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Spiritual Assessment in Clinical Care

Part 1: The Basics
by Walt Larimore, MD

Editor's Note: A shorter version of this article was released in the spring 2015 edition of Today's Christian Doctor.


About 25 years ago, while sharing an early morning cup of coffee with my dear friend and practice partner, family physician John Hartman, MD, he asked, “Walt, how come we don’t bring our faith to work with us more often?”

It was a question the Lord used to convict me of the fact that although my personal relationship with God was the primary and most important relationship in my life, more often than not I tended to leave Him at the door when entering the hospital or medical office.

Over several years, John and I prayed about and explored ways in which we might incorporate a number of spiritual interventions into our practice, including, but not limited to, faith flags, faith stories, faith prescriptions, praying for and with patients, spiritual consults and referrals and incorporating a spiritual assessment.

The fruit we experienced eventually led to my working with William C. Peel, ThM, and CMDA to develop the Saline Solution[1] in the mid-1990s and, more recently, Grace Prescriptions.[2] Feedback from tens of thousands of attendees from these conferences and small-group curricula from around the world indicate that these interventions have revolutionized their witness for Christ and their satisfaction with practice. In the first part of this two-part article, we’re going to explore the basics of spiritual assessment in clinical care.

Are spiritual assessments important?

The value of religiousness and/or spirituality (R/S) to patients and health professionals is underscored by lay polls, medical research, undergraduate curricula, recommendations of professional organizations, government regulations and clinical practice guidelines.

The most recent data from Gallup indicate 86 percent of adults in the United States believe in God and that 78 percent consider religion either very important (56 percent) or important (22 percent).[3]

Similarly, more than 80 percent of physicians identify themselves as Protestant, Catholic or Jewish; 79 percent identify themselves as very or somewhat strong in their beliefs;[4] and 78 percent feel somewhat or extremely close to God.[5] Another informal survey of physicians revealed that 99 percent believe religious beliefs can heal and 75 percent believe others’ prayers can promote healing.[6]

Studies demonstrate that up to 94 percent of hospitalized patients believe spiritual health is as important as physical health,[7] 40 percent of patients use faith to cope with illness[8] and 25 percent of patients use prayer for healing each year.[9]

According to Duke University psychiatrist Harold Koenig, MD, “Nearly 90% of medical schools (and many nursing schools) in the U.S. include something about (religion or spirituality) in their curricula and this is also true to a lesser extent in the UK and Brazil. Thus, spirituality and health is increasingly being addressed in medical and nursing training programs as part of quality patient care.”[10]

Numerous health professional organizations call for greater sensitivity and training concerning the management of religious and spiritual issues in the assessment and treatment of patients.[11] For example, the Joint Commission, whose certification is a requirement for organizations receiving government payment (i.e., Medicare and Medicaid), now requires a spiritual assessment for patients cared for in hospitals or nursing homes or by a home health agency.[12],[13]

Guidelines from the Institute for Clinical Systems Improvement state that addressing spirituality “may help in creating comprehensive treatment plans for those with chronic pain,”[14] and guidelines from the National Consensus Project for Quality Palliative Care state that “spirituality is a core component of palliative care.”[15]

Also, the Institute of Medicine recommends, “Physicians and other clinicians must do a better job of caring for patients with advanced illness who are approaching death … (and) should pay more attention to these patients’ social, emotional and spiritual needs.” They propose that a “core component of end-of-life care” includes “frequent assessment of the patient’s emotional, social and spiritual wellbeing” and “attention to the patient’s spiritual needs.”[16]

Health professionals who don’t take a spiritual history are often surprised to learn how frequently spirituality affects their patient encounters and how open their patients are to their inquiry. For example, one study of 456 outpatients at six academic medical centers found that in the ambulatory setting, 33 percent wanted their physician to inquire about religious beliefs and 19 percent wanted their physician to pray with them. However, when dying, this increased to 70 percent who would want their care providers to know their beliefs and 50 percent would want their health professional to pray with them.[17]

Another hospital study showed that 77 percent of inpatients felt that physicians should consider their spiritual needs and 48 percent wanted their physician to pray with them.[18] Other studies have also found that hospitalized or terminally ill patients are much more likely to welcome a spiritual assessment.[19]

