ARTIGO:
SAÚDE E ESPIRITUALIDADE/ HEALTH AND SPIRITUALITY
No mês
de julho de 2017, a "The JAMA Network", publicou o artigo intitulado “Health and
Spirituality”, com autoria de VanderWeele TJ, Balboni TA e Koh HK, da Harvard e
Dana Farber Cancer Institute.
Este
artigo constitui uma síntese dos principais impactos da espiritualidade na
saúde e a importância da espiritualidade na prática clínica.
Leia em
inglês o artigo original:
JAMA. Published online July 27, 2017.
doi:10.1001/jama.2017.8136
For centuries, physicians and other
healers have witnessed how illness focuses attention on “ultimate meaning,
purpose, and transcendence, and … relationship to self, family, others,
community, society, nature, and the significant or sacred.”1
Patients often discover strength and solace in their spirituality, both
informally through deeper connections with family and friends, and formally
through religious communities and practices. However, modern day clinicians
regularly overlook dimensions of spirituality when considering the health of
others—or even themselves.
This relative neglect represents a
departure from the substantial history linking health, religion, and
spirituality within most cultures.2 However, accumulating evidence
that highlights the richness of the interconnection can inform future
strategies for population health as well as individualized, patient-centered
care. According to a 2016 Gallup Poll of 1025 adults in the United States, 89%
believe in God or a universal spirit, and 75% consider religion of considerable
importance.3 The potential ramifications of these perspectives are
substantial, especially given that increasing numbers of people in an aging
society may be facing difficult end-of-life decisions.
Research
Recent studies suggest a broad protective
relationship between religious participation and population health. A report
from the Nurses’ Health Study, which followed up more than 74 000 study
participants for 16 years, found that women
who attended weekly religious services had a lower mortality rate compared with those who had never attended
religious services (actual rates of 845 vs 1229 per 100 000/y,
respectively; adjusted hazard ratio, 0.74),4 and those who attended religious services more
than once per week had an even lower mortality rate (actual rates of 740 vs
1229 per 100 000/y; adjusted hazard ratio, 0.67), suggesting a possible
dose-response relationship.
Multivariable adjustment for extensive
confounders did not substantially attenuate the association, suggesting that
some of the association might be causal. Although the findings may still be
subject to unmeasured factors and residual confounding4 (eg,
personal, social, psychological, and socioeconomic characteristics),
sensitivity analysis suggested that the association was moderately robust to
such unmeasured confounding. Another report from the Nurses’ Health Study noted
that attendance at religious services
was associated with a reduction in
depression risk (adjusted relative risk, 0.71) and a 6-fold reduction in suicide risk (from 6.5 to
1.0 per 100 000/y).5
Possible mechanisms include that religious service participation may
enhance the social integration that promotes healthy (eg, tobacco-free) behaviors and provides social support,
optimism, or purpose. A recent meta-analysis of 10 prospective studies with
more than 136 000 participants showed having
higher purpose in life was associated with a reduction (relative risk,
0.83) in all-cause mortality and
cardiovascular events.6 Because randomized trials are not
possible (assignment of behaviors such as service attendance and life purpose
is infeasible), these population-based studies represent the strongest
available evidence.
Additional investigations suggest the value of spiritual approaches to
medical care within the clinical realm, particularly in the end-of-life setting.
In a multisite, prospective study7 of 343 patients with advanced
cancer, those whose medical teams (eg, clinicians, chaplains) attended to their spiritual needs had
quality-of-life scores at life’s end that were 28% greater on average than
those who did not receive such spiritual care (20.3 vs 15.8; highest
possible score, 30). In addition, patients
reporting high support of their spiritual needs by their medical teams
(26%) compared with the large majority
who did not receive such care (74%) had
a higher odds of transitioning to hospice care (adjusted odds ratio, 3.5).
In contrast, when religious communities supplied spiritual care in the absence of
the medical team (43%), patients
with terminal illness had a lower odds of receiving hospice services
(adjusted odds ratio, 0.37) together
with a higher odds of receiving aggressive medical interventions (eg,
resuscitation and ventilation) during the last week of life (adjusted odds
ratio, 2.6).7 Other studies indicate that most
patients with serious illness experience spiritual struggles, such as feeling
punished or abandoned by God, associated with decrements in patient well-being.7
All these findings suggest the need for clinicians to integrate spiritual care
into end-of-life settings for patients who wish to receive it.
