Virtual Mentor, May 2005
Ethics Journal of the American Medical Association
May 2005, Volume 7, Number 5
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 . 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 . It also provides a tool through which health
professionals can understand their own beliefs, biases, values, and needs as related to
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 personâ€”Human beings are complex, with physical, mental, and spiritual
aspects. Suffering can result from issues pertaining to any of these aspects.
B. Spiritualityâ€”Pertains to peopleâ€™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 .
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: â€œWhat is the nature of the
universe?â€ â€œIs there a God?â€ â€œWhy do bad things happen to good people?â€
â€œWhat happens after death?â€ â€œWhat beliefs and values are most important to
2. Experiential aspects have to do with connection and inner resilience. They
encompass questions such as: â€œAm I alone or am I connected to something
bigger?â€ â€œAm I able to give and receive love?â€ â€œDo I feel an inner sense of
peace and resilience?â€ â€œCan I find hope in this difficult situation?â€
3. Behavioral aspects have to do with ways in which a personâ€™s spiritual beliefs
and inner spiritual state affect his or her behavior and life choices.
C. Religionâ€”organized or institutionalized belief systems that attempt to provide
specific answers to mankindâ€™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. Faithâ€”can mean a personâ€™s belief and trust in something (eg, God) and may or
may not pertain directly to religion (as in â€œWhat is your faith?â€).
E. Spiritual distress/crisisâ€”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 Assessmentâ€”Methods to identify a patientâ€™s spiritual suffering and
spiritual needs related to medical care.
G. Spiritual Careâ€”Therapeutic aspects of spirituality and medicine.
1. General spiritual careâ€”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 careâ€”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 . 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
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 patientâ€™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.
1. Informal spiritual assessment â€“ Perhaps the most valuable way to gain an
appreciation of a patientâ€™s spiritual beliefs and concerns is to listen carefully
to the patientâ€™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 patientsâ€™ beliefs
may reveal a great deal about a patientâ€™s source of suffering.
2. Formal spiritual assessment â€“ This involves asking specific questions during the
course of a medical encounter in order to determine if spiritual issues play a
role in the patientâ€™s illness or recovery.
C. The HOPE questions are an example of one approach to spiritual assessment .
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. Hâ€”The sources of hope, meaning, comfort, strength, peace, love and
By focusing on a patientâ€™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. Oâ€”Organized religionâ€™s role for the patient.
3. Pâ€”Personal spirituality and practices.
4. Eâ€”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  at www.aafp.org.
Once a patientâ€™s spiritual needs have been assessed, there are several possible options
for health care professionals not specifically trained as clinical chaplains.
1. Do no moreâ€”sometimes just giving the patient the opportunity to express
his or her concerns in a safe, compassionate environment is enough.
2. Incorporate the patientâ€™s own spiritual resources into preventive care or as
3. Modify the treatment plan based on the patientâ€™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 Jehovahâ€™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.
Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?
Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.
Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.
Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.
While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.
Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.
In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.
Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.
We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!
We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.
Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.
We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.
Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.
There is a very low likelihood that you won’t like the paper.
Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.
We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.
You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.
We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.
You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.
Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.
You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.
Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.Read more
Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.Read more
Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.Read more
Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.Read more
By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.Read more