ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 Chart 9.1 – Instruments spiritual tracking Tracking tools Spiritual domains evaluated “Rush” protocol for tracking religiosity/ spirituality 388 Importance of religiosity/spirituality in dealing with disease. Spiritual strength or comfort “Are you at peace?” 389 Inner peace “Do you feel spiritual pain or suffering?” 390 Spiritual pain/suffering Spiritual injury scale 391 Guilt, anger, sadness, feeling of injustice, fear of death 2. Collection of spiritual history – They allow a broader evaluation of the different domains of patients’ spirituality and religiosity that may affect clinical evolution, their attitude towards CVD, self-care and their physical, mental and spiritual well-being during the disease. They are well-structured instruments, addressing the different domains, but they should be applied informally from memory throughout the conversation with the patient, which serve as a tool or guide and should not be viewed rigidly, but as continuous learning and consequent familiarization with the task of completing the anamnesis. There are several validated instruments for collecting spiritual history, whether to evaluate spirituality and religiosity more broadly or for research purposes. 2. a. Religiosity scales – The religiosity index DUREL (Duke University Religion Index) is a scale of five items that measure three dimensions of religious involvement: (1) assesses organizational religiosity (OR); (2) assesses non-organizational religiosity (NOR); and (3, 4 and 5) consider the assessment of intrinsic religiosity (IR) (Chart 9.2). Validated in Brazil, 392 DUREL is succinct and easy to apply, addresses the main domains of religiosity and has been used in various cultures. It has shown good psychometric characteristics, face and competitor validity, and good test-retest reliability, but does not evaluate spirituality. The dimensions of religiosity measured by DUREL have been related to several indicators of social support and health. 39 2. b. Assessment of spiritual history – The assessment of spirituality involves a set of questions about its different domains that are associated with health outcomes, based on previously validated scales. Known by acronyms, some of the main instruments are FICA, 393 HOPE, 394 FAITH 380 and SPIRIT. 395 Among these, the FICA questionnaire has shown the best psychometric characteristics (Chart 9.3). It was created by doctors based on clinical experience and can be used in different clinical situations. It analyzes four dimensions (Faith or Belief, Importance and Influence, Community and Action in treatment), has easy application, fast execution and good memorization 383 Similarly, HOPE has shown good performance in spiritual assessment (Chart 9.3). Studies evaluating the association of spirituality and religiosity with CV outcomes have been criticized for the difficulty in adjusting for multiple comparisons, certain seemingly contradictory findings, and too many instruments. Measuring spirituality is complex because of the many aspects involved in defining it and the multiple domains it encompasses. Systematic reviews 386,396,397 broadly discuss the tools available for assessing spirituality and religiosity, showing that the different instruments measure a wide range of spiritual dimensions, including religious denomination, attendance at religious ceremonies, OR, NOR and IR, religious/spiritual coping, religious and spiritual beliefs, practices and values, well-being and inner peace, stress generated by religion (“struggle”), a tendency towards forgiveness and gratitude. The scale called Brief Multidimensional Measure of Religiousness and Spirituality, validated in Brazil, 392 considers in its analyses the frequency of spiritual experiences, values/beliefs, propensity for forgiveness, personal religious practices, religious and spiritual overcoming, religious support and commitment. The WHO Quality of Life instrument in the Spirituality, Religiosity and Personal Beliefs module (WHOQOL- SRPB) comprises 32 items, distributed in 8 facets involving connection to being or spiritual strength, meaning in life, wonder, wholeness and integration, spiritual strength, inner peace, hope, optimism and faith. 398 In a systematic review, Lucchetti et al., 386 selected and evaluated instruments for clinical research validated in Portuguese. 9.2.5. Attitudes and Behaviors after Spiritual Anamnesis With information on the spiritual dimension of patients, it is possible to establish new possibilities for understanding the pathophysiology illness and consequent medical intervention. Some general lines can be established: 1. Take no action: religious issues are delicate and not always objective to the point of plausible resolution, even though they may be of great importance to the patient. Often, the best course is simply to offer your empathy and understanding; 2. Incorporate spirituality in preventive health: the physician can encourage the patient to use his/her spirituality as a disease prevention tool by engaging in activities such as prayer and meditation; 3. Include spirituality in adjuvant treatment: the physician can help the patient identify spiritual aspects that, along with standard treatment, may help with the outcome of the disease; in the case of serious illness, the physician can collect the spiritual history and help the patient find meaning, accept the illness, and cope with the situation using his/her spiritual resources in the best way; 4. Modify the treatment plan: it is up to the physician to understand that the patient has the freedom to be able to modify the therapeutic plan on the basis of religious beliefs and thus to propose modifications in the course of the treatment. For example, the patient may opt for meditation as an option for chronic pain, change chemotherapy plans, and seek community support. 836