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All faith traditions and cultures encourage a spiritual life. It is important for the physician to heighten the ability to use his or her own spiritual/cultural awareness to discern a patient’s spiritual values, meaningful personal principles, and vital connections; and to respect and enhance these spiritual dimensions in the care of the patient. One of the most important, but most frequently neglected opportunities in providing excellent end-of-life care is to include and enlist the patient’s own personal spiritual leader into his or her care. For numerous but unclear reasons, physicians often fail to invite spiritual leaders into decision-making and holistic patient care, even when they are readily available. Appropriate inclusion of such individuals, however, does not obviate the need for the physician to personally connect with the patient on a spiritual level.

There is a distinction between religion and spirituality that is important for the physician to recognize. Religion is a rich and complex reality that links humans, in their complete being as thinking, feeling, doing, social, and cultural creatures, to Ultimate Reality. Spirituality is “the transcendent relationship between the person and a Higher Being, a quality that goes beyond religious affiliation, that strives for reverence, awe, and inspiration, and that gives answers about the infinite.”(1) Dr. Elizabeth McSherry and her colleagues have emphasized the importance of spiritual assessment. “The spiritual assessment gives the patient an excellent first impression that he or she is valued by the [physician and hospital and other health care workers] as more than just a broken machine.”(2) Obtaining a spiritual history allows clinicians to understand patients more fully,(3) but also may have an important therapeutic role of informing the patient that the physician truly cares.

How does a physician engage a patient about his or her spirituality? Remember that spirituality is about the patient’s values and beliefs, what is important to the person about self and the world we live in. Dr. Christina Puchalski makes five recommendations:(4)

Consider spirituality as a potentially important component of every patient’s physical well-being and mental health.
Address spirituality at each complete physical exam and continue addressing it at follow-up visits, if appropriate. In patient care, spirituality is an ongoing issue.
Respect a patient’s privacy regarding spiritual beliefs; don’t impose your beliefs on others.
Make referrals to chaplains, spiritual directors or community resources as appropriate.
Be aware that your own spiritual beliefs will help you personally and will overflow in your encounters with those for whom you care to make the doctor-patient encounter a more humanistic one.

Handzo has particularly emphasized the importance of recognizing spirituality in cancer patients, suggesting the need for “an integrated system for rapidly assessing distress in outpatients with cancer, triaging them to the proper psychosocial/pastoral clinical pathway,”(5) stressing the importance of recognizing hopelessness and a sense of isolation from religious community. Gleason has proposed that patient spirituality can be assessed by identifying characteristics of the patient’s “spiritual world.”(6) The patient’s spirituality may be very different from the physician’s frame of reference, such that the physician may be unable to understand the patient’s perception of his or her illness, choices regarding treatment, or the emotional and social impact of the disease without some understanding of the patient’s spirituality.

Physicians cannot successfully make a spiritual assessment of the patient without awareness of diversity, which includes all the ways we are unique and different from others. Dimensions of diversity include, but are by no means limited to, race, ethnicity, religion and spiritual beliefs, cultural orientation, physical appearance, gender, sexual identity, ability, education, age, ancestry, place of origin, marital status, family status, socio-economic circumstances, profession, language, health status, geographic location, group history, upbringing and life experiences. Rev. Dr. Carlos Sandoval says “Since culture provides individuals with a framework for understanding experience, it is of great importance to consider culture in the medical setting. Each culture group has its own views about health, illness, and health care practices. These views affect how individuals respond to illness and their symptoms, including pain; how they identify and select medical care; and how they comply with prescribed care.”