In another large national survey, 83 percent of respondents wanted physicians to ask about spiritual beliefs in at least some circumstances. The most acceptable scenarios for spiritual discussion were life-threatening illnesses (77 percent), serious medical conditions (74 percent) and loss of loved ones (70 percent). Among those who wanted to discuss spirituality, the most important reason for discussion was a desire for physician-patient understanding (87 percent). Patients believed that information concerning their spiritual beliefs would affect physicians’ ability to encourage realistic hope (67 percent), give medical advice (66 percent) and change medical treatment (62 percent).[20]

Another review noted, “In general, the public appears to view and value spirituality as a central factor of life when facing illness and desires healthcare professionals to inquire about beliefs that are important to them;”[21] while another added, “Most patients desire to be offered basic spiritual care by their clinicians,” and, “censure our professions for ignoring their spiritual needs.”[22] Another review concluded, “The majority of patients would not be offended by gentle, open inquiry about their spiritual beliefs by physicians. Many patients want their spiritual needs addressed by their physician directly or by referral to a pastoral professional.”[23] 

This patient need only seems to be growing. One recent review found that “studies have shown that (up to) 90% of patients (depending on the setting) want physicians to address their spiritual needs,” and emphasizes that “the ability to identify and address patient spiritual needs has become an important clinical competency.”[24]

Why aren’t more health professionals doing spiritual assessments?

Nevertheless, most ambulatory and hospitalized patients report that no health professional has ever discussed spiritual or religious beliefs with them,[25],[26] even though 85 to 90 percent of physicians felt they should be aware of patient spiritual orientation.[27],[28] In fact, our most recent national data (now about 10 years old) reveals that only 9 percent of patients have ever had a health professional inquire about their R/S beliefs.[29]

So why do health professionals ignore this “important core competency” of quality patient care? When asked to identify barriers to the spiritual assessment, family physicians in Missouri pointed to a lack of time (71 percent), lack of experience taking spiritual histories (59 percent) and difficulty identifying patients who wanted to discuss spiritual issues (56 percent).[30]

In my anecdotal experience teaching spiritual interventions to health professionals over the last 20 years, I have seen the same concerns expressed time and time again. In fact, CMDA’s Saline Solution[31] and Grace Prescriptions[32] conferences and small-group studies were designed specifically to address these apprehensions.

Yet, one review on spiritual assessment concluded:

Assessing and integrating patient spirituality into the health care encounter can build trust and rapport, broadening the physician-patient relationship and increasing its effectiveness. Practical outcomes may include improved adherence to physician-recommended lifestyle changes or compliance with therapeutic recommendations. Additionally, the assessment may help patients recognize spiritual or emotional challenges that are affecting their physical and mental health. Addressing spiritual issues may let them tap into an effective source of healing or coping.

Furthermore, as Koenig points out, in difficult situations (problems that cause suffering, such as incurable disease, chronic pain, grief, domestic violence and broken relationships), providing comfort to patients can increase professional satisfaction and prevent burnout.[33]

From the perspective of the health professional, a spiritual assessment, included routinely in the patient’s social history, provides “yet another way to understand and support patients in their experience of health and illness.”[34]

How do I do a spiritual assessment?

Before you get started, I must share this caution from Stephen Post, PhD: “Professional problems can occur when well-meaning healthcare professionals ‘faith-push’ a patient opposed to discussing religion.” However, on the other side of the coin, “rather than ignoring faith completely with all patients, most of whom want to discuss it, we can explore which of our patients are interested and who are not.”[35]

Simply put, a spiritual assessment can help us do this with each patient we see. We can potentially gain the following from a spiritual assessment:

  • The patient’s religious background,
  • The role that religious or spiritual beliefs or practices play in coping with illness (or causing distress),
  • Beliefs that may influence or conflict with decisions about medical care,
  • The patient’s level of participation in a spiritual community and whether the community is supportive, and
  • Any spiritual needs that might be present.[36]

The Joint Commission writes:[37]

Spiritual assessment should, at a minimum, determine the patient’s denomination, beliefs and what spiritual practices are important to the patient … This information would assist in determining the impact of spirituality, if any, on the care/services being provided and will identify if any further assessment is needed.

