Ethics Journal of the American Medical Association

Virtual Mentor, May 2005
Virtual Mentor
Ethics Journal of the American Medical Association
May 2005, Volume 7, Number 5
Clinical Pearl
Doing a Culturally Sensitive Spiritual Assessment:
Recognizing Spiritual Themes and Using The HOPE Questions
by Gowri Anandarajah, MD
During the last 10 years there has been a considerable increase in the number of
studies showing positive associations between spirituality and health [1, 2].
Incorporating spirituality into medical practice, however, continues to pose many
challenges [3]. These include the multicultural milieu in which medicine is practiced
and the deeply personal meaning these issues carry for both patients and health care
providers. A culturally sensitive spiritual assessment is a first step towards addressing
the spiritual needs of patients [4]. It also provides a tool through which health
professionals can understand their own beliefs, biases, values, and needs as related to
health care.
Words such as spirituality and religion carry a variety of meanings for different people.
For some these terms evoke positive feelings and for others they may trigger negative
responses. Although debate continues regarding the exact meaning of these and
related words, it is helpful to have some common ground from which to start.
A. Whole person—Human beings are complex, with physical, mental, and spiritual
aspects. Suffering can result from issues pertaining to any of these aspects.
B. Spirituality—Pertains to people’s understanding of and beliefs about the meaning
of life and their sense of connection to the world around them. It is multidimensional
and can encompass both secular and religious perspectives [4].
1. Cognitive aspects have to do with the way we make sense of the world around
us. They include the big picture questions such as: “What is the nature of the
universe?” “Is there a God?” “Why do bad things happen to good people?”
“What happens after death?” “What beliefs and values are most important to
2. Experiential aspects have to do with connection and inner resilience. They
encompass questions such as: “Am I alone or am I connected to something
bigger?” “Am I able to give and receive love?” “Do I feel an inner sense of
peace and resilience?” “Can I find hope in this difficult situation?”
3. Behavioral aspects have to do with ways in which a person’s spiritual beliefs
and inner spiritual state affect his or her behavior and life choices.
C. Religion—organized or institutionalized belief systems that attempt to provide
specific answers to mankind’s general spiritual needs and questions. For many people,
religion provides an important foundation from which to meet the numerous
challenges that life presents. For others religion may be associated with negative
D. Faith—can mean a person’s belief and trust in something (eg, God) and may or
may not pertain directly to religion (as in “What is your faith?”).
E. Spiritual distress/crisis—This is a state of suffering due to spiritual causes. For
example: (1) a mother having difficulty understanding why a loving God would allow
her child to die; or (2) a dying patient feeling cut off from sources of spiritual love.
F. Spiritual Assessment—Methods to identify a patient’s spiritual suffering and
spiritual needs related to medical care.
G. Spiritual Care—Therapeutic aspects of spirituality and medicine.
1. General spiritual care—bringing presence, compassion, understanding, and
listening to each encounter. This can be provided by anyone at any time. It can
traverse all cultural barriers by meeting a universal spiritual need without
specific discussion about beliefs or God.
2. Specific or specialized spiritual care—addressing the individual needs of the
patient. Simple issues may be addressed by physicians. More complex issues
will likely require the expertise of well-trained spiritual care counselors such as
chaplains trained in Clinical Pastoral Education.
Ethical and Boundary Considerations
There has been a great deal of discussion in the literature regarding the ethical and
boundary issues involved in incorporating spirituality into medical care [5]. In a
multicultural society, it is important to keep in mind that physicians and patients
frequently do not come from the same cultural background or belief system. Since
patients in medical and spiritual distress are often in a vulnerable position, it is critical
that health care providers be sensitive and careful in their approach to patients.
Physicians should also be aware of their limitations in training and expertise in spiritual
care and should utilize the help of trained chaplains in complex or difficult situations.
Providing a Spiritual Assessment
A. Goals
1. Provide a safe, therapeutic setting for patients to discuss their spiritual needs
related to medical care.
2. Use an approach that will be acceptable and helpful for any patient
regardless of religious or cultural background.
3. Keep patient’s needs as the primary focus.
Virtual Mentor, May 2005
4. Use self-understanding, self-care, and reflection skills to help negotiate
through ethical and boundary challenges.
5. Maintain compassionate care as the foundation to every interaction.
B. Methods
1. Informal spiritual assessment – Perhaps the most valuable way to gain an
appreciation of a patient’s spiritual beliefs and concerns is to listen carefully
to the patient’s stories and narrative and recognize spiritual themes as they
arise. Often, spiritual values and beliefs present in the form of metaphors
and stories rather than in response to direct questions. Recognizing these
themes (such as search for meaning, or connection versus isolation) and
following with open-ended and specific questions about patients’ beliefs
may reveal a great deal about a patient’s source of suffering.
2. Formal spiritual assessment – This involves asking specific questions during the
course of a medical encounter in order to determine if spiritual issues play a
role in the patient’s illness or recovery.
C. The HOPE questions are an example of one approach to spiritual assessment [4].
These questions were designed as a starting place for health care professionals
interested in the spiritual health of their patients. They may open the door for more indepth discussion when needed. The HOPE approach asks about:
1. H—The sources of hope, meaning, comfort, strength, peace, love and
By focusing on a patient’s basic spiritual resources without immediately
introducing the words religion or spirituality, these questions allow for
conversations with people from a wide variety of backgrounds and beliefs.
2. O—Organized religion’s role for the patient.
3. P—Personal spirituality and practices.
4. E—Effects of the patient’s beliefs and values on medical care and end-oflife decisions.
Examples of questions for each of these domains can be found online in an article
describing the HOPE tool [4] at
Spiritual Care
Once a patient’s spiritual needs have been assessed, there are several possible options
for health care professionals not specifically trained as clinical chaplains.
1. Do no more—sometimes just giving the patient the opportunity to express
his or her concerns in a safe, compassionate environment is enough.
2. Incorporate the patient’s own spiritual resources into preventive care or as
adjuvant care.
3. Modify the treatment plan based on the patient’s identified spiritual needs;
eg, continue or stop heroic life sustaining measures; refer a patient in
spiritual distress to a trained clinical chaplain; teach simple relaxation or
meditation techniques to patients interested in this approach; consider
alternatives to blood products for patients who are Jehovah’s Witnesses.
The spiritual assessment is the first step towards addressing the spiritual as well as
mental and physical well-being of patients. If done in a compassionate, culturally
sensitive way, it can help provide a great deal of relief to our suffering patients.
1. Levin JS, Larson DB, Puchalski CM. Religion and spirituality in medicine: research
and education. JAMA. 1997;278:792-793.
2. Mueller PS, Plevak DJ, Rummans TA. Religious involvement, spirituality and
medicine: Implications for clinical practice. Mayo Clin Proc. 2001;76:1225-1235.
3. Koenig HG. Religion, spirituality and medicine: Implications for clinical practice.
South Med J. 2004;97:1194-1200.
4. Anandarajah G, Hight E. Spirituality and medical practice: the HOPE questions as a
practical tool for spiritual assessment. Am Fam Phys. 2001;63:81-88,89.
5. Post SG, Puchalski CM, Larson DB. Physician and patient spirituality: professional
boundaries, competency, and ethics. Ann Int Med. 2000;132:578-583.
Gowri Anadarajah, MD, is associate professor of family medicine at Brown University Medical
School, Providence, Rhode Island.
The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views
and policies of the AMA.
Last updated: May 02, 2005
Copyright 2005 American Medical Association. All rights reserved.

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