Spirituality: The Missing Pillar of Whole-Person Care

By Gael Charbonne, MD; Juan Linares, MD; Kevin Gill, MTh; and Harvey Hahn, MD

Executive Summary

This article reviews the growing recognition of spirituality as an essential dimension of whole-person care and summarizes evidence supporting its effect on patient well-being, clinical outcomes, and provider resilience. It distinguishes spirituality from religion, highlights the prevalence of spiritual needs among patients, and outlines the substantial gap between desired and delivered spiritual care. The article also identifies barriers clinicians face, such as limited training and fear of proselytizing, while clarifying ethical boundaries for spiritual conversations. Finally, it offers practical guidance for implementing spiritual care, including the use of validated spiritual history tools and collaboration with chaplaincy services.

• A majority of patients, whether religious or unaffiliated, desire spiritual support during serious illness, yet up to 91% report not receiving it, underscoring a large unmet need.
• Integrating spiritual care improves patient satisfaction, emotional coping, mental health, and in some populations may contribute to increased longevity and reduced “deaths of despair.”
• Simple frameworks such as HOPE and FICA enable clinicians to initiate respectful spiritual discussions that inform care without crossing into proselytization.
• Clinician engagement in spiritual care is associated with lower burnout, restored sense of purpose, and improved therapeutic alliance.
• When concerns exceed a clinician’s comfort or expertise, chaplaincy consultation provides specialized spiritual assessment and support for both patients and clinical teams.

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Introduction: The Resurgence of Spirituality in Modern Medicine

The modern practice of medicine is built on the foundation of scientific inquiry, evidence-based treatments, and technological innovation. However, recent studies recognize that this biomedical model, although highly effective, often fails to address the full spectrum of the human experience of illness and healing.

The relationship between medicine and spirituality has a long and intertwined history. For example, in ancient Egypt and Mesopotamia, priests often served as physicians, and medical care was deeply embedded in religious practices.¹ This historical continuity persisted through the Middle Ages, with monasteries and religious orders establishing and running hospitals, where care was compassionate and service-oriented, with limited options for curing disease.

This centuries-long integration was fundamentally altered in the early 1900s with the publication of the Flexner Report. This influential report advocated for the integration of science into medicine and a move away from theological or philosophical pursuits, in part to combat the practice of “charlatans.”² This shift led to a strictly scientific, biomedical model of care and a “final and complete” split between religion and medicine.³ The specialized and technical approach that followed delivered impressive results in the treatment of pathology, but later was criticized for becoming “dehumanized” and neglecting the whole person.⁴

The modern resurgence of interest in spirituality within medicine began in the latter half of the 20th century. This movement emerged from the recognition that an essential dimension of the patient’s well-being had long been overlooked. This shift led to the adoption of the biopsychosocial model and the Institute of Medicine’s inclusion of “patient-centered care” as one of its six aims of healthcare quality in 2001.⁴ This evolution in professional thought represents a maturation of the medical profession, where the relief of suffering is not merely a component of attending to the patient’s health but a vital part of “whole person-centered care.”⁵ Increasingly, research affirms what many patients have long known intuitively: Spiritual care is a modern imperative.

A growing body of evidence suggests that addressing patients’ spiritual needs improves a wide range of outcomes, including emotional resilience, coping with illness, and overall quality of life. Spiritual engagement supports mental and emotional health, helps reduce stress, and nurtures hope and a sense of meaning during even the most challenging medical experiences. These benefits are not limited to end-of-life care; they extend across the entire spectrum of health, enhancing well-being in both routine and serious illness.