Several fairly-easy-to-use mnemonics have been designed to help health professionals conduct a spiritual assessment including, but by no means limited to, the SWBS,[38] SIBS,[39] SIWB,[40] HOPE,[41] FICA,[42] SPIRITual,[43] FAITH,[44] CSI MEMO,[45] ACP/ASIM[46] and the Open/Invite[47] tools. Since the mid-1990s, in CMDA’s Saline Solution, we’ve taught the “GOD” spiritual assessment:

  • G = God:
    • May I ask your faith background? Do you have a spiritual or faith preference? Is God, spirituality, religion or spiritual faith important to you now, or has it been in the past?
  • O = Others:
    • Do you now meet with others in religious or spiritual community, or have you in the past? If so, how often? How do you integrate with your faith community?
  • D = Do:
    • What can I do to assist you in incorporating your spiritual or religious faith into your medical care? Or, is there anything I can do to encourage your faith? May I pray with or for you?

However, each of these spiritual assessment tools, including mine, fail to inquire about a critical item involving spiritual health: any religious struggles the patient may be having. A robust literature shows religious struggles can predict mortality, as there is an inverse association between faith and morbidity and mortality of various types.[48] In Part 2 of this article, I’ll review that literature with you and show you a new tool I’m using in my practice to address this factor.

Conclusion
George Washington Crile, Jr. was the son of a famous surgeon who was a founding partner of the Cleveland Clinic. After graduating from Yale and earning his MD from Harvard Medical School in 1933 (summa cum laude and first in his class), he returned to the Cleveland Clinic and became the head of general surgery.[49] In his book Cancer and Common Sense he wrote, “No physician, sleepless and worried about a patient, can return to the hospital in the midnight hours without feeling the importance of his faith. … No physician entering the hospital in these quiet hours can help feeling that the medical institution of which he is part is in essence religious, that it is built on trust. No physician can fail to be proud that he is part of his patient’s faith.”[50]

Sir William Osler, one of the four founding professors of Johns Hopkins Hospital and frequently described as the “Father of Modern Medicine,” [51] wrote “Nothing in life is more wonderful than faith…the one great moving force which we can neither weigh in the balance nor test in the crucible—mysterious, indefinable, known only by its effects, faith pours out an unfailing stream of energy while abating neither jot nor tittle of its potence.”[52]

Psychotherapist Arthur Kornhaber, MD, reflected, “To exclude God from a medical consultation is a form of malpractice. … Spirituality is wonder, joy, and shouldn’t be left in the clinical closet.”[53]

You can experience that driving force of faith when you apply these principles of spiritual assessment in your practice of healthcare, thereby allowing you to minister to your patients in ways you never imagined possible, while also increasing personal and professional satisfaction. One doctor recently shared with me, “Ministering in my practice has allowed God to bear fruit in and through me in new and wonderful ways. I can’t wait to see what He’s going to do in and through me each day. My practice and I have been transformed.”

Are you ready to be transformed? Visit www.cmda.org/graceprescriptions to start learning how to share your faith in your practice.

Look for Part 2 of Dr. Larimore’s article in the fall 2015 edition of Today’s Christian Doctor.

Bibliography

[1] Larimore, W, Peel, WC. The Saline Solution: Sharing Christ in a Busy Practice. Christian Medical & Dental Associations. Bristol, TN. 2000.

[2] Larimore W, Peel WC. Grace Prescriptions. Christian Medical and Dental Associations. Bristol, TN. 2014. See: http://bit.ly/1yAtR1L. Accessed November 21, 2014.

[3] Gallup, Inc. Religion. http://www.gallup.com/poll/1690/Religion.aspx?version=print. Accessed November 21, 2014.

[4] King DE, Sobal J, Haggerty J III, Dent M, Patton D. Experiences and attitudes about faith healing among family physicians. J Fam Pract. 1992;35(2):158–162.

[5] Daaleman TP, Frey B. Spiritual and religious beliefs and practices of family physicians: a national survey. J Fam Pract. 1999;48(2):98–104.

[6] Larimore WL. Providing Basic Spiritual Care for Patients: Should It Be the Exclusive Domain of Pastoral Professionals? Am Fam Physician. 2001(Jan 1);63(1):36-41.

[7] King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994;39(4):349–352.

[8] Koenig HG. Religious attitudes and practices of hospitalized medically ill older adults. Int J Geriatr Psychiatry. 1998;13(4):213–224.

[9] Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993;328(4):246–252.

[10] Koenig, HG. Religion, Spirituality, and Health: The Research and Clinical Implications. ISRN Psychiatry. 2012;Article ID 278730.

[11] Puchalski, CM. Taking a Spiritual History: FICA. Spirituality and Medicine Connection. 1999:3:1.

