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CLINICAL CROSSROADS CONFERENCES WITH PATIENTS AND DOCTORS An 83-Year-Old Woman With Chronic
Illness and Strong Religious Beliefs
Harold G. Koenig, MD, Discussant
strength was decreased, sensation to pinprick was de-creased in the digits bilaterally, and motor strength of the DR BURNS: MRS A IS AN 83-YEAR-OLD WOMAN WHO HAS MUL-
lower extremities was 2/5 proximally and 3/5 distally. Her tiple medical problems and, despite numerous medical in- reflexes were intact.
terventions, chronic progressive pain and weakness. She feels Mrs A continues to have diffuse body pain as well as in- that her faith offers the most help for coping with her ill- creasing weakness of her lower extremities. During the course ness. She lives in a senior residence near Boston and has 3 of her illness, she has steadfastly maintained her indepen- daughters, 2 sons, and many grandchildren. Mrs A attends dence and good spirit. She has consistently stated that her church regularly and has a strong social support network faith in God has enabled her to endure her chronic pain.
through church. She has Medicare insurance, and her pri- She trusts that praying will help her continue to persevere.
mary physician is Dr M, who practices at Beth Israel Dea- Mrs A and her physician, Dr M, continue to struggle with coness Medical Center.
the lack of traditional medicine to provide her with any re- Mrs A has a history of hypertension, diabetes, and goi- lief of her symptoms. Mrs A's beliefs are her one source of ter. In the late 1980s, she developed diffuse body pain. An comfort and strength. The role this should play in her on- evaluation found that she had polymotor and sensory neu- going medical care remains a question.
ropathy, most likely secondary to diabetes. Initially, she wastreated with intravenous gamma globulin without improve- Mrs A: Her View
ment in her symptoms. She was subsequently treated with They said it's kind of a rare pain. Not everybody has it. I gabapentin, topiramate, mexiletine, tramadol, rofecoxib, don't dwell on the pain, you know. Some people are sick celecoxib, acetaminophen with codeine, oxycodone/ and have pain, and it gets the best of them. Not me. Pray- acetaminophen, and fentanyl patch without improvement.
ing eases the pain, takes it away. Sometimes I pray when I Mrs A has also tried acupuncture and massage without ben- am in deep, serious pain; I pray, and all at once the pain efit. The consulting neurologist does not have any further gets easy. Praying helps me a lot. I feel that has helped me therapy to offer her.
more than the medication.
In 1999, Mrs A began experiencing worsening right lower A doctor is a doctor. Not everybody is bound to believe in extremity pain and weakness and was found to have spinal God. It's your own mind, your thought, and your belief. The stenosis with L5-S1 radiculopathy. She underwent mul- doctor gives you the medicine. God works through the doc- tiple lumbar epidural steroid injections without improve- tor. He is a great physician and He heals, but you have to be- ment in her symptoms. She has had recurrent episodes of lieve. I believe in God. He's my guide and my protector.
right hip and bilateral shoulder pain from trochanteric and Whenever you pray, you will get healing from God. You subacromial bursitis. She also had multiple local steroid in- will. But you must have that belief. Because if you don't be- jections with either no or short-term benefit.
lieve in God and turn your life over to Him, it's nothing do- Her medications include losartan potassium, felodipine, ing. You can't just pray, "God, I'm suffering, and I ask You hydrochlorothiazide, levothyroxine, metformin, omepra- to heal my body." It don't work like that. You have to really zole, and acetaminophen. She is allergic to penicillin, aspi- be a child of God.
rin, and angiotensin-converting enzyme inhibitors. She livesalone and has a daughter who lives nearby. She is able to This conference took place at the Medicine Grand Rounds of the Beth Israel Dea-
coness Medical Center, Boston, Mass, on January 24, 2002, and at the 25th An-
perform all her activities of daily living and independent ac- nual Meeting of the Society of General Internal Medicine, Atlanta, Ga, on May 3, tivities of daily living and refuses any assistance from a home- 2002.
Author Affiliation: Dr Koenig is Associate Professor of Psychiatry and Associate
maker or visiting nurse.
Professor of Medicine, Duke University Medical Center, Geriatric Research, Edu- On a recent examination, her blood pressure was 140/88 cation, and Clinical Center, VA Medical Center, Durham, NC.
