47 Medicine for the soul: spirituality in pharmacy

Gina M. Prescott, PharmD, BCPS

Linda M. Catanzaro, PharmD

Introduction

In delivering patient-centered care, patients should be treated holistically as people and not simply as having a disease. Acknowledging spirituality is an important aspect of caring for a patient and is considered part of whole person patient care; however, it is not often integrated into the traditional patient care plan.¹ According to recent Gallup polls, approximately 90% of people in the United States believe in God or a universal spirit; 50% of all Americans define themselves as religious and spiritual, while 25% identify as spiritual but not religious, 5% as religious but not spiritual, and only 20% as neither spiritual nor religious.^2,3

Americans who are more religious tend to have higher wellbeing.⁴ During recent global and domestic crises, including the 9/11 terrorist attacks and the COVID-19 pandemic, Americans reported an increase in church attendance, improved spirituality, and praying for the pandemic to end.⁵ Research in mental health has demonstrated that religious beliefs and practices have been associated with lower rates of anxiety, depression, substance abuse, and suicide, as well as faster recovery, greater meaning in life, and social support.¹ In addition to mental health, religion and spirituality have been associated with improvements related to chronic diseases including diabetes, cancer, renal and cardiovascular diseases.^6-9

Assessing a patient’s religious and/or spiritual needs can be completed through a variety of available spiritual assessment tools. Spiritual assessment tools may be very short or extremely detailed, general or disease-specific, and questions should be open-ended. Some commonly recognized spiritual assessment tools are the HOPE,¹⁰ FICA,¹¹ SPIRITual Assessment,¹² CSI-Memo,¹³ ACP Spiritual History,¹⁴ and Single Question¹⁵ tools. The Joint Commission Accreditation Standards mandate completion of a spiritual assessment,¹⁶ and the American Psychiatric Association, in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), has a diagnostic classification of “religious or spiritual problem.”¹⁷ Generally, spiritual assessments are recommended in the following settings: new patient visits in ambulatory care, new hospital admissions, when a patient is in crisis, when a patient receives “bad news,” when a patient is struggling with lifestyle changes, and in patients with difficult to treat diseases.¹⁵ Notably, healthcare professionals do not need to be of the same religious background to conduct a spiritual assessment.

It is important to recognize that spiritual beliefs of patients will vary widely, even if they are part of an organized religion.¹⁸ As healthcare professionals, there is need to provide patient-centered, whole person care, and be careful not to stereotype or pass judgment. In the realm of spirituality, this includes taking a spiritual assessment when appropriate, supporting a patient’s spiritual or religious practices (e.g., attending religious services, reading religious texts), being sensitive to a patient’s spiritual concerns, praying with a patient (if the patient requests it and the healthcare professional is comfortable doing so), or making referrals to a chaplain or other recognized religious leader.¹⁹

In pharmacy practice, pharmacists must recognize that the spiritual beliefs of patients can influence their general health beliefs and behaviors all the way through end-of-life care.¹⁸ For example, some individuals may favor integrative healing methods or treatments which are thought to support the human spirit.²⁰ Examples may include meditation, massage, prayer, tai chi, yoga, acupuncture, and natural products. In addition, spiritual beliefs may impact patient decisions regarding use of therapies such as blood products or pharmacologic agents including pain medications, contraceptives, immunizations, or medications containing animal products or gelatin.¹⁸ A final consideration is that medications requiring administration with food may need to be adjusted when patients are fasting due to religious observances.

Case

CC: “The doctor wanted me to see you about my medications during Ramadan.”

Patient: MH is a 52-year-old Bengali male (65 in, 65.8 kg) who drives a taxi in New York. He is a refugee from Bangladesh and has been living in the United States for the past 15 years. He is in clinic for a routine follow-up visit.

HPI: MH has episodes of hypoglycemia at least once a month. He monitors his blood glucose once or twice a week and when he feels like his blood glucose is low. He has had no episodes of DKA or HHS and has fasted before for Ramadan; it appears his experience was positive, and he would like to fast again for 16 hours a day.

