Transcript Spirituality and Health Care

Spirituality and Health
Care
Anita S. Kablinger MD
Associate Professor
Psychiatry and Pharmacology
Audience Participation
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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
Definitions
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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.
Religion/Spirituality
Involvement in Medicine:
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-JCAHO requires routine assessment of spirituality needs
-APA issued “Guidelines Regarding Possible Conflict
Between Psychiatry’s Religious Commitment and Psychiatry’s
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
Background
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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.
Scientist and Clinician Beliefs:
Rates of Atheism and Agnosticism
U.S. Population
6%
American Men and Women
of Science: 1916 and 1996
Vermont Family Practitioners
Psychologists
Psychiatrists
55%
36%
28%
21%
Bergin and Jensen, Psychotherapy, 1990, 27:3-7.
Maugans and Wadland, Journal of Family Practice,
1991, 32:210-213.
Myths about religion and
health care:
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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
Benefits to clinicians of
religious/spirituality focus:
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-communicates to patient that their life experience is of
interest and value to them
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-increases understanding of clinical condition’s association
with a religious-spiritual problem
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-allows the development of a case formulation of
interpersonal responses and psychiatric patterns
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-identifies areas of support and community involvement
that may be helpful adjuncts to treatment
Reasons to acknowledge and support
a patient’s spirituality:
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-people regard spiritual and physical health as
equally important
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-enhances coping and quality of life during illness
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-enhances cultural sensitivity
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-enriches the doctor/patient relationship
Barriers (reasons doctors have
problems assessing religion/
spirituality):
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-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
Illness Prevention:
Spirituality 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 1998;10(4):504-531.
Patient Need:
Patient Views Regarding
Spirituality When Seriously Ill
Pulmonary
Patients
Consider self religious
51%
Welcome religious questions in medical history
66%
Not welcome religious questions
Physician asking about their spiritual or religious
beliefs would increase trust in the physician
Ehman JW, Ott BB, Short TH. Archives of Internal Medicine 1999;159 (15):1803-1806.
16%
66%
Recovery from Surgery:
Hip 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 1990;147:758-760.
Those who are religious
tend to demonstrate:
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-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
Illness Prevention:
Substance 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 1998;93(7):979-90.
Illness Prevention:
Spirituality and Marijuana Use
Survey undertaken by Harvard School of Public Health and
University of Michigan’s 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;
581.
92(5);571-
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 change…however 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;
581.
92(5);571-
Patient Need:
Social Histories of Chronic Drug and
Alcohol 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
Mother’s Religious Involvement
Father’s Religious Involvement
During Adolescence: Increased
Religious Interest
no difference
one-half
one-fifth higher
three-fourths
one-fourth
one-eighth
4 times greater
4½ times greater
During Adolescence: Decreased
Religious Interest
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.
Illness Prevention
Spirituality 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 Man’s Blood Pressure”.
Journal of Religion & Health. 1989;28(4):265-278.
Systematic Review
A 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; 29:69-78.
Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health. Oxford University Press, Inc. 2001.
Illness Prevention:
Spirituality 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.
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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 1998;53A(6):M1-M9.
Bell R., et al. The correlates of college student marijuana use: results of a U.S.
national survey. Addiction 1997;92(5):571-81.
Improving Treatment Outcomes
Spirituality and Elective Cardiac Surgery
Group Participation X Religious Strength and Comfort
Percent Who Died Post Surgery:
1)
Group Participation and Strength
and Comfort from Religion
3%
2)
Group Participation But
No Strength and Comfort from Religion
7%
3)
No Group Participation But
Strength and Comfort from Religion
8%
4)
No Group Participation and
No Strength and Comfort from Religion
20%
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; 57:5-15.
Illness Prevention
Suicide and Religious Affiliation
Studies have found that those with no Religious Affiliation
versus those with a Religious Affiliation:
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3)
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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
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 1997;36(10):1416-25.
“Bottom Line” of Prevention:
Living 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 9:10-11
Illness Prevention:
Living Longer
Study sample: national sample of 21,000 U.S. adults with 10year follow-up. 1987 National Health Interview Survey with
1997 NCHS Multiple Cause of Death File
Study results:
1. “Life expectancy gap between those who attend more than
once a week and those who never attend is over 7 years.”
2. For Blacks, the life expectancy gap is 14 years.
Hummer RA, et al. Religious involvement and U.S. adult mortality. Demography
1999;36(2)273-85.
U.S. Life Expectancy at Age 20
by Religious Attendance
(n=21,204)
85
Blacks
Whites
75
65
Never
<1/wk-1/wk
>1/wk
Frequency of Attendance
Hummer et al (1999). Demography 36:273-285
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:
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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:
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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
Greatest fears of a dying person:
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abandonment
pain
shortness of breath
The Forgotten Factor:
Systematic Reviews of the Findings
Of studies examining religious commitment
variables in clinical research:
Psychiatry
Clinical harm
Clinical benefit
Family
Medicine
Frequency
of Worship
--ALL less than 5%--- ALL greater than 80%--
Questions That Can Be Used to Facilitate
Clinical Discussions About Patient Spirituality
From “SPIRITual History:”
1. What does your spirituality/religion mean to you?
2. What aspects of your religion/spirituality would you like
me to keep in mind as I care for you?
3. Would you like to discuss the religious or spiritual
implications of your health care?
4. 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; 5:11-6.
Questions That Can Be Used to Facilitate
Clinical Discussions About Patient Spirituality
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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 patient’s 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; 30:203-11.
Taking a spiritual history. . .
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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..)
Research tells us:
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-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