Importantly, the positive effects of spiritual care are observed in all patients, including those who do not identify with a particular religion.² A landmark study published in 2022 in the Journal of the American Medical Association concluded that spirituality should be recognized as a “vital part of future whole person-centered care.”⁵ Together, these findings emphasize that integrating spiritual care into medical practice is far from optional. In fact, a recent review article in the Journal of Lifestyle Medicine advocated adding meaning, purpose, and spirituality (MPS) as the seventh health pillar or using it as a foundational level in lifestyle medicine.⁶ In a parallel and just as important direction, delivering spiritual care improves the providers’ well-being, which is especially important with the burnout epidemic, a widespread phenomenon that leads to poor staff health and diminished quality of medical care.^7,8 In one study, 61% of internal medicine physicians reported at least one manifestation of burnout, but having a religious affiliation was found to be protective against this.⁹

Many physicians are drawn to medicine as a vocation, with almost one-third choosing the career because of spiritual or faith commitments.⁷ When a physician’s work aligns with their core human values, it provides a strong sense of meaning that can be a potent defense against burnout. Conversely, a feeling of emptiness can arise when this sense of purpose is lost, despite professional competence and success. Therefore, acknowledging and supporting a clinician’s spiritual identity is a crucial part of a comprehensive strategy to combat burnout and enhance wellness.⁷

This literature review will discuss the evidence behind spiritual care and its importance to both patients and providers. It will explore the patient’s perspective, including the definitions of spirituality and religion, the prevalence of spiritual beliefs, and the demonstrated benefits of spiritual care. The review then will present the provider’s perspective, examining the barriers to implementing spiritual care, the benefits it offers to clinicians, and the vital role of the interdisciplinary team and professional chaplains. Finally, it will offer practical guidance on how to deliver spiritual care in daily practice, including how to take a spiritual history and start the conversation respectfully. The goal is to provide a structured overview that can inform and inspire clinicians to practice medicine that blends rigorous science with compassion, restores humanity to care, and reaches beyond symptoms and disease.

The Patient’s Perspective

Defining Spirituality and Religion: Distinctions and Overlap

One of the initial challenges in the study and practice of spiritual care is the absence of a universally accepted definition. For the purpose of this review, a distinction will be made between the broad concept of spirituality and the more formal structure of religion.

Spirituality refers to an individual’s search for ultimate meaning and purpose in life. It can be expressed through a sense of connectedness to self, to others, to nature, or to the transcendent. While spirituality may be nurtured within religious traditions, it also can be experienced through non-religious avenues, such as humanism, philosophy, or the arts. This search for meaning is considered a universal aspect of the human condition, present across cultures and societies.

Religion, by contrast, is a more specific and often communal expression of spirituality. It involves adherence to an organized system of beliefs, rituals, and practices, typically shared within a community of faith.¹⁰ This distinction is important because conflating the two can obscure the needs of patients who identify as “spiritual but not religious,” a group that now represents a substantial and growing portion of the U.S. population.¹¹

Current Statistics and Trends

A significant majority of patients in the United States hold spiritual or religious beliefs, highlighting the necessity of considering these aspects in a patient-centered model of care. As of 2024, approximately 74% of U.S. adults identify with a specific religious faith. Specifically, 68% identify as Christian, encompassing 33% Protestant, 22% Catholic, and 13% from other Christian denominations. Additionally, 7% identify with non-Christian religions, including 2% Jewish, 1% Muslim, and 1% Buddhist.¹² At the same time, the proportion of Americans with no religious preference, often referred to as “nones,” has been increasing, growing from less than 5% in the early 1970s to 22% in 2023. However, it is important to note that the majority of these religiously unaffiliated individuals still consider themselves spiritual.¹³

The high prevalence of spiritual and religious belief among patients is paralleled by a strong desire to address these needs within the medical system. Literature estimates show that spirituality is important to most patients with serious illness (71% to 99%), and spiritual care frequently is desired by these patients (50% to 96%).¹⁴ One outpatient survey found that a majority of family medicine patients wanted to have spiritual discussions, with 74% desiring it for serious medical conditions and 77% for life-threatening illnesses.¹⁵ Despite this demand, a significant gap exists between the care desired and the care provided, with estimates of patients not receiving spiritual care ranging from 49% to 91%.¹⁴

Clinical and Psychosocial Benefits

Beyond the well-documented individual benefits of spiritual engagement, providing spiritual care during illness offers a range of measurable advantages. Integrating spiritual care is particularly important for patients facing serious or chronic conditions, who may experience spiritual distress and grapple with existential questions about life and purpose. By attending to a patient’s spirituality, healthcare providers can strengthen the patient-provider relationship and foster a deeper connection to the healthcare system.¹⁶ (See Table 1.) For instance, a study of nearly 9,000 patients found that those who met with chaplains rated their hospital stay more positively and were more likely to recommend the hospital. Additional research demonstrates that receiving spiritual care is consistently associated with higher patient and family satisfaction, independent of clinical outcomes.

