How to take a spiritual history and offer prayer to patients

Sometimes I want to ask my patients if I can pray with them, but I do not know how. should I take out my religious book or do an informal prayer? Is it okay to pray with someone of a different religion or someone who isn’t religious? -anon

Okey dokey, Zealous Zoey, slow down there a bit.

I recently gave a talk on this subject to my residency, so expect some long-winded-ness from me today.

Let’s talk first about some clinical reasons from the literature WHY we should address spiritual needs with our patients (1):

1. Patients often have spiritual needs related to their physical or mental illness that often go unmet.

2. These unmet needs may continue to affect their health and their ability to cope with their illness.

3. Poor coping or unaddressed spiritual needs may negatively affect health outcomes, patient compliance, medical decision-making, even length of hospital stay.

On top of those reasons, many of us who have a strong religious faith feel led to share it or use it as a way to encourage our patients. So where do you start? Can you jump right in to praying with a patient?Ummm, probably not, unless they explicitly ask you to.

Before you come to a point where you offer prayer to a patient, you need to know a bit about their religious or spiritual beliefs and background. I usually include this as a part of my social history on my own continuity clinic patients, and I’m trying to incorporate it more into my inpatient care as well. You can get the background stuff out of the way along with all of your other awkward questions about sexual history and drug use and then bring it up later as needed.

Taking a basic spiritual history is actually considered standard of care in the US, as evidenced by the fact that 90% of medical schools teach some form of this and that many major secular medical organizations including the AAFP, ACP, ACGME, and JCAHO have called for better training of doctors in this subject. It is also REQUIRED by JCAHO in the inpatient setting (2). You know JCAHO, those guys in suits that make sure your hospital is up to snuff?

Anyway, taking this history helps you be sure that

1) they would accept or appreciate your prayers or any other spiritual intervention you might be so inclined to provide.

2) you’re not forcing or coercing anyone (but rather just asking about their personal beliefs)

3) you’re not sending mixed messages to the patient.

How do you get this background information? There are several little mnemonics to help you remember the appropriate questions. I like the Open Invite method (3) described in the American Family Physician, among others.

•Open (i.e., open the door to conversation) –May I ask your faith background? –Do you have a spiritual or faith preference?
•Invite (the patient to discuss spiritual needs): –Do you feel that your spiritual health is affecting your physical health? –Does your spirituality impact your health decisions? –Is there a way in which you would like for me to account for your spirituality in your care? –Is there a way we can provide spiritual support? –Are there resources in your faith community that you would like for me to help mobilize?

When you get to the “spiritual support” bit, the patient may not know what you mean. This is where you can offer them prayer if you are comfortable with it, or chaplain services, etc. Ask them how they would like you to proceed - let them lead prayer, let you lead, pray silently, etc. If a patient does not want prayer (or doesn’t want to discuss spiritual concerns in general), you stop. You never force it on anyone. Even patients with no faith or those of different faiths will occasionally agree to prayer. As the old saying goes, “there are no atheists in the ICU”. But part of the point of asking the earlier questions is to let THEM tell you what they’re comfortable with. They may ask for a chaplain of their own faith instead of your prayers. You do what they ask.

Pulling out a religious text is usually only appropriate if you have formed a good relationship with that patient and know that this is something they would welcome.

Remember that the manner in which you address these issues will vary greatly by the culture of your town or neighborhood. In the Bible Belt where I live, I don’t usually have to go through all those questions. My patients are pretty open about their faith. But that’s not the case in other areas of the country. If a patient meets your questions about spirituality with opposition, explain to them that these questions are standard because religious and spiritual beliefs often affect a patient’s medical decision making, and as a doctor who cares, you want to be sure that you’re addressing their specific needs.

Now I understand that this is uncomfortable for A LOT of you out there. But heck, asking people about their sexual history was SUPER uncomfortable for me when I first learned it, and still is to some degree. Just because it makes you uncomfortable doesn’t mean it’s not potentially beneficial to your patient.

I’m not saying every doc should pray with their patients, but I do think every doc should be able to at least get a basic spiritual history and figure out how a person’s faith will affect their medical care. When I presented this topic to my fellow residents, over 75% of them raised their hands to indicate that they would be uncomfortable praying with a patient. That’s fine. That’s when you offer chaplain services. But addressing a spiritual history should really be a given in this bio-psycho-social model of medicine we’ve been taught to practice today.

So, Zealous Zoey, I hope this has given you some tools you can use with patients. Check the references below as well - I highly recommend the article listed from the AFP.

(1) Koenig H. ISRN Psychiatry 2012. Article ID 278730. Religion, Spirituality, and Health: The Research and Clinical Implications. http://www.hindawi.com/isrn/psychiatry/2012/278730/

(2) The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, Ill.: The Joint Commission; 2010.

(3) Saguil A, et al. The Spiritual Assessment. Am Fam Physician 2012;86(6):546-550.