Spiritual Pain: Should Medical Professionals do Spiritual Care? if Yes, How

Human Being is a complex Being with not just physical, emotional and social needs but also Spiritual needs. Medical Professionals are trained to treat the physical and sometimes emotional and social aspect of a dis-ease but receive no formal training in addressing spiritual needs of a patient. This article is mini-review of the literature and an opinion on should medical professionals provide care to address spiritual pain.


Introduction
Human Being is a complex being with not just physical, emotional and social needs but also with Spiritual needs ( Figure  1). Spiritual Care is a complex and a vast subject and requires the same professional and tailored approach as any physical or psychiatric care. Medical Professionals are trained to treat the physical and sometimes emotional and social aspect of adis-ease but receive no formal training in addressing spiritual needs of a patient. Spiritual pain is often experienced during the end of life when the patients often tackle the fear of death among other fears. Deeken in his paper identifies nine types of fears and anxieties about death which become a "source of spiritual pain: 1. Fear of pain; 2. Fear of loneliness; 3. Fear of unpleasant experiences; 4. Fear of becoming a burden to the family and to society; 5. Anxiety towards the unknown; 6. Fear of death resulting from fear of life; 7. Fear of death as a feeling that one's life task is still incomplete; 8. Fear of death as fear of personal extinction; 9. Fear of death as fear of judgment and punishment after death" [1].

Discussion
Spiritual Care is a complex and a vast subject and requires adequate training to recognise and treat the pain. For example in a study which was aimed to see the nurses' and the physicians' desire to provide Spiritual care to terminally ill patients, 11 potential barriers were identified. The conclusions were that "Most nurses and physicians desire to provide Spiritual Care within the setting of terminal illness (74% vs. 60%, respectively) however, 40% of nurses/physicians provide Spiritual care less often than they desire. The most highly endorsed barriers were "lack of private space" for nurses and "lack of time" for physicians. Barriers that predicted less frequent Spiritual Care for all medical professionals included inadequate training, "not my professional role", and "power inequity with patient". A minority of nurses and physicians 21% and 49% did not desire Spiritual Care training" [2].
Best care is only possible when the care recipient and the care giver both are in agreement. Do patients want their medical care givers to talk about Spirituality? In a systematic literature review of 54 studies comprising 12,327 patients, the majority of studies over half the sample thought it was appropriate for the doctor to enquire about spiritual needs in at least some circumstances [3]. The real challenge was what those 'circumstances' should be. From the above it is clear that best to seek a balance and the medical care professionals should do the General Spiritual Care with the Specialised and Detail Spiritual care done by a 'SPIRITUAL EXPERT' [4].

What are the aspects of Generalised Spiritual Care? To begin, as in any consultation it is important to take a Spiritual History. This can be done by asking appropriate questions like
a. "Would you like to discuss the spiritual or religious implications of your health care?" b.
"Are there aspects of your religion or spirituality that you would like to discuss?" c.
"Would you like to discuss the spiritual or religious implications of your health care?" Many tools exist that can be used by the physician for spiritual assessment but it must be kept in mind that these tools were used in a palliative care set-up. Maugans developed a tool with an acronym SPIRIT [4] which mainly dealt with questions on one's religious belief and its impact on healthcare. The FICA [5] spiritual assessment tool and the HOPE [6] questions are other such tools. Lo et.al, in their paper provide simple open ended questions that help in spiritual assessment (Table 1) and warn against common pitfalls (  Trying to solve the patient's problems or resolve unanswerable questions.
Going beyond the physician's expertise and role, or imposing the physician's religious beliefs on the patient.
Providing premature reassurance

Conclusion
In concluding we acquiesce with Elizabeth A. Catlin and colleagues who suggest "roles of physician and pastoral counsellor should be separate in the early stages of the relationship because patients and their families may not be prepared initially to trust or understand the role of such a fused figure. However, as the patient-physician relationship develops, we believe that it may be of value to both the patient and the caregivers for the physician to explore the patient's existential and spiritual concerns. For physicians to attain the selfconfidence to perform this function, however, requires a deeper understanding of the issues than can be provided by reading an article on practical guidelines" [8]. They recommend a "clinical pastoral education program" modified for clinicians so as to provide the medical professionals with the skills, language, and experience to provide good Spiritual Care. It is also important to have an environment and an infrastructure which is conducive to providing Spiritual Care (Table 3) [9].