replacement
Hip fracture patients with stronger religious
beliefs and practices were less depressed and
could walk a greater distance at discharge than
patients with lower levels of religious
commitment. Pressman P, et al. Am J Psychiatry
1990147758-760.
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Those who are religious tend to demonstrate

• -less cardiovascular disease
• -decrease in blood pressure and hypertension
• -more health promoting behaviors
• -a decrease in depression, anxiety, and suicide
• -less alcohol abuse or use of illicit drugs

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Illness PreventionSubstance Abuse

• Individuals suffering from these (alcohol or
  drug abuse) problems are found to have a low
  level of religious involvement . . . spiritual
  re(engagement) appears to be correlated with
  recovery.
• Miller WR. Addiction 199893(7)979-90.

16
Illness Prevention Spirituality and Marijuana
Use

• Survey undertaken by Harvard School of Public
  Health and University of Michigans Survey
  Research Center.
• Study Sample 17,592 college students sampled
  from 140 U.S. colleges with survey sample
  nationally representative of U.S. college
  population.
• Study Results
• Increased Risk-Marijuana Use
• - Lower Grades Grade B and below
• - More time hanging with friends
• - Four-Fold Increased Risk Parties Important or
  Very Important
• - Five-Fold Increased Risk Cigarette Smoking
• - Six-Fold Increased Risk Binge Drinking
• Bell R., et al, The correlates of college
  student marijuana use results of a US National
  Survey. Addiction. 1997 92(5)571-581.

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Illness Prevention Spirituality and Marijuana
Use

• Study Results (cont.)
• Lowered Risk-Marijuana Use
• - One-Half Risk students who viewed Community
  Service as important to them
• - One-Fourth Risk Students who viewed Religion
  as very important to them
• - Religion as important strongest predictor of
  marijuana use,
• even stronger in size than identification as
  party animal
• - After controlling for other predictor
  variables - Religion as important
• still at ONE-THIRD the risk
• This study supports the notion that college drug
  use is social in nature (which)
• makes it resistant to changehowever the findings
  do suggest approaches to
• prevention
• Bell R., et al, The correlates of college
  student marijuana use results of a US National
  Survey. Addiction. 1997 92(5)571-581.

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Patient Need Social Histories of Chronic Drug
andAlcohol Abuse

• Study Results (cont.)
• Religious Histories Parents and Subjects
• Frequency Comparison (as ratios) for Narcotic
  Abusers (NA) and Alcohol Abusers (AA) to control
  sample
• Religious History Items NA/Controls
  AA/Controls
• Mothers Religious Involvement no difference
  one-fifth higher
• Fathers Religious Involvement one-half
  three-fourths
• During Adolescence Increased
• Religious Interest one-fourth
  one-eighth
• During Adolescence Decreased
• Religious Interest 4 times greater
  4½ times greater
• Larson DB Wilson WP. Religious life of
  alcoholics. Southern Medical Journal. 1980
  73(6) 723-727.
• Cancellaro LA, Larson DB, Wilson WP. Religious
  life of narcotic addicts. Southern Medical
  Journal. 1982 75(10) 1166-1168.

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Illness PreventionSpirituality and Blood
Pressure Status

• Importance of Religion for those 55 Older
• Age ? 55 Mean Systolic BP Mean Diastolic BP
• High Importance of Religion 139.7
  82.6
• Not High Importance 146.2
  88.5
• High VS Not High Difference 6.5 mm Hg
  5.9 mm Hg
• Adjusted for socioeconomic status and smoking
• Larson DB, Koenig HG, Kaplan BH et al. The
  Impact of Religion on Mans Blood Pressure.
  Journal of Religion Health. 198928(4)265-278.
  

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Systematic ReviewA Review of Findings Concerning
Spirituality and Hypertension
Study Results For the Religious Commitment
Studies Of the seven studies found, six revealed
higher levels of religious commitment were
associated with lower rates of hypertension. By
2000, 11 years later, Koenig, McCullough and
Larson noted that of the 16 studies that have
examined the relationship between the level of
religious involvement and blood pressure, 14
(88) found lower blood pressure (levels) among
the more religious. Levin JS, Vanderpool HY.
Social Science and Medicine 1989
2969-78. Koenig HG, McCullough ME, Larson DB.
Handbook of Religion and Health. Oxford
University Press, Inc. 2001.
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Illness PreventionSpirituality and Smoking

• Study sample Duke Central Carolina sample of
  nearly 400 adults over age 65
• Study results
• Older adults who both attended religious services
  and prayed (or read the Bible) were nine times
  less likely to smoke.
• Frequently attending services -- strongest
  predictor of not smoking (much stronger than
  prayer/Bible reading).
• Koenig HG, et al. The relationship between
  religious activities and cigarette smoking in
  older adults. J Gerontol Medical Sciences
  199853A(6)M1-M9.
• Bell R., et al. The correlates of college student
  marijuana use results of a U.S. national survey.
  Addiction 199792(5)571-81.

