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10 Things Your Primary Care Doctor Does That Should Make You Run for the Hills
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Dr Orrange received her BA in Biology at the University of California San Diego and a Masters Degree in Health Sciences at the Johns Hopkins University School of Public Health She received her MD from the USC Keck School of…
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Religious Faith and Decisions at the end of life; not what you would expect
As someone who is not a person of strong religious faith, I have always appreciated that religious faith provides many with great comfort during the end of life. Many of my patients who believe strongly in God rely on their faith to cope with cancer and other terminal illnesses. From my perspective religious faith should serve to comfort patients who believe in God and Heaven (or some sort of afterlife) during death and dying and perhaps allow them to accept death more easily. I have also seen in my 13 years of practicing medicine that I am unable to predict decisions patients and their families make at the end of life.
The largest study to look at religious faith and intensive life prolonging measures was just published in the March 18th Journal of the American Medical Association (JAMA) and should get us all talking. The authors set out to determine the way religious coping relates to the use of intensive life-prolonging end-of-life care among patients with advanced cancer.
What I would expect: According to theorists, and what I have believed as a Physician, religious coping can offer patients a sense of meaning, comfort, control, and personal growth while facing life-threatening illness. Religious coping refers to how a patient makes use of his or her religious beliefs to understand and adapt to stress....relying on faith ("seeking Gods love and care") to adapt. Research, and my own experience as a Physician, also indicates that religious factors affect medical decisions at the end of life. As an example of this, in a recent survey of 1006 members of the general public 57.4% believed that God could heal a patient even if physicians had pronounced further medical efforts to be futile.
What we know: Religiousness and religious coping have been associated with increased preference for cardiopulmonary resuscitation, mechanical ventilation, hospitalization near death and heroic end-of-life measures. This seems contrary to me.
What was this study all about? Data from the Coping with Cancer Study were used to examine patient's use of positive religious coping and the receipt of intensive medical care during the last week of life. A 14 item questionnaire assessed to what extent patients engage in 7 types of positive religious coping and 7 types of negative religious coping. Examples of positive religious coping would be that it helps them cope "to a moderate extent or more" with their illness, and that "it is the most important thing that keeps you going." Additionally, positive religious coping may include engaging in times of prayer, meditation or religious study at least daily.
What kinds of questions did this study ask about end-of life-care and heroics? Patients were asked: if you could chose, would you prefer 1) a course of treatment that focused on extending life as much as possible even if it meant more pain and discomfort or 2) A plan of care that focused on relieving pain and discomfort as much as possible even if it meant not living as long. Heroic measures are those where the patient wants the doctors to do everything possible to keep you alive even if you were going to die in a few days anyway.
What did we find out? A high level of positive religious coping was associated with receipt of mechanical ventilation, intensive life-prolonging measures in the last week of life, cardiopulmonary resuscitation, heroic measures, and death in the intensive care unit.
Take home message from this study: Patients with advanced cancer rely heavily on religion to cope with their illness and that greater use of positive religious coping is associated with the receipt of intensive life-prolonging medical care near death.
Why might this be? I am not sure. Is it that religious copers choose aggressive therapies because they believe that God could use the therapy to provide divine healing? Do they hope for a miracle while intensive medical care prolongs life? Do they trust that God could heal them through the proposed treatment? Is it believed that only God knows a patient's time to die? The problem I have with some of the above theories is that heroics are an unnatural prevention of the natural process of dying and I hope we all understand that.
In this I believe: I have been with patients of all cultures and religion through death and dying. I have always been sensitive to the influence of religious coping on medical decisions and goals of care at the end of life. I care about these findings because aggressive end-of-life care has been associated with poor quality of death and caregiver bereavement adjustment in SEVERAL studies, and in my 13 years of doing this I believe this to be true. From a financial perspective spending an enormous percentage of healthcare costs on the intensive care in the last week of life is incredibly painful while we watch so many struggle to get primary care needs met. What it comes down to for me is when I speak to patients I have known for years who are facing death and ask how they see the end of their life playing out never once have I heard someone tell me they wish to be in an ICU, on a ventilator, with IVs, catheters and other invasive procedures going on to the last minute. Not once. For those of us who have been there to resuscitate someone aggressively, per their wishes, who has no chance of surviving it will forever change the way I look at this. I want for my patients what I want for myself: to be at home or in a place they love, free from pain and anxiety, surrounded by friends and family.
Thoughts?
Dr O.
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Displaying comments 75-56 of 75
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The results of the study do not surprise me. Deeply religious people are not fact-based people. They tend toward myth and superstition. They respond to fear in a different way than the non-religious. Fear is the driving force of it all. Most religious books are so full of violence, no wonder these folks are afraid to pass. They have the possibility of hell dangling before them. The non-religious do not. These tendencies are probably not learned, but genetic I believe. They are an artifact of our evolution. The peace of death will be welcome to me at some point.
As a Christian woman, I rely heavily on my faith to pull me through the dark times of life. I am not afraid of moving from here to heaven yet I know many people are afraid of death. I think if they read the book "Final Gifts" by Callanan and Kelley (two hospice nurses), they would begin to understand the dying process. I have been blessed to be with three relatives as they went to their heavenly home.
When my now deceased brother-in-law struggled with kidney disease for 18 years, and faced kidney rejected after 14 years, he asked the hospital chaplain why God gave him such a painful disease. The message blew him away. "God didn't give this to you to make you suffer. It was his way of keeping you closer to him." You need to know that before my brother-in-law got kidney disease he didn't have a faith life yet when things got rough, he turned to God - and that is what God him through the darkest of times, through the painful dialysis, and what gave him the grace to say no to ventilation. He wasn't even 40 years old when he passed away.