Corresponding Author and Reprints: Harold G. Koenig, MD, Duke University Medi-
mm Hg, and she had mild restriction of motion of the left cal Center, Box 3400, Durham, NC 27710 (e-mail: koenig@geri.duke.edu).
shoulder, pain with any motion of the right shoulder, pain Clinical Crossroads at Beth Israel Deaconess Medical Center is produced and ed-
to palpation of the small joints, and pain over the trochan- ited by Risa B. Burns, MD, Eileen E. Reynolds, MD, and Amy N. Ship, MD. TomDelbanco, MD, is series editor. Erin E. Hartman, MS, is managing editor.
teric bursa on the right. On neurologic examination, grip Clinical Crossroads Section Editor: Margaret A. Winker, MD, Deputy Editor.
2002 American Medical Association. All rights reserved.
(Reprinted) JAMA, July 24/31, 2002—Vol 288, No. 4 487
CLINICAL CROSSROADS Dr M: Her View
Americans who turned to religion in response to the Sep- She continues to have chronic, diffuse pain from her poly- tember 11th terrorist attacks.17 Even the baseline rate of re- motor and sensory neuropathy, and she is beginning to de- ligious coping in the United States before those events was velop some lower extremity weakness. She now has to walk high (78% of Americans indicate that they receive comfort with a cane and even with that is somewhat unstable at times.
and support from religious beliefs).18 She is a very impressive patient in that, throughout the 15 years that I have known her, she has continued to live Do Religious Beliefs Make a Difference?
with a chronic, progressive, and debilitating illness and has Mrs A certainly thinks so. But what is the objective evi- done so with incredible spirit, particularly in light of the lack dence that such persons cope better with illness? To an- of traditional medicine to offer her a lot of hope. She very swer this, our team examined religious coping in 850 con- much relies on her belief in God and her own prayers to secutively admitted hospitalized patients to determine get her through what have been some really tough times.
whether those depending on religion coped better than those Most of our visits consist of her telling me where she hurts handling stress in other ways.19 Those depending on reli- and my telling her that I understand that and then having gion coped better independent of demographic character- to acknowledge that there is not a lot that I can do to help istics, social support, economic resources, psychiatric his- that pain go away.
tory, and physical health status. In the cross-sectional I would like to ask Dr Koenig what should I be asking analysis, a significant inverse correlation was found be- her about her beliefs? To what extent should I be encour- tween religious coping and depressive symptoms, whether aging or discouraging those beliefs? What is appropriate for self-rated (partial F1,799=19.8; Pⱕ.001) or observer-rated (par- me to bring into the context of a medical visit? Is it appro- tial F1,306=12.2; Pⱕ.001). An interaction appeared between priate for me to use that as part of a therapeutic treatment physical disability and religious coping, with the most dis- plan for this patient? abled patients experiencing the most benefit (partialF1,798=3.9; Pⱕ.05). In the prospective portion of this study, AT THE CROSSROADS:
202 patients were followed up for an average of 6 months QUESTIONS FOR DR KOENIG
to determine what baseline characteristics predicted change What is the role of spirituality in helping patients cope with in depressive symptoms over time. Only 2 characteristics serious medical illness? What data exist to support such a predicted later depressive symptoms: kidney disease pre- role? What is the pathophysiology explaining a benefit? How dicted more symptoms and religious coping predicted fewer does spiritual coping affect quality of life for a patient with (partial F193=10.4; P=.002).
serious medical illness? What are the risks vs benefits of pro- To determine whether religious attitudes are related to speed moting a focus on spirituality? How should physicians ask of recovery from depression, we used the National Institute patients about spirituality? Should a patient seek a physi- of Mental Health Diagnostic Interview Schedule to inter- cian with similar spiritual beliefs? What are the profes- view 87 medical inpatients (from consecutive admissions to sional boundaries between physicians and chaplains? What general medicine, cardiology, and neurology services).20 De- do you recommend for Mrs A? pressed patients were prospectively followed up for an aver- DR KOENIG: Mrs A has a lot to deal with. She has chronic
age of 47 weeks after discharge, during which weekly change progressive pain secondary to diabetic neuropathy, spinal in depressive symptoms was measured. Of nearly 30 base- stenosis, recurrent bursitis, and arthritis. The pain has been line characteristics, intrinsic religiosity was 1 of only 5 inde- resistant to narcotic and nonnarcotic analgesics, acupunc- pendent predictors of speed of remission. For every 10- ture, and massage, and her neurologist says there is noth- point increase on the intrinsic religiosity scale21 (with scores ing more he can do for her. She lives alone and receives no ranging from 10-50), there was a 70% increase in the speed formal assistance. She copes by using religion.
