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.