Christina Pulchalski has developed an acronym, FICA, which can be used in performing a spiritual assessment:55,56
|F||Faith:||"What do you believe in that gives meaning to your life?" A broad, open-ended question is usually asked. There is no single correct question, although Dr. Pulchalski has found the above and the following to be useful. "Do you consider yourself to be a religious or spiritual person?" Both religious and spiritual are used because individuals may relate to one and may even take offense at the other. Many individuals who will say they are not religious will admit to being spiritual, which should prompt a discussion of what this means to them. Conversely, an answer such as, "Yes, I'm Catholic," tells you something but begs exploration of what this means.|
|I||Importance and Influence:||"How important is your faith (or religion or spirituality) to you?" Just hearing that the person is spiritual or a member of a particular religion tells you little. How important is this? How is it important? There is a big difference between a Catholic who has not been to Mass since childhood and one who goes to Mass daily.|
|C||Community:||"Are you a part of a religious or spiritual community?" Particularly for those who participate in an organized religion, community is often a central part of their spiritual and social experience. It is not uncommon that just when this community becomes most important, when death approaches, the individual is cut off from that community because of illness and caregiving needs.|
|A||Address or Application:||"How would you like me to address these issues in your health care?" "How might these things apply to your current situation?" "How can we assist you in your spiritual care?" Patients and families often feel better simply because they have been given permission to share their beliefs. That you have inquired is usually seen as a sign of respect. However, there may be very specific things you can do to be of assistance. In a talk on assessing suffering, Baines told the story of a man who reported 10 of 10 on a scale of suffering that related entirely to his spiritual care. He had regularly attended a certain service and was now unable to do so, which resulted in unbearable suffering. With permission the hospice team contacted the ministry, which sent a home ministry team to the patient's home. His suffering score drop to 0 of 10.57 As in this case, assistance for many will mean access. A simple phone call to the proper clergy member can significantly relieve distress. Patients and families may also have fears related to spiritual issues that they may be hesitant to express. For example, Sikhs wear sacred regalia that should not be removed from the person at any time.58 Patients and families may become terrified that health care workers will remove them. Asking if patients have any special concerns or fears and then addressing them may be of great assistance.|
Like all mnemonics, FICA has a certain artificiality. Dr. Pulchalski has stressed that performing it usually takes only a few minutes and can reveal a wealth of information. She also points out that it often leads naturally to other discussions, such as an exploration of patient and family preferences. Such discussions often make more sense following an exploration of spirituality. It is also possible to incorporate aspects of FICA into the normal flow of conversation. In my experience many patients and families toss out a hint that they would like to enter a discussion of spirituality with a statement such as, "Why do you think this happened to me?" The clinician faces a choice - cut off that thread with a response such as, "Darned if I know," or expand the lead by saying "I wish I knew. What do you think?" Most people do not expect us to have the answers. However, they are looking for an opportunity to share and explore their own beliefs and concerns. The clinician may reflect back such questions: "Why do you think this has happened to you?" Such reflection often naturally leads to a broader exploration of spirituality.
It has puzzled me that so little work, even in palliative care, has gone into teaching clinicians about dealing with spirituality. Even the American Medical Association EPEC (Educating Physicians about End-of-Life Care) program did not include a module on this. When we first attempted to include spirituality as a topic in our End-of-Life Care (ELC) faculty development curriculum at the Stanford Faculty Development Center, we got a clearer sense of why this might be so. Not surprisingly (in retrospect), the physicians we were training had strong opinions about spirituality. Some physicians seemed to be just waiting for the opportunity to bring spirituality to the fore. Although we tried to stress that the focus in raising spirituality as a topic area was on what spirituality means to the patient and family and that our curriculum should be useful to all physicians, including atheists, some participants seemed unable to resist the temptation of making strong statements regarding their own beliefs. One student began a practice session on spirituality by stating, "You are all spiritual beings" - or words to that effect, which made some cringe. Although I might personally agree with such a statement, I think it is very important that any clinician training in this area be assiduously neutral relative to the importance, or value, of spirituality apart from the value spirituality holds for our patients and families. Not to do so risks an imposition of beliefs and values that many quite rightly would find offensive. Not everybody agrees that "We are all spiritual beings."
We remain committed to discussing spirituality as a component of our curriculum but have learned that a special cautionary note is called for. To put it bluntly, it is not about you, it is about the patient and family. In teaching spirituality as a component of a broader palliative care curriculum, it is not what I, the teacher, believes or you, the learner, believes that is most important. It is about acquiring skills necessary to address the spiritual needs of patients and families, period. If spirituality is important to you in your life and your work (as it personally is in mine), fine - let your spirituality shine through the quality of care you deliver and the quality of your teaching. Sometimes, when a patient asks "Do you believe in God," he or she really is curious about how you are struggling with this issue as a person. Sharing your thoughts and beliefs may meet a need of the patient to know that we physicians, too, are mortal and are struggling with the same big questions. Most patients and families are relatively preoccupied with their own struggle and ask such questions as an inquiry to determine if you are open to exploring their spiritual concerns. I might say something such as "I'm still struggling myself to understand what this world is all about. What about you? What do you believe?"
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.