of remission from depression (hazard ratio [HR], 1.70; 95% At least 60 studies1 have now examined the role of reli- confidence interval [CI], 1.05-2.75) after controlling for so- gion in medical conditions such as arthritis,2 diabetes,3 kid- cial support, changes in physical health, psychiatric history, ney disease,4 cancer,5 heart disease,6 lung disease,7 HIV/AIDS and other covariates. The speed of remission in patients whose (human immunodeficiency virus/acquired immunodefi- physical functioning was either stable or worsening more than ciency syndrome),8 cystic fibrosis,9 sickle cell disease,10 amyo- doubled for every 10-point increase on the scale (HR, 2.06; trophic lateral sclerosis,11 and chronic pain12 and in se- 95% CI, 1.02-4.15).
verely ill adolescents,13 with the majority finding high rates In both studies, religious beliefs were particularly impor- of religious coping. Religion is used more often to cope in tant for patients whose physical condition was not improv- the United States than in other areas of the world such as ing despite medical treatments. Mrs A eloquently summa- northern Europe, where weekly church attendance is 2%,14 rizes it: "Some people are really sick, really sick and going to religious coping is about 1%,15 and even among cancer pa- doctors and hospitals, and still they stay the same way. So I tients, 43% do not believe in God and 45% receive no com- think praying helps a lot, but praying without belief is no good.
fort from religious beliefs.16 Compare this with the 90% of I believe in God. He's my guide and my protector." 488 JAMA, July 24/31, 2002—Vol 288, No. 4 (Reprinted)
2002 American Medical Association. All rights reserved.
CLINICAL CROSSROADS The Duke studies above are not the only ones finding a tion over to God and stop worrying and obsessing about it.
connection between religion and better coping with medi- Prayer gives patients something to do so they don't feel as cal illness.22-27 In fact, a systematic review of research pub- helpless: by praying to God, they believe that they can in- lished during the 20th century identified 724 quantitative fluence the outcome. As Mrs A demonstrates, prayer may studies, of which 478 (66%) found a statistically signifi- also result in a deep state of relaxation that reduces muscle cant relationship between religious involvement and bet- tension and improves function.36 ter mental health, greater social support, or less substance For Mrs A, belief is a very important part of the process.
abuse.1 Even in Europe where religious involvement is low, Beliefs are the basis for a worldview, which is how indi- studies find that those who are less religious experience more viduals interpret and make sense of reality, especially the depression28,29 and recover more slowly from depression.30 reality of pain, suffering, and tragedy. The Western reli- For example, a 12-month prospective study of 177 older gious worldview is an optimistic one that gives hope, pur- adults in the Netherlands found that low religiosity pre- pose, and meaning to negative life circumstances. Mrs A's dicted persistent depression (odds ratio, 5.85; 95% CI, strong belief frames her entire situation. Her trust and con- 1.52-22.6). In that study, no depressed women with low re- fidence are in God, with whom she is in constant commu- ligiosity recovered from depression compared with 50% of nication: "I pray every day. I walk and talk with God. I read those with high religiosity.30 Religious involvement may also my Bible and I pray. . I hold onto that for no man can take postpone the development of physical disability in later life,31 that away from me." Whether an illness gets better or not, and chronically ill persons who are religious may perceive having such a powerful ally and companion can have an enor- themselves as less disabled than they really are.32,33 Mrs A, mous impact on relieving loneliness and isolation and, again, for example, remains independent despite her pain and mul- regaining a sense of control. As long as God is with her, lead- tiple medical problems.
ing and directing her, she can rest.