[12] Koenig, HG. Spirituality in Patient Care. Why, How, When, and What. 2nd Ed. Templeton Press. West Conshohocken, PA. 2007:188–227.

[13] Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. The Joint Commission. Oakbrook Terrace, IL. 2010. (This document mentions spirituality throughout, but see especially pp. 15, 21-22, 27, and 85. See: http://bit.ly/1vx3NXA and http://bit.ly/1r668Cj. Accessed November 21, 2014).

[14] Institute for Clinical Systems Improvement. Assessment and management of chronic pain. Institute for Clinical Systems Improvement. Bloomington, MN. 2011.

[15] National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 2nd ed. National Consensus Project for Quality Palliative Care. Pittsburgh, PA. 2009.

[16] Graham J. IOM Report Calls for Transformation of End-of-Life Care. JAMA. 2014;312(18):1845-1847.

[17] MacLean CD, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality. J Gen Intern Med. 2003;18(1):38–43.

[18] King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994;39(4):349–352.

[19] MacLean CD, Susi B, Phifer N, et al. Ibid.

[20] McCord G, Gilchrist VJ, Grossman SD, et al. Discussing spirituality with patients: a rational and ethical approach. Ann Fam Med. 2004(Jul/Aug);2(4):356-361.

[21] Hatch, RL, Burg, MA, Naberhaus, DS, et al. The Spiritual Involvement and Beliefs Scale. Development and testing of a new instrument. J Fam Prac. 1998(Jun);46(6):476-486.

[22] Larimore WL, Parker M, Crowther M. Should clinicians incorporate positive spirituality into their practices? What does the evidence say? (Review) Ann Behav Med. 2002(Feb);24(1):69-73.

[23] McLean, CD, Susi, B, Phifer, N, et al. Patient Preference for Physician Discussion and Practice of Spirituality. Results From a Multicenter Patient Survey. J Gen Int Med. 2003(Jan);18(1):38–43.

[24] Katz PS. Patients and prayer amid medical practice. ACP Internist. 2012(Oct).

[25] King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994;39(4):349–352.

[26] Maugans TA, Wadland WC. Religion and family medicine: a survey of physicians and patients. J Fam Pract. 1991;32(2):210–213.

[27] Monroe MH, Bynum D, Susi B, et al. Primary care physician preferences regarding spiritual behavior in medical practice. Arch Intern Med. 2003;163(22):2751–2756.

[28] Luckhaupt SE, Yi MS, Mueller CV, et al. Beliefs of primary care residents regarding spirituality and religion in clinical encounters with patients: a study at a midwestern U.S. teaching institution. Acad Med. 2005;80(6):560–570.

[29] McCord G, Gilchrist VJ, Grossman SD, et al. Discussing spirituality with patients: a rational and ethical approach. Ann Fam Med. 2004(Jul/Aug);2(4):356-361.

[30] Ellis MR, Vinson DC, Ewigman B. Addressing spiritual concerns of patients: family physicians' attitudes and practices. J Fam Pract. 1999;48(2):105–109.

[31] Larimore, W, Peel, WC. The Saline Solution. Ibid.

[32] Larimore, W, Peel, WC. Grace Prescriptions. Ibid.

[33] Koenig HG. Spirituality in Patient Care: Why, How, When, and What. 2nd ed. Templeton Foundation Press. Philadelphia, PA. 2007:72–89.

[34] Saguil, A, Phelps, K. The Spiritual Assessment. Am Fam Phys. 2012(Sep 15);86(6):546-550.

[35] Post SG. Ethical Aspects of Religion in Healthcare. Mind/Body Medicine: J Clin Behav Med. 1996;2(1):44-48.

[36] Koenig, HG. Religion, Spirituality, and Health: The Research and Clinical Implications. ISRN Psychiatry. 2012. http://bit.ly/1wnA4iP.  Accessed December 13, 2014.

[37] Advancing Effective Communication. Ibid.

[38] Paloutzian RF, Ellison CA. Manual for the Spiritual Well-Being Scale. Life Advance, Inc. Nyack, NY. 1982.

[39] Hatch RL, Burg MA, Naberhaus DS, et al. The Spiritual Involvement and Beliefs Scale. Development and testing of a new instrument. J Fam Pract. 1998;46:476–486.

[40] Daaleman TP, Frey BB. The Spirituality Index of Well-Being: A New Instrument for Health-Related Quality-of-Life Research. Ann Fam Med 2004;2:499-503.