For patients with chronic conditions such as heart failure, spiritual interventions enhance coping, reduce stress and depression, and lower the risk of suicide.¹⁷ A systematic review of patients with cardiovascular disease showed that spiritual interventions effectively reduce anxiety, depression, pain, and stress, while improving overall quality of life and potentially extending life expectancy.¹⁸ Similarly, studies of older adults with chronic illness report that spiritual care improves psychological comfort and overall well-being.¹⁹

Compelling evidence links spiritual health to positive physical outcomes and longevity. Research from the “Blue Zones,” regions where people live exceptionally long lives, found that the 263 centenarians studied belonged to a faith-based community. Attending faith-based services just four times per month is associated with an increase in life expectancy of four to 14 years.²⁰ This remarkable longevity often is associated with health-promoting behaviors and strong social support.

A clear example is the Seventh-Day Adventist community in Loma Linda, CA, one of the original Blue Zones. In this community, known for its weekly church attendance, faith serves as the central organizing principle for a lifestyle that emphasizes a plant-based diet, regular physical activity, and abstention from smoking, alcohol, and other substances. These communities, along with those from other religious traditions, foster a sense of Ummah, a close-knit network of believers whose shared connection and mutual support exemplify the “power of belonging.” The protective effect of spiritual participation is so substantial that it is sometimes compared to a statin (such as atorvastatin) in its effect on longevity and is so robust that studies have linked it to a significantly lower risk of “deaths of despair,” which include deaths related to suicide, drug overdose, and alcohol poisoning. For example, a meta-analysis found that religious beliefs and practices were associated with a 69% reduction in suicide death.²¹ Importantly, the benefits of these communities extend beyond their members, producing a halo effect that positively influences the surrounding population.

Similarly, clinicians should aim to cultivate a strong sense of purpose, empathy, and spiritual engagement, transforming their workplace, whether hospital or clinic, into a Blue Zone of healing that nurtures both body and mind and extends its positive influence into the surrounding community they strive to serve.

Finally, in the context of end-of-life care, addressing spiritual needs provides comfort to both patients and their families, helps them navigate the challenges they face, supports thoughtful and meaningful decision-making, and can ease the transition to hospice care while reducing the burden of medical costs.²²

Provider Perspective

The Value-Practice Gap

Despite widespread acknowledgment of its importance, the integration of spiritual care into clinical practice remains limited. Data from multiple specialties reveal a striking discrepancy between clinicians’ beliefs and behaviors. An international study found that 70.6% of healthcare workers believed spiritual care meaningfully enhances patients’ quality of life and nearly seven in 10 U.S. adults identify with a religious affiliation and find it important in daily life.^1,23 Yet, patients with serious illnesses, such as heart failure, frequently report minimal spiritual support from clinicians. Research confirms advanced heart failure patients experience spiritual distress, but this holistic dimension is under-investigated in cardiology compared to oncology, signifying a persistent care gap.^24,25 Following crises such as the COVID-19 pandemic, many turn to faith for coping.²⁶ Despite this persistent need, less than than one-third of physicians routinely take a spiritual history or initiate such conversations.^27,28

Collectively, these findings highlight a near-universal theoretical agreement among clinicians on the relevance of spirituality to healing, contrasted by critically low rates of practical implementation. This disconnect likely reflects a deficiency not of intent, but of training and systemic support. For spiritual care to be meaningfully integrated into modern practice, we need to identify and address the cognitive, educational, and structural barriers that prevent clinicians from translating belief into consistent bedside practice.

Barriers and Hesitations

Commonly reported barriers were lack of time (73%), inadequate training (62%), and the perception that spiritual care is best provided by other members of the healthcare team (62%).⁸ The strong association between “inadequate training” and the belief that spiritual care is “better done by others” suggests a causal relationship: When clinicians are not trained properly to address sensitive topics, they understandably defer the task. Standardized education in spiritual engagement, integrated into medical curricula, therefore represents a high-yield opportunity to prepare future physicians to fulfill a professional responsibility they already recognize as essential.