The relationship between religion and chronic pain such Note that Mrs A also attends church regularly, despite pain as Mrs A experiences is particularly complex. Of the 5 stud- and multiple health problems. This provides her not only ies in our systematic review that evaluated religious activ- with socialization but also with opportunities to support and ity and pain, all 5 found that prayer is associated with greater encourage others. She is a member of a prayer group, where severity of pain when examined cross-sectionally (individu- she prays for others and they pray for her. She even visits als tend to pray more as pain worsens).1 In the only pro- and prays for those who are sick—and says she sees re- spective study, 74 patients with low back pain lasting at least sults: "I was praying for a lady and she was very sick, could 6 months were followed up for 8 weeks. At baseline, scores barely sit up in her bed. And we went and prayed for her, on a prayer subscale were positively related to pain and she prayed with us . . and now she's feeling all right; (F1,68=8.28; P⬍.01). Over time, however, increased use of she comes to church now." Praying for others likely helps prayer predicted decreased reports of pain intensity (r=−0.21; to distract her from her pain and gets her mind on some- P⬍.05).34 Only 1 intervention study has examined the ef- thing outside of herself. In a cross-sectional survey of 577 fects of prayer and meditation on chronic pain; 10 of 14 (71%) medically ill older adults, providing "religious help" to oth- subjects receiving the intervention experienced at least a one- ers predicted less depression (␤=−.13; Pⱕ.01), higher qual- third reduction in chronic pain compared with 2 of 19 (11%) ity of life (␤=.2; Pⱕ.001), and greater personal growth re- in the comparison group (P⬍.005, based on unpaired t test sulting from life stressors (␤=.5; Pⱕ.001), independent of corrected for multiple testing).35 How does religion facilitate coping with chronic pain, dis- Relationships between mental health and strong faith, de- ability, and serious illness? Mrs A's comments again pro- vout prayer, and religious socialization may have conse- vide key insights: "I don't dwell on the pain. Some people quences that are far-reaching and perhaps greatly underes- are sick and have pain and it gets the best of them. Not timated. Religious involvement is associated with improved me. . Prayer helps me a lot—I give God my heart and attendance at scheduled medical appointments,38 greater co- soul—and you don't have to worry about nothing. He leads operativeness,37 better compliance,39-41 and improved medi- you and directs you, and he takes care of you. That is my cal outcomes.42,43 A number of well-designed prospective studies have found that those who are more religious or spiri- Many patients have little control over their health con- tual have lower blood pressure,44 fewer cardiac events,45 pos- ditions, which creates anxiety and, in some cases, furious sible regression of coronary artery obstruction,46 better re- attempts to regain control. When such attempts fail, anxi- sults following heart surgery,43 and longer survival in ety worsens and depression develops as the person feels in- creasingly overwhelmed. Religious beliefs and practices pro- Pathways exist to help explain why religious beliefs and vide an indirect form of control that helps to interrupt this practices like prayer could influence physical as well as men- vicious cycle. They enable a patient to turn a health situa- tal health. Sympathetic and parasympathetic nerve tracks 2002 American Medical Association. All rights reserved.
(Reprinted) JAMA, July 24/31, 2002—Vol 288, No. 4 489
CLINICAL CROSSROADS struggle predict worse mental and physical health out- Box. Taking a Spiritual History
comes after hospital discharge.62 In a prospective study of Do your religious or spiritual beliefs provide comfort and 595 hospitalized patients, those who believed that God was support or do they cause stress? punishing them, had abandoned them, didn't love them, or How would these beliefs influence your medical decisions didn't have the power to help or felt their church had de- if you became really sick? serted them experienced 19% to 28% higher mortality dur- Do you have any beliefs that might interfere or conflict with ing a 2-year period following hospital discharge (relative risk your medical care? for death ranging from 1.19 [95% CI, 1.05-1.33] to 1.28 [95% Are you a member of a religious or spiritual community and CI, 1.07-1.50]). This effect was statistically significant and is it supportive? independent of physical health, mental health, and social Do you have any spiritual needs that someone should support. Such patients may refuse to speak with clergy be- cause they are angry with God and have cut themselves offfrom this source of support.
Would religious beliefs influence medical decisions if the connect thoughts and emotions in the brain to the circula- patient becomes seriously or terminally ill?63 One cross- tory system, coronary arteries, lymph nodes, bone mar- sectional survey of 177 outpatients attending a university- row, and spleen.49,50 If religious beliefs and prayer help pa- based pulmonary clinic found that nearly half of patients tients cope better with illness and result in less stress, anxiety, (45%) indicated that religious beliefs would influence their and depression and greater social support, then they may medical decisions if they became gravely ill. End-of-life de- counteract stress-related physiological changes that impair cisions are often influenced by religious beliefs, especially healing. Preliminary evidence suggests that religious in- do-not-resuscitate or discontinuation-of-treatment deci- volvement may be related to stronger immune function- sions.64 Patients or families with strong beliefs may not agree ing51-54 and lower cortisol levels.51,53 Religious involvement to a do-not-resuscitate order or withdrawal of life support is also associated with less substance abuse (98/120 stud- because they are praying for a miracle and determined not ies), less cigarette smoking (23/25 studies), and more ex- to give up faith.
