Spiritual care should be deferred to chaplains
Set stage properly to avoid negligence
Does a physician have an ethical obligation to assist patients with spiritual matters? The answer is mixed, depending on who you ask.
The lack of physician attentiveness to matters of the spirit "can constitute a form of negligence," says David Larson, MD, president of the National Institute of Healthcare Research in Rockville, MD.
In an article published in the April 4, 2000, edition of the Annals of Internal Medicine1, Larson and his colleagues argue that spiritual care is very appropriate for almost all patients suffering from chronic disease, especially those with terminal illnesses. However, the stage must be set properly, and the person who should deliver that type of care should, in most cases, be a chaplain, he says.
"It simply doesn’t work if a physician or other health care professional inquires about the patient’s religion or spiritual beliefs on the fourth or fifth appointment. The patient might, appropriately, consider it intrusive," says Larson. "But if it is a routine part of the case history, asked on the first visit, it is appropriate and usually well-accepted by patients and viewed as an opportunity to express their spirituality in a respectful and supportive clinical environment."
"It would be disrespectful and not beneficial or supportive of autonomy to encourage patients to get religious or spiritual beliefs if they do not have them," he cautions.
Larson, whose organization encourages professional collaboration to advance the understanding of spirituality and health and develops educational programs, says the chaplain plays a key role in the health care team, "although very few doctors even know about their existence."
Referral to a chaplain for the deep matters of spirit is not only helpful, it is essential, Larson says. He recalls when he was in medical school and even in the early years of internship and residency, he was completely unaware of the presence of chaplains. "Our concern is that when doctors don’t address something, it doesn’t happen."
"We don’t want to make doctors into ministers or chaplains. We just want to let them know chaplains are available when the questions get to be more than they are prepared to deal with because of time constraints or lack of expertise," says Larson.
He notes that patients turn to their belief systems, whatever those might be, in times of crisis, and they are basic concerns not necessarily tied to any particular religious tradition. "Spirituality is the functioning thing. Spirituality is what’s important, whether it’s through a church, mosque, temple, or 12-step program."
Physicians need to recognize those belief systems and support them but should never proselytize, Larson stresses.
He also warns of the importance of professional boundaries, even though those may be somewhat blurred in the mind of the patient. "The pressure to blur the boundaries between the professions comes from patients," he wrote. "For example, about half the patients indicate a desire to have physicians pray with them. If this finding is accurate, physicians might find a need to explain to patients why such activities usually fall best under the purview of competent pastoral care."
He suggests that physicians and nurses tell their patients that chaplains have higher degrees of competency because of their specialized training.
Larson agrees with Richard P. Sloan, PhD, associate professor of psychiatry at Columbia University College of Physicians and Surgeons in New York City, that the physician’s influence, almost deified until very recently, might result in the coercion of patients or the perception on the patient’s part that an even greater power than would occur without religious sanction. (See cover story.)
Larson offers these examples: "We would not condone a Jesuit medical geneticist who maintains that it is appropriate and nondirective’ to wear his clerical collar while doing reproductive genetic counseling in a non-Roman Catholic health care setting. Nor would we want the clinician in a nonreligious health care institution to raise the question, Have you accepted the Lord?’ Many patients would be confused and rightly offended," he says.
Larson disagrees with the proposal for a return to the times of the healer-priests and argues that in the past 30 years, the medical profession has made a concerted effort to demystify itself, with a special effort to change the image of the paternalistic omnipotent physician.
Learning more about spiritual concerns
Yet at the same time, Larson advocates the education of health care professionals so they can better understand the spiritual concerns that arise in a clinical environment.
For that reason, he says, more than 70 medical schools in the United States currently offer courses on religion, spirituality, and health.
And what about the patient who requests bedside prayer with his health care team? "Physician-led prayer is acceptable only when pastoral care is not readily available, when the patient is intent on prayer with the physician, and when the physician can pray without having to feign faith and without manipulating the patient," says Larson.
If those circumstances do not present themselves, Larson suggests the health care professionals "simply listen respectfully while the patient prays."
Reference
1. Post S, Puchalski C, Larson D. Physicians and patient spirituality: Professional boundaries, competency and ethics. Ann Int Med 2000; 132:578-593.
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