Another important barrier identified was clinicians’ fear of being perceived as proselytizing.^8,9 This hesitation is reinforced by the ethical boundary that healthcare professionals must not prescribe religion, impose personal beliefs, or provide counsel beyond their scope of expertise.²⁹ Critically, spiritual care must address ultimate concerns, not merely function as psychological resilience.³⁰

Clarifying the Boundaries: Spiritual Care vs. Proselytization

Spiritual care in clinical practice is not synonymous with conversion or persuasion. Rather, it is a form of supportive inquiry that seeks to understand, affirm, and assist patients in drawing on their own sources of meaning and hope. Although specific tools for spiritual assessment will be discussed later, it is important to emphasize from the outset that recognition alone, listening respectfully, and validating patients’ beliefs can strengthen trust and support autonomy.

Ethical spiritual care should be aimed at assessing and supporting the patient’s existing sources of meaning and hope, not to impose another. Patients, particularly those in acute distress or facing serious illness, are highly vulnerable and may feel dependent on their healthcare provider. They become, in effect, a “captive audience.” In this context, even a well-intentioned discussion of a provider’s faith can be perceived as coercive, potentially exploiting the patient’s desperation or desire to please the clinician to secure conformity. Therefore, the initiative for deeper spiritual dialogue must rest unequivocally with the patient. When spiritual themes do arise, clinicians can apply a set of professional principles to help restore balance within the inherent power asymmetry of the medical authority-captive audience relationship. These include:

• Reciprocity: Ensuring the patient has an equal opportunity to share their perspective.
• Honesty: Maintaining transparency of purpose and avoiding any hidden or secondary motives for the discussion.
• Humility: Approaching the dialogue without arrogance, presumption, or condescension.
• Respect for the person: Recognizing that the patient is a moral agent — not an object of persuasion — and preserving their freedom to make independent choices.

Ultimately, the clinician acts as a steward of the patient’s vulnerability. Only by prioritizing understanding over imposition and ensuring that personal beliefs remain secondary to professional practice can medicine fulfill its ethical commitment to compassionate, non-coercive care.

Benefits for Physicians

The current crisis of professional burnout, marked by emotional exhaustion and depersonalization, poses an existential threat to the quality and sustainability of medical care. We present spiritual care as a unique and powerful safeguard against this phenomenon, one that helps clinicians reconnect with their deeper sense of vocation and purpose.

A systematic review confirmed that a higher level of spiritual health correlates inversely with physician burnout.¹¹ Engagement strengthens therapeutic alliances and reconnects providers with purpose, a factor supported by research linking spirituality to better health outcomes overall.²² Integrating this care, particularly in heart failure, improves patient quality of life by facilitating meaning-making.³¹ Furthermore, embedding health behaviors (e.g., diet, activity) within a religious framework promotes sustained internalization and adherence, benefiting both parties.⁶

The Japanese concept of ikigai, meaning a reason for being, provides a powerful framework for understanding this link between purpose and professional fulfillment. Ikigai is the intersection of what one loves, what one is good at, what the world needs, and what one can be compensated for.¹¹ For many physicians, the initial career choice is driven by a strong sense of calling and a desire to serve.³² Yet, as the realities of modern practice set in (administrative burdens, imposed excessive documentation, and the fragmentation of the provider-patient relationship), physicians often find themselves distanced from this core sense of purpose, giving rise to burnout. The practice of spiritual care directly addresses this by shifting the focus from tackling a disease to caring for the person who bears it, and the clinician is restoring their core healer’s identity.

This intrinsic reward serves as an effective psychological buffer against the external stressors of medical practice. Studies have shown that medical residents with higher levels of personal spirituality tend to experience less burnout.^33,34 Moreover, when health-promoting behaviors, such as healthy diet and physical activity, are embedded within a spiritual or religious framework, they are more likely to be internalized and sustained. This integration benefits both patients and clinicians: The physician becomes more impactful and patients become more adherent to care plans rooted in shared meaning. As such, if spiritual engagement is presented not as an added administrative burden but as an inherent source of professional self-care and resilience, it will become more appealing to the provider. When physicians attend to the spiritual needs of their patients, they may find that in healing others, they begin to heal themselves.