ercise (3/5 studies), which adds to the health effects of so- Are there religious beliefs that might conflict with medi- cial and cognitive factors.1 Although randomized clinical trials cal care? Patients may stop taking their medications or fail that demonstrate causality are lacking, such studies are now to seek medical care on religious grounds.65 Religious ac- under way among patients with breast cancer and will soon tivities like prayer may be used instead of traditional medi- be undertaken in patients with congestive heart failure.55 cal care to treat illness. For example, religiousness is asso-ciated with lower use of physician services in type 2 diabetes66 and less use of antiretroviral medications in HIV infec- When Mrs A was asked what kind of advice she had for pa- tion.67 In the latter study of 202 HIV-positive patients, those tients, she responded, "I think doctors should tell the pa- indicating that prayer was the most important influence on tient they must read their Bible and pray to help with the their decisions about HIV medication were significantly less medicine." I am impressed by her enthusiasm, but I must likely than other patients to be taking antiretroviral medi- disagree. Although there is growing evidence that prayer and cations (7.1% vs 23.0%; P = .003 by Fisher exact test). Even other religious activities are associated with better coping, if beliefs conflict with medical care (as those of Jehovah's less depression, more social support, and better health out- Witnesses or Christian Scientists), however, physicians comes, recommending religious beliefs to nonreligious pa- should be cautious about rejecting them. Instead, they should tients is premature.56 Religion is an intensely personal and try to understand the patient's worldview by beginning a private affair for many people, and no matter how much data dialogue that shows respect for the beliefs and a willing- accumulate, there will probably never be enough to justify ness to work with the patient. Unless patients feel as though imposing religious beliefs on patients. There is a lot that phy- they can talk to their doctors about such issues, they will sicians can do, however, short of prescribing religion.
simply conceal noncompliance.
Least controversial among these is taking a spiritual his- Is the patient a member of a spiritual community and is tory,57-60 although less than 10% of physicians routinely do that community supportive? The answer will help deter- so.61 A spiritual history inquires about the role that reli- mine how much support patients have when they return gion or spirituality plays in the patient's ability to cope with home. According to a survey of 106 consecutive older pa- and make sense of illness (BOX). Perhaps the most power-
tients treated at a university-based clinic in Springfield, Ill, ful rationale for taking a spiritual history is not the positive more than half (52%) reported that 80% or more of their effects of religion on health, but the potential negative ef- closest friends came from their church congregations.68 Re- fects. Are religious beliefs a source of comfort and support ligious congregations often serve as extended families for for the patient, as they are for Mrs A, or are they a source of older adults, especially those who live alone or have lim- stress and emotional turmoil? Beliefs indicating religious ited support from relatives. Church members may check on 490 JAMA, July 24/31, 2002—Vol 288, No. 4 (Reprinted)
2002 American Medical Association. All rights reserved.
CLINICAL CROSSROADS such patients, monitor their health, provide rides for office gious issues with patients.61 Space precludes a more de- visits, and render many other practical services.
tailed discussion of integrating spirituality into patient care, Does the patient have any other spiritual needs? A cross- which can be found elsewhere.72 sectional survey of 50 medical-surgical inpatients and 51 psy- Should a patient seek a physician with similar beliefs? That chiatric inpatients at Rush-Presbyterian-St Luke's Medical depends on the patient. In Mrs A's case, the religious be- Center in Chicago found that 76% of medical-surgical and liefs of her physician did not seem to matter that much. When 88% of psychiatric inpatients had 3 or more religious needs asked whether she would prefer to have a physician who during hospitalization69: Does the patient wish to speak with believes in God, she answered: "A doctor is a doctor. Not a chaplain or other clergy? Would the patient like an op- everybody is bound to believe in God." For most medical portunity to attend a hospital worship service? and Would patients, even very religious ones, the beliefs of the physi- the patient (or family) like spiritual reading materials or cian are less important than the patient-physician relation- someone to pray with? Although physicians may not be able ship and the respect and support that the physician shows to personally address these spiritual needs, they should en- for the patient's beliefs.70 sure that someone does.
