Tuesday, March 24, 2009

But not yet, Lord

HOW do a person’s religious beliefs influence his attitude to terminal illness? The answer is surprising. You might expect the religious to accept death as God’s will and, while not hurrying towards it, not to seek to prolong their lives using heroic and often traumatic medical procedures. Atheists, by contrast, have nothing to look forward to after death, so they might be expected to cling to life.

The Economist piece entitled But not yet, Lord reports on the startling (to me at least) study published in the Journal of the American Medical Association by Andrea Phelps and her colleagues at the Dana-Farber Cancer Institute in Boston that religious people seem to use their faith to cope with the pain and degradation that “aggressive” medical treatment entails, even though such treatment rarely makes much odds.

Apparently, end-of-life chats conducted by doctors with religious patients had little impact on “religious copers”, most of whom still wanted doctors to make every effort to keep them alive.

This led the Economist to observe that, Saint Augustine of Hippo, one of Christianity’s most revered figures, famously asked God to help him achieve “chastity and continence, but not yet”. When it comes to meeting their maker, many religious people seem to have a similar attitude.

What is the relevance of this post you may well ask?

I have no idea. The responses of the patients imbued with religiosity that they wished to hang on to their mortality despite the inconvenience of disease is, somehow, quite intriguing.

One would truly have thought that the strength of one's faith would encourage a terminally ill patient to welcome the relief of crossing over so to speak. But...apparently not.


walla said...

Hope, faith and trust.

Hope that outcome will be positive;
faith that man should leave it to Him to make the final decision; and trust that He will use the scientific method to conduit life extension.


Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients With Advanced Cancer
(JAMA, March 18, 2009—Vol 301, No. 11; p1140-1148)

Context: Patients frequently rely on religious faith to cope with cancer, but little is known about the associations between religious coping and the use of intensive life-prolonging care at the end of life.

Objective: To determine the way religious coping relates to the use of intensive lifeprolonging
end-of-life care among patients with advanced cancer.

Design, Setting, and Participants: A US multisite, prospective, longitudinal cohort of 345 patients with advanced cancer, who were enrolled between January 1,
2003, and August 31, 2007. The Brief RCOPE assessed positive religious coping. Baseline interviews assessed psychosocial and religious/spiritual measures, advance care planning, and end-of-life treatment preferences. Patients were followed up until death, a median of 122 days after baseline assessment.

Main Outcome Measures: Intensive life-prolonging care, defined as receipt of mechanical ventilation or resuscitation in the last week of life. Analyses were adjusted for
demographic factors significantly associated with positive religious coping and any end-of-life outcome at P<.05 (ie, age and race/ethnicity). The main outcome was further adjusted for potential psychosocial confounders (eg, other coping styles, terminal illness acknowledgment, spiritual support, preference for heroics, and advance care planning).

Results: A high level of positive religious coping at baseline was significantly associated with receipt of mechanical ventilation compared with patients with a low level(11.3% vs 3.6%; adjusted odds ratio [AOR], 2.81 [95% confidence interval {CI}, 1.03-7.69]; P=.04) and intensive life-prolonging care during the last week of life (13.6%
vs 4.2%; AOR, 2.90 [95% CI, 1.14-7.35]; P=.03) after adjusting for age and race.

In the model that further adjusted for other coping styles, terminal illness acknowledgment, support of spiritual needs, preference for heroics, and advance care planning
(do-not-resuscitate order, living will, and health care proxy/durable power of attorney),
positive religious coping remained a significant predictor of receiving intensive life-prolonging care near death (AOR, 2.90 [95% CI, 1.07-7.89]; P=.04).

Conclusions Positive religious coping in patients with advanced cancer is associated with receipt of intensive life-prolonging medical care near death. Further research is needed to determine the mechanisms for this association.


Sullivan et al found that religious patients with cancer were less likely to understand
the definition of a do-not resuscitate order and were more likely to think a do-not-resuscitate order was morally wrong. Positive religious copers
in the Coping With Cancer sample
were less likely than nonreligious copers to have a do-not-resuscitate order or other forms of advance care planning; however, these differences were largely
a function of the effect of race/ethnicity (analysis not presented). Indeed, lower rates of advance care planning did not
mediate the relationship between positive religious coping and intensive life-prolonging care.