Still Not Comfortable? Get a Consult

When a spiritual concern is recognized but confidence is lacking, a chaplaincy consultation should be obtained. Professional chaplains are trained to conduct nuanced spiritual assessments, explore meaning and coping, and provide informed support within the clinical setting.^5,6 Most hospitals maintain 24/7, on-call chaplaincy services, typically accessible via electronic medical record consult order or hospital operator paging, in accordance with Joint Commission standards for spiritual assessment, yet these services remain underused. Much like seeking ethics or palliative care input for complex moral or end-of-life decisions, chaplaincy consultation should be normalized as part of comprehensive, whole-person care.

Chaplains’ specialized preparation equips them to deliver crisis intervention, grief and bereavement counseling, and spiritual guidance for individuals and families of all faiths and worldviews. They can serve as interpreters of belief and culture, ensuring that care remains both clinically sound and spiritually congruent. Their participation in goals-of-care discussions adds depth to shared decision-making by identifying nonmedical factors, faith, hope, and fear, that shape patient choices. Importantly, chaplains also provide vital support to healthcare staff through debriefings, reflective programs such as Tea for the Soul, and assistance in processing ethically challenging cases, all of which foster resilience and sustain a sense of meaning and purpose.^35,36

How to Practice Spiritual Medicine

The remainder of this review is not intended as a comprehensive guide on how to deliver spiritual care in medicine, but rather as a practical introduction on how to start. The central question for every clinician is whether they are willing to intentionally integrate spiritual care into their existing model of practice. As discussed earlier, there are many advantages of doing so, but this implementation comes with certain challenges. These challenges include, but are not limited to, time demands, reduced efficiency, possible misunderstanding and rejection (even, in some cases, offending the patient and creating uncomfortable situations), and the need to learn a new practice pattern.

Having said that, the data show that both patients and clinicians stand to gain substantially from even modest efforts to incorporate spirituality into care. Many will opt to refer to their local chaplain support services, which still offer an excellent way to provide spiritual care in their practice.

Although many providers are excellent communicators, and have excellent interpersonal skills, starting a conversation about something as deeply personal and diverse as spiritual or religious beliefs can feel as daunting as obtaining their first sexual or substance use history. Fortunately, several validated tools exist in the form of preset spiritual questionnaires to help guide these conversations. Commonly used spiritual history questionnaires are listed in Table 2.

Among the available instruments, the Duke University Religion Index (DUREL) is perhaps the most widely recognized, consisting of five concise items.³⁷ However, two even shorter tools, the HOPE and FICA questionnaires (defined in the following paragraphs), often are easier to integrate into routine clinical encounters.

The HOPE framework and the FICA tool both are designed to facilitate natural, patient-centered dialogue.^38,39 They are simple to administer and can lead to meaningful, actionable insights that inform diagnostic reasoning and therapeutic planning.

The HOPE model includes four questions:

• H: What are your sources of Hope?
• O: Do you belong to an Organized religion or faith community?
• P: What are your Personal spirituality practices?
• E: What is the Effect of your beliefs on your medical care and end-of-life decisions?

The FICA tool asks:

• F: Do you have a particular Faith or belief system?
• I: What is Important to you, and what Influences your life?
• C: Are you part of a spiritual or faith Community?
• A: How should these beliefs Affect the way I care for you?

The goal is not to complete a checklist or document a score, but to use open-ended questions as a doorway to a genuine conversation. To this end, it may not even be necessary to ask every question, since sometimes the first question alone can open a meaningful exchange. As clinicians get to know their patients on a deeper level, they naturally will learn more about their social networks, emotional health, and sources of stress, allowing them to better support and treat them.

The authors hope this review offers both a rationale and encouragement for clinicians to step out in faith in their own practices.

Gael Charbonne, MD, is with Kettering Medical Center, Kettering, OH.

Juan Linares, MD, is with Kettering Medical Center, Kettering, OH.

Kevin Gill, MTh, is with Kettering Medical Center, Kettering, OH.

Harvey Hahn, MD, is Program Director, Cardiovascular Fellowship Training Program, Kettering Medical Center, Kettering, OH.

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