Once a spiritual history has been taken, the physician may decide to support religious beliefs the patient finds helpful, What professional boundaries separate the responsibilities particularly if they do not conflict with medical care. Mrs A of the physician from those of the chaplain? Most physi- reported that when she told her physician about her reli- cians do not have the training to address religious or spiri- gious beliefs, the doctor said, "Keep it up." Brief encour- tual issues in the setting of medical illness. More than half agement from the physician like this may help to reinforce of US medical schools now have courses on religion and religious beliefs that are relied on for comfort and hope. The medicine that introduce medical students to these issues.73 existing beliefs of the patient should always be supported Attending such a course is useful. However, a couple of lec- and encouraged; this is not a time to introduce new or unfa- tures or even a more intensive course throughout a semes- miliar spiritual beliefs or practices.
ter or 2 is no match for the training a chaplain receives.60 What about the patient who is not religious or who doesn't Whenever anything but the most simple and uncompli- wish the physician to address religious issues? Willingness cated spiritual issues come up, chaplains or pastoral coun- to participate in spiritual discussions with doctors is closely selors should be consulted.
tied to the patient-physician relationship.70 Although most Not all patients, however, wish to talk to unfamiliar chap- patients want physicians to ask about coping and support lains about deeply personal religious issues laced with feel- mechanisms, a survey of 83 inpatients in Pennsylvania and ings of anger and guilt. Alternatively, the patient may be will- 120 inpatients in North Carolina found that one third to one ing to discuss these issues with a caring physician who is half felt uncomfortable about physicians discussing reli- known and trusted. In those cases, the physician should take gious beliefs with them.71 If the patient resists such in- a few minutes to listen to the patient's spiritual concerns.
quiry, the physician should not persist but rather should re- Caring and listening is the intervention, not giving advice direct the conversation to a discussion of what enables the or trying to fix the spiritual problem.
patient to cope or gives life meaning and purpose in the set- Prayer with patients is a more controversial activity that ting of illness. The initial inquiry about religion will let the many physicians (at least one third) sometimes engage in.61,74 patient know that such issues can be discussed in the fu- Certain conditions should be met before such activity is con- ture if needed.
sidered: a spiritual history has been taken, the patient is re- Taking a spiritual history or addressing spiritual issues ligious, the patient requests prayer, the physician's reli- must be done in addition to competently and completely gious background is similar to that of the patient, and the addressing the patient's medical concerns ("competence is situation calls for prayer (significant patient distress).72 Prayer the first act of kindness").58 Therefore, it will take addi- should be physician-initiated only if the physician is cer- tional time. Where does a busy physician find the time? There tain the patient would want it and be comforted by it; oth- is no easy answer, particularly in a health care system that erwise, physician-led prayer has the potential to be coer- rewards productivity and numbers over compassion and car- cive.60 Prayer or any other religious activity should not be ing. Here are a few suggestions. Not every patient needs a spiritual history on every visit. A 5-minute spiritual his-tory can be taken during an initial evaluation of patients with Recommendations for Mrs A
serious or chronic medical illness or at the time of hospital To Mrs A, I would say, "Keep it up!" Despite disabling, unre- admission as part of the social history. Spiritual issues may lenting chronic pain and multiple other complex medical be addressed during a health maintenance evaluation when problems, she is optimistic, cooperating with her treat- there is a little more time to talk about social and personal ment, functioning independently, and staying socially active.
concerns. Interestingly, only about one quarter (26%) of phy- Mrs A's physicians should respect and support the beliefs sicians indicate that they don't have time to discuss reli- that help her cope, ensure that her spiritual needs are met 2002 American Medical Association. All rights reserved.
(Reprinted) JAMA, July 24/31, 2002—Vol 288, No. 4 491
CLINICAL CROSSROADS when she is hospitalized, and be aware that religion is likely beliefs are serving. Doing this demonstrates to the patient to influence her medical decisions. Because of her strong and family that the physician cares about what may be their faith, Mrs A may rely more heavily on her religious beliefs last anchor of hope. It also helps keep open avenues of com- and activities than on her medical treatments, so it is impor- munication that will allow the physician to gently convey tant to keep lines of communication open on this subject important medical information that can be heard more eas- and periodically gently explore how her beliefs are influ- ily than if that dialogue is based on criticism and confron- encing compliance. Finally, religious patients like Mrs A tation, which could elicit a need to defend their faith against sometimes see their declining health status or need for assis- the physician. If patients feel that they can talk to the phy- tance as a spiritual failure and should feel free to talk with sician about these issues and know their religious beliefs are their physicians about such feelings should they arise.