[41] Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Phys. 2001;63(1):81–89.

[42] FICA Spiritual Assessment Tool. The George Washington. Institute for Spirituality and Health. Washington, DC. 2014. http://bit.ly/1y07swq. Accessed November 21, 2014.

[43] Maugans, TA. The SPIRITual History. Arch Fam Med. 1996(Jan);5(1):11-16.

[44] King, DE. Spirituality and Medicine. In Mengal, MB, Holleman, WL, Fields, SA (eds). Fundamentals of Clinical Practice: A textbook on the Patient, Doctor, and Society. Springer Publishing. New York, NY. 2002:651-659.

[45] Koenig, HG. An 83-Year-Old Woman With Chronic Illness and Strong Religious Beliefs. JAMA. 2002;288(4):487-493.

[46] Lo B, Quill T, Tulsky J. Discussing palliative care with patients. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Ann Int Med. 1999(May 4);130(9):744-749.

[47] Saguil, A, Phelps, K. The Spiritual Assessment. Am Fam Phys. 2012(Sep 15);86(6):546-550.

[48] Pargament, K, Koenig, HG, Tarakeshwar, N, et al. Religious struggle as a predictor of mortality among medically ill elderly patients: a two-year longitudinal study. Arch Int Med. 2001(Aug);161(15):1881-1885.

[49] George Crile, Jr. Wikipedia. 2014. http://bit.ly/1uAlIGL. Accessed December 13, 2014.

[50] Crile, GW. Cancer and Common Sense. Viking Press. New York, NY. 1955. Quoted in: Aronowitz RA. Unnatural History: Breast Cancer and American Society. Cambridge University Press. Cambridge, England. 2007: 190.

[51] William Osler. Wikipedia. 2014. http://bit.ly/1wsfixo. Accessed December 13, 2014.

[52] Osler W. The faith that heals. BMJ. 1910;2:1470–1472.

[53] Woodward K. Talking to God. Newsweek. 1992(Jan 6);119:40.


Part 2: The LORD's LAP
by Walt Larimore, MD

Editor's Note: A shorter version of this article was released in the fall 2015 edition of Today's Christian Doctor.


In Part 1 of this article, we discussed how a spiritual assessment of each patient is now considered a core component of quality patient care. Since the mid-1990s, I’ve taught the “GOD” spiritual assessment in CMDA’s Saline Solution and Grace Prescriptions conferences and small-group curricula. The “GOD” questions can be used when you take a social history from a patient:

  • G = God:
    • May I ask your faith background? Do you have a spiritual or faith preference? Is God, spirituality, religion or spiritual faith important to you now, or has it been in the past?
  • O = Others:
    • Do you now meet with others in religious or spiritual community, or have you in the past? If so, how often? How do you integrate with your faith community?
  • D = Do:
    • What can I do to assist you in incorporating your spiritual or religious faith into your medical care? Or, is there anything I can do to encourage your faith? May I pray with or for you?

I’ve used this assessment with hundreds and hundreds of new patients over the last 25 years; however, this spiritual assessment tools, like most described in the medical literature, fails to inquire about a critical item involving spiritual health: religious struggle.

A developing and robust literature shows religious struggle can predict mortality, as there has been shown to be an inverse association between faith and morbidity and mortality of various types. For example, a study conducted among inpatients at the Duke University Medical Center found patients (>55 years of age) who felt alienated from or unloved by God or attributed their illnesses to the devil were associated with a 16 percent to 28 percent increase in risk of dying during a two-year follow-up period, even when all other measured factors were controlled.[i]

I call these religious struggles the “LAP factors:”

  • L = Loved:
    • Patients who “questioned God's love for me” had a 22 percent increased risk of mortality.
  • A = Abandoned:
    • Patients who "wondered whether God had abandoned me" had a 28 percent increased risk of mortality.
  • P = Punished:
    • Patients who “felt punished by God for my lack of devotion” had a 16 percent increased risk of mortality over the two years after hospital discharge, while those who “felt punished by the devil or “decided the devil made this happen” had a 19 percent increased risk of mortality.

