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Alan B. Astrow, MD; Daniel P. Sulmasy, OFM, MD, PhD
St Vincent's Hospital, New York, NY

JAMA. 2004;291:2884.

Recently, the role that spiritual beliefs should play in the patient-physician relationship has generated controversy within the medical community. Several small studies have examined the attitudes and practices of patients and physicians about spirituality in the clinical encounter.

In a convenience sample survey of 150 adult patients seen in 3 family practices in Vermont, 52% of the 135 respondents believed that a physician had the right to inquire about religious beliefs, although only 21% felt that it was the physician's responsibility to do so. The majority of patients could not recall any physician inquiries about religion regardless of the clinical situation.¹ In another convenience sample of 100 patients at a university-based family practice center in Kansas, 80 completed questionnaires were returned. Patients who regularly attended religious services (57%) were more likely than infrequent attendees to believe that physicians should ask patients about their personal faith (63% vs 13%).² A cross-sectional survey of 203 inpatients (total number of potentially eligible patients not identified) at 2 family practice services found that, regardless of religious service attendance, the majority (77%) of patients believed physicians should consider their spiritual needs and 48% actually wanted their physicians to pray with them.³ Patients were less enthusiastic about physicians discussing their own specific beliefs. Thirty-seven percent wanted their physicians to do so more than they do now but 47% did not want physicians to discuss their religious beliefs at all.

In a study of 100 patients with newly diagnosed advanced lung cancer (total potentially eligible not identified), patients ranked faith in God just beneath their oncologists' recommendations as the most important factors in their decision about treatment.⁴ Another cross-sectional study administered to 163 Indiana outpatients with advanced cancer found that spiritual well-being was correlated with quality-of-life measures.⁵ Similarly, 200 of 3212 potentially eligible patients who were interviewed in a New York City palliative care hospital were more likely to report end-of-life despair if they also reported low spiritual well-being.⁶ A needs assessment survey of 248 outpatients with cancer, 70% of whom were eligible for the study, found that many reported unmet spiritual needs, including 40% wanting help "finding meaning in life," 42% with "finding hope," and 51% with "overcoming my fears."⁷

A few studies have addressed physicians' attitudes and behaviors about spirituality in the clinical encounter. A cross-sectional study of 476 physicians (62% response rate) reported that 85% agreed that they should be aware of their patients' religious or spiritual beliefs, but only 31% agreed that the physician should ask about these beliefs during a routine office visit. This proportion increased to 74% in scenarios in which the patient was dying.⁸ Another mailed survey of 94 oncologists (47% response rate) in the Midwest found that 38% saw themselves as responsible for addressing their patients' spiritual distress but still gave these issues low priority compared with competing concerns.⁹

A study of 121 Israeli women with breast cancer found that physicians' communication about dimensions beyond the clinical affected how they viewed their condition.¹⁰ In a cross-sectional study of 261 house staff, nurses, and attending oncologists (98% response rate of nurses, 97% of house staff, 47% of in-house attending staff, and 37% of former house staff) at a New York City cancer center, participants who viewed themselves as "quite a bit" to "extremely" religious had significantly lower scores on items assessing "diminished empathy" and "emotional exhaustion."¹¹

Current studies are limited, however, by selection bias, small sample sizes, varying definitions, lack of validated instruments, and geographic clustering. Further studies should develop valid methods of assessing patients' spiritual needs in a group more representative of the general population and test how meeting these needs affects outcomes such as treatment response, compliance, quality of life, and satisfaction with physician communication.¹²

REFERENCES
1. Maugans TA, Wadland WC. Religion and family medicine: a survey of physicians and patients. J Fam Pract. 1991;32:210-213. ISI | PUBMED 2. Daaleman TP, Nease DE Jr. Patient attitudes regarding physician inquiry into spiritual and religious issues. J Fam Pract. 1994;39:564-568. ISI | PUBMED 3. King DE, Bushwick B. Beliefs and attitudes of hospitalized patients about faith healing and prayer. J Fam Pract. 1994;39:349-352. ISI | PUBMED 4. Silverstri GA, Knittig S, Zoller JS, Nietert PJ. Importance of faith on medical decisions regarding cancer care. J Clin Oncol. 2003;21:1379-1382. FREE FULL TEXT 5. Fisch MJ, Titzer ML, Kristeller JL, et al. Assessment of quality of life in outpatients with advanced cancer: the accuracy of clinician estimations and the relevance of spiritual well-being—a Hoosier Oncology Group study. J Clin Oncol. 2003;21:2754-2759. FREE FULL TEXT 6. McClain CS, Rosenfeld B, Breitbart W. Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients. Lancet. 2003;361:1603-1607. FULL TEXT | ISI | PUBMED 7. Moadel A, Morgan C, Fatone A, et al. Seeking meaning and hope: self-reported spiritual and existential needs among an ethnically-diverse cancer patient population. Psychooncology. 1999;8:378-385. FULL TEXT | PUBMED 8. Monroe MH, Bynum D, Susi B, et al. Primary care physician preferences regarding spiritual behavior in medical practice. Arch Intern Med. 2003;163:2751-2756. FREE FULL TEXT 9. Kristeller JL, Zumbrun CS, Schilling RF. "I would if I could": how oncologists and oncology nurses address spiritual distress in cancer patients. Psychooncology. 1999;8:451-458. FULL TEXT | PUBMED 10. Sered S, Tabory E. You are a number, not a human being: Israeli breast cancer patients' experiences with the medical establishment. Med Anthropol Q. 1999;13:223-252. FULL TEXT | ISI | PUBMED 11. Kash KM, Holland JC, Breitbart W, et al. Stress and burnout in oncology. Oncology. 2000;14:1621-1630. PUBMED 12. Sulmasy DP. A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist. 2002;42:24-33. FREE FULL TEXT

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