I speculate that regardless if one has a strong faith foundation or not, many people are afraid to let go. I cannot encourage enough the value of reading "Final Gifts" as it really helps a person face death with dignity, grace, humor (yes, humor!), and compassion. As my sister-in-law said "WOW! This book really changed my perspective on death and dying and I'm no longer afraid."
About faith, there are many things that people believe in strongly that can carry them through the toughest times but religion gives a sense of community and connectedness with the human and the immortal. But religion may not be the only form for this. It is the form that works for many, but too often they presume that this is the path that guides all. There are many paths to faith.
As the saying goes, someone to love, something to do and something to look forward to.
There's a joke that I like, where a man is in a lone rowboat in the middle of the ocean, a devout man who is confident that God will save him. So three progressively larger boats come by to save him. Each time denying their help because he knows God will save him. In the end, God tells him "I sent you three boats, what more do you want?"
I know that someday I will die, but that is not today, and God willing, it won't be tomorrow either.
Death is not the end, it is the beginning.
Doctors at a local hospital gave up on the grandson of a dear friend of mine ~ they went so far as to encourage the parents of this young boy to let him starve to death after he maintained following the cessation of a respirator, because there was very little brain activity.
The parents in no way could allow that to happen ~ when they went home w/ their young child, because the hospital said they'd done everything they could, they were treated badly by the doctors whose recommendations they didn't follow ~ they were given absolutely no encouragement or hope, only a grim prognosis presented w/ a superior & callous 'told you so!' attitude.
This family's faith persevered ~ they took their child to St Jude's Hospital to be seen by a doctor infamous for successfully treating children other doctors have given up on ~ he didn't implement 'heroic measures' ~ his suggestions were actually very basic.
Following his recommended treatment plan, little Alex reached many milestones ~ he began tracking movement w/ his eyes; he began responding to the barking of his dog; he began smiling in recognition at familiar faces; he resumed his playful demeanor; he was eventually able to eat again independent of his feeding tube (which remained in place for medicine administration); w/ the help of a very devoted therapist he simulated crawling ~ all of these strides he made were completely contradictory to the prognosis of the local doctors, but it was the faith in God of Alex's family calling the shots rather than the doctors, fortunately.
Faith is an extremely powerful thing & I personally feel blessed to have witnessed it in this capacity ~ it changed forever my outlook. Little Alex did not make it out of the woods entirely, he had another medical event that took him. That is sad, of course, & yet, for his family & friends of the family, knowing that he is running & playing again has been their ultimate comfort. The day before he passed, he so very playful & happy, his therapist could only laugh & takes pictures of him, & his mom bundled him up to go visiting, as he was so much like his old self again. Many of us feel like this little boy had his goodbyes to say on that day.
I have another friend who thankfully got rid of the doctor who didn't try for an 'heroic measure' ~ had she stuck w/ the first guy, she would have had her foot amputated. She persevered until she found a doctor who promised not to give up before doing everything he could ~ today, on the more tiring days, she has to use a cane to get around, but she gets around on her own two feet.
I've always believed in HOPE & I've always respected the FAITH others have in their religious convictions ~ it's very personal decision as to when to give up & not one that doctors should presume to know above & beyond everyone else what is worth fighting for.
I would think non-believers would do whatever they can to stick around since they they believe there is nothing else after this life.
Yes, I am a Christian, which is far from being religious. I believe in God and Jesus and the Holy Spirit. Religious people generally believe in themselves, rocks, crystals or statues, etc;.
I was 26 yrs. old when I was told that I had terminal Cancer, on my sons 4th birthday, they said I would probably not see him turn 5. Well this May he will be 36 yrs. old. I didn't give up, I relied on God.
Yes when it is our time to go it is our time to go, but a lot of people write their own destiny, because God gives free will in whom you serve, Him or yourself, and they choose to become Drug Addicts or Alcoholics, or live dangerous livestyles and kill their own bodies. God made us and yes He LOVES ALL OF US, but we do have to Choose HIM. God is the one who gives us our talents, some are doctors, some are artists, some are stay at home parents, opera singers,etc: So it is with your talent we expect all that you can do for us as patients, the same as you would expect from us if we were singing for you, taking care of your children or whatever talent we had that you need.
And yes, people have walked out of ICU who were given up for dead. People have been taken off the Medical Examiners Table because the person was found to be alive. And on and on.
I have a Living Will, so does my husband, but I want the very best doctors to keep me as healthy as possible and me keeping my lifestyle healthy as possible, and not a doctor who looks over me when they think my life is approaching the end and pull the plug too quickly.
We seem to be so afraid of death in the West. Like you say, we so often demand heroic measures that end up prolonging death not life. We want neat, tidy, antiseptic passages. This does not honour death or the dying. It makes taboos of such a natural process.
Although I know religion does play a role in the west, it does seem to be more about avoiding death or dealing with the aftermath of it. It doesn't seem to be hands on in the actual rite of passage. It appears to me to be more of a cultural phenomena that is left up to doctors to manage discreetly.
While watching a documentary on death the world over, I saw a beautiful scene in India, where a dying man was washed by his family, in a holy river. They cried with him and loved him and told him how much he'd be missed. They didn't pressure him to stay. They simply released him. It was so beautiful.
So much of the dying I've experienced in Canadian hospitals has been so impersonal and sanitary; tubes and machines and pain. I just don't see the dignity in dying this way.
Of course, I believe in euthanasia and dying with dignity. I believe I should have the right to choose the time of my passing, if I developed a terminal disease.
It would be interesting to replicate the study in a different culture to see if the results are the same.
I would much rather live my final days and hours with dignity rather than die a prolonged death attached to a bunch of machines that merely keeps my body alive. I believe that there is some sort of afterlife for our spirits. Life on this Earth and in this body is just a transitionary stage. This belief gives me the courage to just let go when it is my time to die.