Patient and Clinician
Since the 1990s, national and global
health organizations (including the Association of American Medical Colleges,
the American Medical Association, the American College of Physicians, and the
Joint Commission) have increasingly called for attention to various aspects of
spiritual challenges as part of whole-person, culturally competent care. The
National Consensus Project for Quality Palliative Care has established
standards for clinical practice that include the spiritual, religious, and
existential aspects of care as 1 of 8 core domains. The World Health
Organization has recognized spirituality as a core dimension of palliative care
to improve quality of life for patients and families.
However, response to these calls has been
limited. More than 80% of US medical schools currently offer training in
spiritual care but most physicians have not received such training, which is
usually delivered as an elective course. Despite evidence associating chaplain
involvement with improved patient satisfaction in the hospital setting,7
formal systems of collaboration between spiritual leaders and clinicians remain
limited.
Moreover, studies suggest that even though
most patients desire spiritual care, few receive it. One multisite study8
that included 75 patients with advanced cancer and 339 nurses and physicians
showed that even though 86% of patients viewed spiritual care as important to
cancer care, 90% never received any form of such care from their oncology
nurses or physicians. Another study2 with 100 patients with advanced
lung cancer and 257 medical oncologists indicated that of 7 possible factors in
medical decision making, patients rated faith in God as the second most
important factor, whereas physicians rated this factor as the least important.
Clinicians can begin to address the need
by acknowledging spiritual health as part of obtaining a routine social
history. Asking questions such as “Do you have a faith or spirituality that
is important to you?” and “Do you
have a religious or spiritual support system to help you in times of need?”
signals respect for such issues while eliciting critical information to inform
future care. Without overstepping bounds, clinicians can also implement formal models for spiritual history taking such as
the FICA model (attention to faith or spirituality, its personal importance
in health and illness, and the role of the patient’s spiritual community and
the health care team in addressing these issues).7 As appropriate,
clinicians can also inquire about communal involvements, including religious
services, and how they affect patients’ well-being.
Clinicians might also benefit from attending to their own spiritual
health. Pressing professional issues related to burnout,
avoidable medical errors, attrition, and higher suicide rates among physicians
than among the general population are of increasing concern. Access to spiritual resources and practices
could build resilience in both medical students and practicing clinicians. The
act of providing such care to patients may help clinicians draw on their own
internal spiritual resources. One study8 demonstrated that
physicians (n = 204) who provided such care to patients with terminally ill
cancer better integrate their religion or spirituality into their profession;
therefore, providing spiritual care to patients may derive from or facilitate
the clinician’s own spiritual well-being. Another study9 of more
than 1500 physicians found that those who regarded medicine as a calling
experienced more career satisfaction and less burnout.
Community Resources
Clinicians can better connect patients
with health-related resources offered by faith-based organizations in
communities. Some of these organizations provide accessible settings for a wide
range of health promotion activities with respect to smoking cessation,
nutrition education and intervention, vaccination programs, cancer screening,
and partnerships to address issues related to human immunodeficiency virus and
AIDS. Federal agencies have encouraged such collaboration provided that
inherently religious activities (eg, prayer, worship) are not funded by the
government and that other conditions outlined in the First Amendment’s
Establishment Clause are not violated. This collaboration theme has had
bipartisan support through the White House Office of Faith-Based and Community
Initiatives (established by the Bush Administration in 2001) and later known
during the Obama Administration as the Office of Faith-Based and Neighborhood
Partnerships.
Conclusions
More explicit focus on spirituality, often
considered outside the realm of modern medicine, could improve person-centered
approaches to well-being long sought by patients and clinicians. Because most
research has involved predominantly US and Christian populations, future work
should examine these dimensions within broader ethnic and religious contexts.
More attention to such spiritual matters could bring medicine closer to the
World Health Organization’s longstanding definition of health as “a state of
complete physical, mental and social well-being and not merely the absence of
disease or infirmity.”10
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