The increased rate of intensive
life-prolonging care among
religious copers was also not mediated by baseline preference for aggressive care, suggesting a more complex relationship between religious coping and end-of-
life care outcomes. Religious coping may influence medical decision making rather than directly affecting treatment
preferences or orientation toward
care. Religious copers may decide to undergo therapies with high risks and uncertain benefits because they trust that God could heal them through the proposed

Intrinsic to positive religious coping is the idea of collaborating with God to
overcome illness and positive transformation through suffering. Sensing a religious purpose to suffering may enable patients to endure more invasive and painful therapy at the end of life.

Alternatively, religious copers might feel they are abandoning a spiritual calling as they transition from fighting cancer
to accepting the limitations of medicine and preparing for death. Religious patients might thus equate palliative care to “giving up on God [before he has] given up on them.”34 Qualitative studies
commonly report spiritual reasons for preferring life-sustaining treatments, including a belief that only God knows a
patient’s time to die.11,35,36

Finally, high rates of intensive end-of-life care among religious copers may be attributable to
religiously informed moral positions that place high value on prolonging life.

Taken together, these results highlight the need for clinicians to recognize and be sensitive to the influence of religious coping on medical decisions and goals of care at the end of life. When appropriate, clinicians might include chaplains or other trained professionals (eg, liaison psychiatrists37) to inquire about religious coping during family meetings while the patient is in
an intensive care unit and end-of-life discussions occurring earlier in the disease
course.38 Because aggressive endof-
life cancer care has been associated with poor quality of death and caregiver bereavement adjustment,38 intensive end-of-life care might represent a
negative outcome for religious copers.

These findings merit further discussion within religious communities, and consideration from those providing pastoral counsel to terminally ill patients
with cancer. Clear associations are often elusive in religiousness/spirituality research because of the complex interactions between religious and other psychosocial

Because the Coping With Cancer
Study included comprehensive assessments of psychosocial measures, we were able to control for demographic confounders as well as more subtle potential
explanatory effects. The effects of
religious coping may have been confounded by other coping mechanisms; however, controlling for other coping styles did not alter its relationship with
end-of-life care. Patients with cancer with unrealistically optimistic expectations of survival prefer and receive more
aggressive end-of-life care.27,31

We attempted to account for this by controlling for acknowledgment of terminal illness, which did not alter the relationship between religious coping and the primary
outcome. Failure to address the
spiritual needs of patients with terminal cancer could conceivably contribute to spiritual crisis at the end of life, thereby leading to more aggressive care.

Similarly, adjusting for support of spiritual needs did not alter the main findings. Research is needed to determine the mechanisms by which religious coping might influence end-of-life care preferences, decision making, and ultimate care outcomes.

Strengths of this study include ethnic and socioeconomic diversity among participants, use of validated surveys, and its prospective design. The brief
RCOPE is a well-validated research tool that enabled empirical observations about a complex psychosocial construct.

Nevertheless, clinicians should
appreciate that the effects of religious coping are likely to be moderated by the environment and belief system from which they arise. Our findings should
not be misinterpreted as denying the experience of many patients who find peaceful acceptance of death and pursue comfort-centered care because of their religious faith. Although religious
coping is a theoretically appealing measure of functional religiousness, we cannot say that positive religious coping rather than other religious factors (eg, religiously based morals) completely accounts for the associations observed. Given the observational nature of this
study, other hidden confounders are
possible. Because our study sample was predominantly Christian, the applicability of our findings to non-Christian populations is uncertain.

Religious coping is common among patients with a variety of illnesses but attitudes toward
end-of-life care vary substantially
across diagnoses with intensive end-of-life care being much more prevalent among noncancer populations. Future studies are needed to determine the extent to which these findings apply to patients with other terminal illnesses. Despite these limitations, this study demonstrates that positive religious coping is associated with receipt of more intensive
life-prolonging medical care at the end of life. These results suggest that clinicians should be attentive to religious methods of coping as they discuss prognosis and treatment options with terminally ill patients.

de minimis said...

bro walla

It reminds me of the final phrase in JFK's Inaugural Address in 1961, "asking His blessing and His help, but knowing that here on earth God's work must truly be our own".