Wednesday, March 18, 2009

Religious Coping and Aggressiveness of Medical Care at the End of Life

I'm expecting a lot of discussion about this study in the current issue of JAMA, "Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer." Religious coping is defined as "how a patient makes use of his or her religious beliefs to understand and adapt to stress." Previous studies have shown that people with high positive religious coping are more likely to have preferences for aggressive life-prolonging treatment and less likely to have advance directives. "Positive" religious coping employs reliance on faith to promote healthy adaptation. "Negative" religious coping tends to see illness as punishment and may indicate existential crisis. Positive and negative religious coping are not mutually exclusive, but negative coping is uncommon. This is the first study to look at actual outcomes in patients with high vs low religious coping.

The subjects in this study were enrolled in the Coping with Cancer Study, a multi-institutional, prospective, psychosocial study of patients with advanced cancer. The Coping study is funded by the National Cancer Institute and the National Institute of Mental Health. Data was collected in a 45-minute interview. Both English and Spanish-speaking subjects were enrolled. In addition to patients, caregivers completed separate questionnaires, although caregiver religiousity was not a focus of the current study. Caregivers were approached a few weeks after the patient's death for information about the death (post-mortem chart reviews were also done). The instrument used was the Brief RCOPE, a validated 14-item questionnaire that assesses religious coping. Seven positive and seven negative types of religious coping are included, answered with a 4-point Likert scale. 92% endorsed a least one positive coping scale item, while only 43% endorsed any negative item. Patients were designated as having either high or low religious coping depending on whether they scored above or below the median. In addition, the Structured Interview for DSM IV Axis I to identify patients with panic, anxiety, or posttraumatic stress disorders or depression. Finally patients were asked to characterize their health status and whether their religious/spiritual needs were being met by the medical system.

A total of 664 patients participated in the overall study. Data were available on 345 of the 385 patients who had died at the time of the analysis. Death came a median of 122 days after the patient interview. The primary findings were that "a high level of positive religious coping at baseline was significantly associated with receipt of mechanical ventilation compared to patients with a low level;" and with "intensive life prolonging care in the last week of life." Nonsignificant differences were found for CPR received, death in the ICU, and hospice enrollment. In addition, a high level of religious coping, compared to low, was associated with the following: use of negative religious coping, active coping, greater acknowledgement of terminal illness, greater support of spiritual needs, preference for heroic measures, less advance care planning in all forms.

The findings persist when adjustment for various psychosocial factors are included. "These results suggest that relying upon religion to cope with terminal cancer may contribute to receiving aggressive medical care near death." The authors characterize this as a possible negative outcome for religious copers "because aggressive end-of-life cancer care has been associated with poor quality of death and caregiver bereavement adjustment." This is a problematic statement for me. It seems to contradict a previous statement that these patients see themselves as "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." In addition, some patients see prolonging life as an essential acknowledgement of the sacredness of life. It seems to me that the task of spiritual care with this population is to support, to the extent possible, the patient's expressed beliefs and values while maintaining informed decision-making and consent. It is also important for patients who belong to an organized religion to receive adequate teaching and counsel in the teachings of that religion in order to clear up misunderstandings and misconceptions that may impact their decision making.

The authors recommend earlier spiritual assessment and support and inclusion of clergy/chaplains in the care team. A follow up research recommendation is to study the "mechanisms by which religious coping might influence end-of-life care preferences, decision making, and ultimate care outcomes."

ResearchBlogging.orgAndrea C. Phelps, Paul K. Maciejewski, Matthew Nilsson, Tracy A. Balboni, Alexi A. Wright, M. Elizabeth Paulk, Elizabeth Trice, Deborah Schrag, John R. Peteet, Susan D. Block, & Holly G. Prigerson (2009). Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients With Advanced Cancer JAMA, 341 (11), 1140-1147

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