One study of outpatients with diabetes, congestive heart failure or cancer found that while 52 percent reported no religious struggle, 15 percent reported moderate or high levels of religious struggle. Even younger patients reported high levels of religious struggle, and religious struggle was associated with higher levels of depressive symptoms and emotional distress in all three patient groups.[ii] A study of patients with myeloma found that negative religious coping “predicted worse post-transplant anxiety, depression, emotional well-being and transplant-related concerns” and that “religious struggle may contribute to adverse changes in health outcomes for transplant patients.”[iii]

While further research is needed on religious struggle, what is clear is that “clinicians should be attentive to signs of religious struggle” and “where patient’s responses indicate possible religious struggle, clinicians should consider referral to a trained, professional chaplain or pastoral counselor.”[iv]

Furthermore, should we as health professionals not inquire about these religious struggles, “Such patients may, without their doctor’s encouragement, refuse to speak with clergy because they are angry with God and have cut themselves off from this source of support.”[v]

A New Tool
When I began to realize the importance of these religious struggle factors and that I, as the health professional, needed to inquire about this, I developed and began using and teaching to my students and residents a new tool I call the “LORD’s LAP” assessment:

  • L = Lord
  • O = Others
  • R = Religious struggles or relationship
  • D = Do

The “L,” “O,” and “D” questions of the “LORD’s LAP” tool are identical to the “GOD” questions. It’s the “R” part of this acrostic that’s new for me. After completing the “L” and “O” questions, I usually have a pretty good idea if the patient is a religious believer or not. Now, I’m not referring to whether they are a Christian or not, just whether they are or have been a religious believer. If so, I need to ask about any religious struggles they may have. To do this, I use what I call the “LAP” questions,” which are based upon the factors discussed above:

  • Love: Has this illness caused you to question God’s love for you?
  • Abandon: Has this illness led you to believe God has abandoned you? Have you asked God to heal you and He hasn’t?
  • Punish: Do you believe God or the devil is punishing you for something? 

If the patient answers positively to any of these questions, then the patient’s risk of mortality may be significantly increased over similar patients not experiencing religious struggle. If the patient does indicate they are having a religious struggle, then I need to either consult with or refer them to a pastor or Christian psychological professional. Or, if I feel comfortable providing spiritual counsel, it certainly would be indicated.

Now, it’s important to point out that I don’t usually take such actions immediately, as the patient likely has more pressing health concerns. But I also no longer ignore religious struggle, which I did for so many years. Furthermore, for the patient with religious struggle, I need to record this on the patient’s problem list. In fact, diagnostic coding systems have codes that can be applied to spiritual or religious struggles or problems (ICD-9-CM: “V62.89, psychological or physical stress, not elsewhere classified,” including “a religious or spiritual problem,”[vi] and ICD-10-CM: “Z65.8, other specified problems related to psychosocial circumstances,” including “a spiritual problem”[vii]).

If the “L” and “O” questions reveal my patient has no religious or spiritual interests or beliefs at all, then the religious struggle (LAP) questions would not be indicated. So, for these patients, I briefly indicate I am in the “LORD’s LAP.”

First of all, I thank the patient for their honesty, let them know I’m aware how difficult it can be to discuss religious or spiritual beliefs and tell them I appreciate their trust. Then I might share a brief testimony that may be something like, “Even though religion and spirituality are not important to you now, I often see patients who, when facing a health crisis or decision, will begin to have spiritual thoughts or questions. When I was younger, I had similar questions that resulted in my coming into a personal relationship with God. I just want you to know that if you ever want to discuss these things, just let me know.”

Or, I might say something like this: “Well, I want you to know that when I was younger I also had no interest in religion or spirituality. And then, when I learned how I could have a personal relationship with God, it changed my life, particularly in the area of prayer. So, if at any time you’d like me to pray with you or for you, just let me know. I’d be happy to do so.”

Then, the final step of the “LORD” acrostic involves the “Do” questions. For believers, I might ask, “What can I do to assist you in incorporating your spiritual or religious faith into your medical care? Do you have any spiritual beliefs of which I need to be aware?” Or, “Is there anything I can do to encourage your faith? Do you need any spiritual resources or to see a chaplain?” Or for a hospitalized patient I may add, “May I have the staff let your pastoral professional know you’re here?” For believers and non-believers, I may ask, “May I pray with or for you?”

Putting It into Practice

I remember the first patient with whom I used the “LAP” questions. I was rounding on a middle age man who had been admitted in respiratory distress secondary to bilateral pulmonary effusions secondary to lung cancer. During my social history, he indicated he frequently attended church and had done so since childhood. He prayed and studied the Bible, even memorizing dozens of verses. In the past, I would have offered to pray with and for him. But this day I asked him the LAP questions.

