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Harold G. Koenig, MD
Duke University Medical Center and GRECC VA Medical Center, Durham, NC

JAMA. 2000;284:1708.

Patients want to be seen and treated as whole persons, not as diseases. A whole person is someone whose being has physical, emotional, and spiritual dimensions. Ignoring any of these aspects of humanity leaves the patient feeling incomplete and may even interfere with healing. For many patients, spirituality is an important part of wholeness, and when addressing psychosocial aspects in medicine, that part of their personhood cannot be ignored. In this article, I use spirituality and religion interchangeably, since the vast majority of Americans do not make distinctions between these concepts. Furthermore, most research linking spirituality to health has measured religious beliefs or practices.

Many seriously ill patients use religious beliefs to cope with their illnesses.¹ Religious involvement is a widespread practice that predicts successful coping with physical illness.^2-3 In fact, high intrinsic religiousness predicts more rapid remission of depression, an association that is particularly strong in patients whose physical function is not improving.³ More than 850 studies have now examined the relationship between religious involvement and various aspects of mental health.¹ Between two thirds and three quarters of these have found that people experience better mental health and adapt more successfully to stress if they are religious.

An additional 350 studies have examined religious involvement and health. The majority of these have found that religious people are physically healthier, lead healthier lifestyles, and require fewer health services.¹ The magnitude of the possible impact on physical health—particularly survival—may approximate that of abstaining from cigarette smoking⁴ or adding 7 to 14 years to life.⁵ However, religious practices should not replace allopathic therapies. Also, while many people find that illness spurs them to ask metaphysical questions and helps them rediscover religion, no studies have shown that people who become religious only in anticipation of health benefits will experience better health.

What does all this mean for clinical practice? While no research exists on the impact of physician-directed religious assessments or interventions, some recommendations based on clinical experience and common sense can be made. First, what should physicians not do? Physicians should not "prescribe" religious beliefs or activities for health reasons. Physicians should not impose their religious beliefs on patients or initiate prayer without knowledge of the patient's religious background and likely appreciation of such activity. Except in rare instances, physicians should not provide in-depth religious counseling to patients, something that is best done by trained clergy.

What should physicians do? Physicians should acknowledge and respect the spiritual lives of patients, and always keep interventions patient-centered. Acknowledging the spiritual lives of patients often involves taking a spiritual history. A spiritual history is not appropriate for every patient, although for those with illness that threatens life or way of life, it probably is. A consensus panel of the American College of Physicians⁶ recently suggested 4 simple questions that physicians might ask seriously ill patients: (1) "Is faith (religion, spirituality) important to you in this illness?" (2) "Has faith been important to you at other times in your life?" (3) "Do you have someone to talk to about religious matters?" and (4) "Would you like to explore religious matters with someone?" Taking a spiritual history is often a powerful intervention in itself.

The physician may consider supporting the patient's religious beliefs that aid in coping. Religious patients, whose beliefs often form the core of their system of meaning, almost always appreciate the physician's sensitivity to these issues. The physician can thus send an important message that he or she is concerned with the whole person, a message that enhances the patient-physician relationship and may increase the therapeutic impact of medical interventions.

Should physicians pray with patients? Post and colleagues⁷ provide guidelines for this issue. They suggest that physicians should not pray with a patient without his or her explicit request, and further state that physician-led prayer is appropriate only when a religious professional is not available, or when the patient prefers this. Alternatively, prayer can always be led by the patient. Our calling as physicians is to cure sometimes, relieve often, comfort always. If a distressed and scared patient asks for a prayer and the physician sees that such a prayer could bring comfort, then it is difficult to justify a refusal to do so. The comfort conveyed when a physician supports the core that gives the patient's life meaning and hope is what many patients miss in their encounters with caregivers.

REFERENCES
1. Koenig HG, McCullough M, Larson D. Handbook of Religion and Health. New York, NY: Oxford University Press; 2000:7-14. 2. Koenig HG, Cohen H, Blazer D, Pieper C, Meador K, Shelp F, et al. Religious coping and depression in elderly hospitalized medically ill men. Am J Psychiatry. 1992;149:1693-1700. FREE FULL TEXT 3. Koenig HG, George L, Peterson B. Religiosity and remission from depression in medically ill older patients. Am J Psychiatry. 1998;155:536-542. FREE FULL TEXT 4. Koenig HG, Hays J, Larson D, et al. Does religious attendance prolong survival? J Gerontol A Biol Sci Med Sci. 1999;54:M370-M377. 5. Hummer R, Rogers R, Nam C, Ellison C. Religious involvement and US adult mortality. Demography. 1999;36:273-285. WEB OF SCIENCE | PUBMED 6. Lo B, Quill T, Tulsky J. Discussing palliative care with patients. Ann Intern Med. 1999;130:744-749. FREE FULL TEXT 7. Post SG, Puchalski C, Larson D. Physicians and patient spirituality: professional boundaries, competency, and ethics. Ann Intern Med. 2000;132:578-583. FREE FULL TEXT

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