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 Health professionals involved should keep in mind that spirituality and religiosity favorably influence ability to cope with the disease, but the isolation imposed by hospitalization may be negative as it removes patients from their religious meetings or practices, from religious leaders and of dedicated communities. These beliefs and practices can impact and often antagonize proposed medical strategies. It is worth noting that health professionals also present their own profiles of spirituality and religiosity, influencing their practice, especially in severe, critical or limiting situations. Every professional should be aware of the relevance of screening involving spirituality, and those focused on direct care such as doctors, nurses, and chaplains should have an anamnesis of spirituality and religiosity, viewed not only as part of identifying where professed religion is concerned, but how a broader construction obtained by structured or unstructured questionnaires, allowing to penetrate and understand the true identity of spirituality and religiosity in patients and relatives. 387,432,433 Most professionals are sensitive to the demand of patients only when informed, but the contemporary view is to actively search for this information and demands, because the patient often does not feel comfortable discussing it. 432 In a holistic view of a human being, the anamnesis of spirituality and religiosity should be remembered in each care interaction and by all health professionals. 366,433 Naturally, this approach may be unimportant or difficult to use in many situations, such as in major emergencies, but it is of enormous relevance in critical, terminal, chronic degenerative diseases or palliative care. Critically ill patients have high rates of not only pain, dyspnea, anorexia, and fatigue, but also of anxiety, nervousness, sadness and depression. For this patient profile, Cicely Saunders’ concept of “total pain,” understood as a sum of physical, psychological, social, emotional and spiritual elements, must be valued and addressed in a systematic and structured manner, even in the first days of hospitalization. 434,435 Patient-centered approaches with a greater focus on spirituality make it easy to understand and value the motivations for consultation, understand the patient’s universe (including emotional and existential issues), and strengthen the relationship between practitioners and patients, shared decision making, and prevention and promotion of health. 433,436 It is essential for professionals to be technically prepared and the patient to agree on addressing issues related to spirituality and religiosity so that the interaction is constructive and without conflict. In the absence of technical training or resistance to the subject by the patient, the spiritual history should be postponed to a more opportune time or even canceled. When these alignments do not occur, serious conflicts can develop and sometimes very deleterious to medical management. To avoid conflicts in the doctor-patient relationship, it should always be borne in mind that this area is deeply personal as well as intensely emotional, and therefore, the physician should not address emotional issues without proper approximation of spiritual and/or religious aspects. The physician should be sure of the patient’s agreement to address the issue. Health professionals, especially those involved in critical or terminal patient care or palliative care, are subject to a significant burden of professional stress. This work involves a lot of compassion, understood as an attitude of addressing the needs of others and helping those in distress, which can be viewed as a spiritual practice. Training and practice strategies on spirituality and religiosity in this setting can contribute to a better sense of meaning and purpose at work, spiritual well- being, less fatigue and reduced burnout. 366 The reasons for professionals not addressing spirituality and religiosity are diverse, such as feeling uncertain about initiating spiritual discussions, being misunderstood as imposing religion, invasion of privacy, causing discomfort, difficulties with the language of spirituality. 436 These justifications have also been identified in Brazilian medical students 437 and represent weaknesses in medical education and practice, with specific ignorance or inadequate dimensioning, lack of mastery of specific tools and training. The solution to these limitations lies in the development of hospital spirituality support and training programs. These programs contribute to well-being and health improvement, assist with misunderstanding in conducts, and meet patients’ expectations, and they are part of accreditation processes and prospects for reducing hospitalization costs. 438 For the development of these programs, there should be deep institutional involvement, formal training of the teams most directly connected to care, availability of infrastructure and resources, adjustments to care routines, and alignment with the various religious communities. Health teams, especially when acting in scenarios where there is a higher demand for spirituality and religiosity, should be structured with systematic training and clear definition of responsibilities, such as obtaining and recording anamnesis in medical records, clarifying the observed demands and the implemented clinical course, as well as the observed outcomes. At initial contact, spiritual history can be obtained through open and brief questions by the doctor, nurse or chaplain, thus tracking needs and anticipating conflicts. For the spiritual approach, no professional is expected to be able to do so, but a certified chaplain or a spiritual care professional with equivalent technical training and structured standards and concepts to develop a spiritual care plan. 387 Religion should never be prescribed, forced or even encouraged, at the risk of adding guilt to the burden of disease. Identifying the right time for spirituality and religiosity approaches is important to avoid any kind of misunderstanding, always under the rule of common sense. We emphasize that the evaluation of spirituality is always desirable, enabling the search for information in all patients regardless of religion or religiosity, but the approach in extreme situations can lead to stress and even worsen patient evolution. Respect for spirituality, religiosity and individual beliefs is essential and should match the therapeutic plan if it is not harmful. If necessary and at the patient’s wishes and in the face of risk or harm or in conflict situations, the presence of religious 840