I started with the “L” question: “Does this cause you to question God’s love for you?” His response surprised me as his lips began to tremble and his eyes watered. He could only nod his head.

I then asked the “A” question: “Do you think God’s abandoned you?” His head dropped into his hands and he wept for a few moments. When he composed himself, he whispered, “I’ve asked Him again and again to heal me, and He hasn’t. Even went to a healing service. No luck there, either.”

Taken aback a bit, I pressed on with the “P” question: “Do you believe God or the devil is punishing you for something?” Big tears continued to streak down his cheeks as he confessed, “I’ve sinned in so many ways. I’m sure this is God’s punishment of me.” I was grateful for his honesty, but even more grateful to the Lord for teaching me this new way to approach patients.

Another patient, a lifelong, devout Buddhist who immigrated to the U.S. from Myanmar, shared that she was sure her chronic dermatitis was punishment from God for her lack of devotion. A Muslim patient, when asked about divine punishment as a cause for his injuries from a traumatic fall, looked at me as if I had two heads, smiled and replied, “Of course God’s punishing me. What other explanation could there be?”

With these, and many other patients who have openly shared with me about their religious struggles, I simply would not have known had I not asked. In fact, over the 25 years in which I took spiritual assessments from my patients, I can only remember a few who spontaneously shared their religious struggles with me when I didn’t inquire. I can only wonder how many opportunities for significant spiritual impact passed by because I did not know how to ask.

Conclusion
In the last two years of systematically asking my religious or spiritual patients the “LAP” questions, my impression is that about one of five patients confesses to me one or more religious struggles. I’m thankful I’ve learned this new skill and pleased to see the many ways it helps me bear witness to God and His grace in my practice each day.

One large review concluded, “The available data suggest that practitioners who make several small changes in how patients’ religious commitments are broached in clinical practice may enhance healthcare outcomes.”[viii]

In a systematic review I published, my co-authors and I concluded, “Until there is evidence of harm from a clinician's provision of either basic spiritual care or a spiritually sensitive practice, interested clinicians and systems should learn to assess their patients’ spiritual health and to provide indicated and desired spiritual intervention.”[ix]

Duke University psychiatrist Harold Koenig, MD, writes, “At stake is the health and wellbeing of our patients and the satisfaction that we as healthcare providers experience in delivering care that addresses the whole person—body, mind and spirit.”[x]

Most of all, a spiritual assessment allows us, as followers of Jesus and Christian health professionals, to find out where our patients are in their spiritual journeys. It allows us to see if God is already at work in their lives and join Him there in His work of drawing men and women to Himself.                                                                              

Are you ready to start using these techniques in your practice? Visit www.cmda.org/graceprescriptions to learn how to share your faith in your practice.


[i] Pargament, K, Koenig, HG, Tarakeshwar, N, et al. Religious struggle as a predictor of mortality among medically ill elderly patients: a two-year longitudinal study. Arch Int Med. 2001(Aug);161(15):1881-1885.

[ii] Fitchett G, Murphy PE, Kim J, et al. Religious struggle: Prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients. Int J Psych Med. 2004;34(2):179-196.

[iii] Sherman AC, Plante TG, Simonton S, et al. Prospective study of religious coping among patients undergoing autologous stem cell transplantation. J Behav Med. 2009(Feb);32(1):118-128.

[iv] Fitchett. Ibid.

[v] Koenig HG. An 83-Year-Old Woman With Chronic Illness and Strong Religious Beliefs. JAMA. 2002;288(4):487-493.

[vi] World Health Organization. International Statistical Classification of Diseases and Related Health Problems, 9th Revision (ICD-10). WHO. Geneva, Switzerland.

[vii] World Health Organization. International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) . WHO. Geneva, Switzerland.

[viii] Matthews DA, McCullough ME, Larson DB, et al. Religious commitment and health status: A review of the research and implications for family medicine. Arch Fam Med. 1998(Mar);7(2):118-124.

[ix] Larimore, WL, Parker, M, Crowther, M. Should clinicians incorporate positive spirituality into their practices? What does the evidence say? Ann Behav Med. 2002 Winter;24(1):69-73.

[x] Koenig, HG. Religion, Spirituality, and Health: The Research and Clinical Implications. ISRN Psychiatry. 2012;Article ID 278730.