valued, they will be better able to trust and accept what thephysician is saying, ie, sometimes God answers our prayers QUESTIONS AND DISCUSSION
for healing in psychological, interpersonal, and spiritual ways A PHYSICIAN: Can you elaborate on your statement that it
that may ultimately be even more important than physical would be unethical to prescribe prayer, even where the data Funding/Support: Clinical Crossroads is made possible by a grant from The Rob-
DR KOENIG: The risk in prescribing prayer—the doctor
ert Wood Johnson Foundation.
imposing this on the patient—is that it goes from being pa- Acknowledgment: We thank the patient and her physician for sharing their sto-
ries. We also thank the Society of General Internal Medicine for hosting this con-
tient-centered to being physician-centered. When you move the center away from the patient, you run into the risk ofcoercion, particularly for a nonreligious patient who is not 1. Koenig HG, McCullough M, Larson DB. Handbook of Religion and Health. New
York, NY: Oxford University Press; 2001.
HYSICIAN: When people's religious beliefs conflict with
2. Cronan TA, Kaplan RM, Posner L, Lumberg E, Kozin F. Prevalence of the use
medical treatment, what is the extent to which you believe of unconventional remedies for arthritis in a metropolitan community. Arthritis that we should respect and support them, or is it legitimate Rheum. 1989;32:1604-1607.
3. Samuel-Hodge CD, Headen SW, Skelly AH, et al. Influences on day-to-day self-
management of type 2 diabetes among African-American women. Diabetes Care.
DR KOENIG: If patients' beliefs are conflicting with their
2000;23:928-933.
4. Tix AP, Frazier PA. The use of religious coping during stressful life events. J Con-
medical care, the important thing to do is not to criticize sult Clin Psychol. 1997;66:411-422.
the beliefs but to try to better understand them. Learn more 5. Schnoll RA, Harlow LL, Brower L. Spirituality, demographic and disease fac-
about their view, show respect for it, and stay in commu- tors, and adjustment to cancer. Cancer Pract. 2000;8:298-304.
6. Ai AL, Dunkle RE, Peterson C, Bolling SF. The role of private prayer in psycho-
nication with the patient on it.
logical recovery among midlife and aged patients following cardiac surgery (CABG).
HYSICIAN: Has the relationship between level of edu-
7. Matthees BJ, Anantachoti P, Kreitzer MJ, Savik K, Hertz MI, Gross CR. Use of
cation and religious beliefs been studied? complementary therapies, adherence, and quality of life in lung transplant recipi- DR KOENIG: Education level does seem to have an effect,
ents. Heart Lung. 2001;30:258-268.
8. Avants SK, Warburton LA, Margolin A. Spiritual and religious support in re-
although not a great one. A few studies have looked at this covery from addiction among HIV-positive injection drug users. J Psychoactive Drugs.
relationship.19,47,48 They found that the effects on mental and 2001;33:39-45.
9. Stern RC, Canda ER, Doershuk CF. Use of non-medical treatment by cystic fi-
physical health are independent of education.
brosis patients. J Adolesc Health. 1992;13:612-615.
A PHYSICIAN: When some religious people have a life-
10. Cooper-Effa M, Blount W, Kaslow N, Rothenberg R, Eckman J. Role of spiri-
threatening illness, they bring to their view a sense of hav- tuality in patients with sickle cell disease. J Am Board Fam Pract. 2001;14:116-122.
ing done this to themselves. How do you respond to this? 11. Murphy PL, Albert SM, Weber CM, Del Bene ML, Rowland LP. Impact of spiri-
DR KOENIG: People's behavior does influence their ill-
tuality and religiousness on outcomes in patients with ALS. Neurology. 2000;55:1581-1584.
nesses. The question is how do you deal with that in a com- 12. Keefe FJ, Affleck G, Lefebvre J, et al. Giving with rheumatoid arthritis: the role
passionate manner. Some people feel that they are being pun- of daily spirituality and daily religious and spiritual coping. J Pain. 2001;2:101-110.
ished, and many of our patients are probably asking the 13. Silber TJ, Reilly M. Spiritual and religious concerns of the hospitalized adoles-
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(Reprinted) JAMA, July 24/31, 2002—Vol 288, No. 4 493

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ERIC Digest A Guide for Helping Professionals Robert L. Smith and Elda E. Garcia clinicians. After a comprehensive diagnostic evaluation, an individual treatment plan, based on any coexisting mental and physical conditions Certain mental disorders are caused by or accompanied by should be selected. Medications should not be considered as the first or