Even more fundamental issues, such as whether an individual has the right or ability to attempt to control personal health, may be deeply rooted in culture. Eric Law characterizes an important aspect of cultures as “Power Distance.” (7) Power distance is related to peoples’ perception of power. That is, in a Higher Power Distance culture, the majority of the people believe that they have little power to change their environment of inequality. The small elite group who has the power and authority is rarely challenged. In a Low Power Distance culture, the majority of the people believe that they have power to change the social system. They are not afraid to challenge authority figures and work towards a more even distribution of power. Power distance is not only a cultural variable, but it is also a variable based on economic classes and education. Interaction and communication of patients and their families with physicians and other authority figures and even more fundamental beliefs about illness, treatment, death, and dying may be profoundly impacted by the individual’s Power Distance background. The majority of High Power Distance (feel powerless) people are from Latin American and Asian countries, such as Philippines, Mexico, Venezuela, India, Singapore, Brazil, Hong Kong, France, Colombia, Turkey, Belgium, Peru, Thailand, and Chile. Low Power Distance individuals are usually from English-speaking and Germanic language-based countries, such as Australia, Israel, Denmark, New Zealand, Ireland, Sweden, Norway, Finland, Switzerland, Great Britain, Germany, Australia, Netherlands, Canada, and the U.S.A.(8)

Law further cites the effect of the Power Distance cultural variable to explain why there is a dichotomy between ethnic and racial minorities and European Americans in their perception of power. Individuals from High Power Difference cultures, for example, more commonly defer to the medical staff when it comes to making medical decisions. Law suggests that three points are important to consider in dealing with end-of-life decision-making:

	The majority of recent immigrants in the US are from Latin American and Asian countries.
	From the class perspective, the majority of the lower-income and less educated people in the US are people of color and recent immigrants.
	The “melting pot” theory does NOT work for people of ethnic/racial minorities in the US. The second and third-generation European American can “melt” into the dominant American culture fairly easily. No matter how hard people of minority populations try to “melt”, they are not yet accepted by the majority as true Americans.

Difficulties in bridging cultural differences may be primarily responsible for healthcare disparities now well documented in the United States.(9) The Rev. Celillon Alteme draws upon his origins in Haiti and his many years experience as a hospital chaplain in the U.S. to suggest that physicians need to:

	Gain knowledge about a patient’s culture.
	Understand that the physician's own cultural views are just one way to look at reality.
	Develop communication skills that allow for nonjudgmental exchange of values in problem solving.
	Use open-ended questions.
	Use language and culture-appropriate phrases in educating patients and families.
	Include families through respect of their cultural values.
	Include clergy and church groups when interacting with patients and families.
	Do not rely on stereotypes.
	Be aware of your own multicultural heritage.
	Be aware of your own biases regarding end-of-life.
	Be open to a multicultural approach to end-of-life care.
	Be aware of institutional barriers to minorities.
	Be willing to facilitate referrals, when culturally appropriate.

^[1] Murray, R, et al. The Nursing Process in Later Maturity. Englewood Cliffs, New Jersey: Prentice Hall, 1980.

^[2] McSherry, Elizabeth, et al., “Pastoral Care Departments more necessary in the DRG era?” HCMR, 1986, 11(1): 47-59.

^[3] Puchalski, Christina & Romer, Anna L. “Taking a Spiritual History Allows Clinicians to Understand Patients More Fully” Journal of Palliative Care, 2000, 3 (11):129-137.

^[4] Puchalski, Christina (GWISH) George Washington University. “FICA: A Spiritual History”

^[5] Handzo, G. “An integrated system for the assessment and treatment of psychological, social, and spiritual distress” Chaplaincy Today, 1998, 14 (2), 30-37.

^[6] Gleason, J. “The four worlds of spiritual assessment and care” Journal of Religion and Health, 1999: 38(4), 305-317.

^[7] Eric HF Law, The Wolf Shall Dwell with the Lamb – Spirituality for Multicultural Community. Chalice Press, Missouri, 1993.

^[8] Holstede, G. Cultural Consequences-international Differences in work-related Values. Sage, Beverly Hills, CA. 1980.

^[9] Addressing Racial and Ethnic Disparities in Health Care. Fact Sheet, February 2000. AHRQ Publication No. 00-PO41. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/disparit.htm

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