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Improving Treatment OutcomesSpirituality and
Elective Cardiac Surgery

• Group Participation X Religious Strength and
  Comfort
• Percent Who Died Post Surgery
• Group Participation and Strength 3
• and Comfort from Religion
• Group Participation But 7
• No Strength and Comfort from Religion
• No Group Participation But 8
• Strength and Comfort from Religion
• No Group Participation and 20
• No Strength and Comfort from Religion
• Oxman TE, Freeman DH and Manheimer ED. Lack of
  Social Participation or Religious Strength or
  Comfort as Risk Factors For Death after Cardiac
  Surgery in the Elderly. Psychosomatic Medicine.
  1995 575-15.

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Illness PreventionSuicide and Religious
Affiliation

• Studies have found that those with no Religious
  Affiliation versus those with a Religious
  Affiliation
• find suicide more acceptable
• are more likely to have suicidal ideation
• are more likely to have attempted suicide
• if providers, they have more favorable attitudes
  towards physician-assisted suicide

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Illness Prevention Mothers Religion and
Depression in their Children

• Study sample 60 mothers and their 151 children
  who were followed up 10 years later
• Study results If mothers viewed religion as
  highly important
• daughters (not sons) 60 less likely to have had
  major depressive disorder
• mothers themselves 80 less likely to have had
  major depressive episode during 10 year follow-up
• Miller, L., et al. Religiosity and depression
  ten-year follow-up of depressed mothers and
  offspring. J Am Acad Child Adolesc Psychiatry
  199736(10)1416-25.

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Bottom Line of PreventionLiving Longer
Respect for God is the beginning of wisdom and
the knowledge of the sacred is understanding. By
wisdom your days will be MULTIPLIED and the years
of your life will be INCREASED. Proverbs 910-11
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Illness Prevention Living Longer

• Study sample national sample of 21,000 U.S.
  adults with 10-year follow-up. 1987 National
  Health Interview Survey with 1997 NCHS Multiple
  Cause of Death File
• Study results
• Life expectancy gap between those who attend
  more than once a week and those who never attend
  is over 7 years.
• For Blacks, the life expectancy gap is 14 years.
• Hummer RA, et al. Religious involvement and U.S.
  adult mortality. Demography 199936(2)273-85.

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U.S. Life Expectancy at Age 20by Religious
Attendance
(n21,204)
Average Age at Death
Frequency of Attendance
Hummer et al (1999). Demography 36273-285
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Stages of death and dying Elizabeth Kubler-Ross

• talked to 400 dying patients
• knew they were dying even if not told
• they need to talk about it
• need to maintain hope, even if not hope of a cure

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• 5 stages that most dying people go through from
  the time they learn they are dying to actual
  death
• Denial
• Anger
• Bargaining
• Depression
• Acceptance
• She also described unfinished tasks of the dying
  including reconciliations, resolution of
  conflicts, and the pursuit of specific remaining
  goals.

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Breaking the news of impending death

• physician should be present
• spouse should be present if possible
• relatives need comfort, as does the patient
• use simple words, even with educated patients
• show compassion and support, do not be abrupt or
  blunt
• guessing how long a patient has to live is often
  inaccurate and unadvisable
• encourage and answer questions
• truth is not the enemy of hope
• communicate willingness to see patient through
  death
• explain the situation and introduce the next step

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Greatest fears of a dying person

• abandonment
• pain
• shortness of breath

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The Forgotten FactorSystematic Reviews of the
Findings
Of studies examining religious commitment
variables in clinical research
Family Frequency Psychiatry Medicine of
Worship Clinical harm --ALL less than
5-- Clinical benefit -- ALL greater
than 80--
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Questions That Can Be Used to Facilitate Clinical
Discussions About Patient Spirituality

• From SPIRITual History
• What does your spirituality/religion mean to you?
• What aspects of your religion/spirituality would
  you like me to keep in mind as I care for you?
• Would you like to discuss the religious or
  spiritual implications of your health care?
• As we plan for your care near the end of life,
  how does your faith impact on your decisions?
• Maugans TA. The SPIRITual history.
• Arch Fam Med 1996 511-6.

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Questions That Can Be Used to Facilitate Clinical
Discussions About Patient Spirituality

• How close do you feel to God or a higher power?
• Have you ever had an experience that convinced
  you that God or a higher power exists?
• How strongly religious (or spiritually oriented)
  do you consider yourself to be?
• McBride JL, et al. The relationship between a
  patients spirituality and health experiences.
  Fam Med 1998 30(2)122-6.
• Kass JD, et al. Health outcomes and a new index
  of spiritual experience. J Scientific Study of
  Religion 1991 30203-11.

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Taking a spiritual history. . .

• S Spiritual Belief System
• P Personal Spirituality
• I Integration in a Spiritual Community
• R Ritualized Practices and Restrictions
• I Implications for Health Care
• T Terminal Events Planning (advance directives,
  DNR wishes, DPOA etc..)

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Research tells us

• -patients want clinicians to consider spiritual
  issues
• -religious commitments are associated with
  health enhancing behaviors and attitudes
  influence preventative practices in all aspects
  of medicine
• -incorporating spiritual concepts in some areas
  of treatment enhances their relevance for
  patients
• -using religion-oriented treatments for
  religious patients may be effective for treating
  some psychiatric disorders
• -recovery from episodes of major mental illness
  may be associated with religious involvement