PMH: T2DM x 11 years; HTN; GERD

FH: Unknown

SH:

• History of smoking (1/2 ppd; quit seven years ago)
• Denies alcohol or illicit drug use

Medications:

• Metformin 1000 mg BID
• Liraglutide 1.2 mg subcutaneously daily
• Amlodipine 10 mg daily
• Lisinopril 10 mg daily
• Famotidine 20 mg daily PRN

Allergies: NKDA

Vitals:

• BP 135/95 mmHg
• HR 85 bpm
• RR 16/min
• Temp 97.9°F
• SpO₂ 100% RA

Labs:

• SCr: 1.1 mg/dL
• POC fasting glucose: 138 mg/dL
• HgbA1c: 9.2%

SDH: MH speaks Bengali as his dominant language and completed English as second language classes upon arrival in the United States. His income is approximately $39,500/year. His wife does not work and is responsible for most of the food preparation; they follow a halal diet. They have three children at home who currently attend the local public school. MH’s neighborhood community is diverse and consists of other Bengali refugees, Polish immigrants, and Black Americans. He is a devout Muslim and lives within walking distance of the mosque.

Additional context: Your physician colleague’s FICA assessment notes the following:

• F (Faith or Beliefs): MH is a practicing Muslim who considers himself to be religious.
• I (Importance and Influence): MH’s faith is extremely important to him and greatly impacts his daily life. Specific to our meeting today, he believes that it is his duty to fast during Ramadan, but he will still take care of his diabetes and believes his current medications are allowed when he fasts. It is very important for him to be able to fast during this time.
• C (Community): MH is part of a religious community, and they are supportive of each other. He does attend religious services at a mosque. It is close to his house, and he walks there to pray five times a day when not working.
• A (Address): He would like our team to recognize that he would like to continue to fast during this time and would like to do so safely.

Case Questions

1. What role would acknowledging MH’s spirituality have when caring for him?

2. What challenges might you, as a healthcare professional, face when addressing MH’s spirituality?

3. Why is it important to you, as the pharmacist, to conduct a spiritual assessment? What important religious or spiritual beliefs impact patient care?

4. What specific spirituality-related concerns might you have regarding MH’s pharmaceutical care?

5. What specific non-pharmacologic interventions could you recommend to integrate MH’s spirituality into his care plan, both in general, and during Ramadan specifically?

6. What specific pharmacologic interventions could you recommend to integrate MH’s spirituality into his care plan?

Author Commentary

Spirituality and its role in patient care is often overlooked and under-valued. As the demographics of the United States change, it is expected that pharmacists and other clinicians will continue to care for patients with a wide range of different beliefs. From a global perspective, faith-based organizations (FBOs) have played a role in assisting with social determinants of health and providing healthcare services.^21,22 These FBOs have assisted in providing educational services, healthcare access, and psycho-social support/counseling. FBOs have also been integral in policy formation to achieve the United Nations Sustainable Development Goals.²¹ During the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) offered guidance for providing spiritual care to patients; however, it is important to note that this guidance may have differed from what FBOs would have recommended.²³ In addition, religious leaders were instrumental in educating their communities, specifically the African American community, on the realities of COVID-19.²⁴

Pharmacists should be aware of the potential impact of religion/spirituality on patient outcomes. For example, religion/spirituality has been identified as an important aspect of care for patients with HIV, including a positive association with medication adherence and clinical health outcomes,^25,26 as well as HIV prevention strategies.²⁷ There have also been positive associations in addiction medicine, with implications for helping to combat the current opioid epidemic and other substance use disorders, specifically alcohol use disorder.^28-30 Pharmacists should consider providing spiritual assessments to these patients and determining the role spirituality may have in assisting patients in improving their health. In addition, pharmacists are aptly situated towards recognizing and addressing spiritual or religious medication related concerns.

Patient Approaches and Opportunities

Recognizing the role of spirituality in patients’ lives will allow pharmacists to provide holistic patient-centered care. It is important to realize that pharmacists do not need to be experts on every religion or have comprehensive knowledge about integrative medicine. What is important is determining the role of spirituality in the life of each patient through a standardized spiritual assessment tool. Oftentimes, particularly in a busy practice setting, utilizing the single-question tool will provide enough information to begin a conversation. Allow the patient to lead you in a discussion about what is important for them; if they are of a particular faith/religious background listen to them about what restrictions they may have based on their religion, keeping in mind that everyone may approach religion differently.

From a pharmacologic perspective, most spiritual-based medication restrictions are in utilizing animal-derived products, gelatin or stearic acid-containing tablets/capsules, pain medications, contraceptives, immunizations, and blood products.^18,31 If you are caring for a patient who has a terminal condition or has a recent major life change, consider the role that spirituality or religion might have in their life. They may have or choose restrictions about end-of-life or palliative care, try integrative medicine, benefit from prayer, reading religious texts or simply need the support of a religious/spiritual community.^18,20 Do not hesitate to refer a patient to a chaplain or other member of the religious community for assistance.¹⁵