Source of spiritual support influences EOL care decisions
Conflicts in spirituality: Why me versus why not me
“Though religious communities play a critical role in providing needed support to patients facing advanced cancer, they may be influencing patients to choose aggressive end-of-life interventions,” said Tracy A. Balboni, MD, MPH, Harvard Medical School, the lead author of a study on the association of spiritual support and end-of-life care decisions. Previous studies found that spiritual support from medical teams results in less aggressive end-of-life medical care and better quality of life (QoL) among patients facing advanced cancer.2 Balboni said, “These current findings suggest that, in contrast, spiritual support from religious communities can result in cancer patients choosing greater aggressive medical interventions at life's end and less hospice care.”
This study included 343 patients with advanced cancer. The patients were asked to what extent their religious/spiritual needs were being supported by their religious community and by the medical system, and how important religion was to them, with a range of five possible responses offered to each question. The enrolled patients were also asked if they had received chaplaincy services, and their QoL was measured with the McGill QoL questionnaire.
Patients who were members of racial or ethnic minorities made up 55% of the study participants. Patients who reported high support of their spiritual needs were more likely to be of racial or ethnic minorities, less educated, and have lower rates of health insurance. These patients also had better QoL, existential well-being, and social support than those who reported less spiritual support. They were also more likely to be aware that they were terminally ill and less likely to have advanced care planning.
Notably, religious community support was not found to have significant associations with QoL near death. In addition, QoL near death was not associated with a patient being highly religious or of racial or ethnic minorities. Nonetheless, aggressive care near the end of life had stronger associations with patients who were highly religious or of racial or ethnic minorities. Aggressive care at end of life was defined as receiving care in an intensive care unit, ventilation, or resuscitation in the last week of life.
Among the racial/ethnic minority participants, those who received only religious community support had very low odds for hospice care (odds ratio [OR] 0.17) and very high odds for aggressive interventions (OR=8.03) and for death in an intensive care unit (ICU; OR=11.21). However, when these patients also received spiritual support from the medical team, the odds reversed, such that they had high odds for receiving hospice care (OR=6.62) and low odds for aggressive interventions (OR=0.16) and for death in an ICU (OR=0.14).
WHY MORE AGGRESSIVE CARE?
The research team suggested two possible explanations for the high rates of aggressive care at the end of life among patients receiving high levels of spiritual support from religious communities. The first was that religious congregations may not be aware of the biomedical realities regarding terminal illness; and therefore may lack clarity about when or whether death will occur. Further, a strong belief in miracles is part of the Christian traditions that represent much of the US religious demographics, and this belief is also held by other religious traditions. The researchers suggested that supporting ill congregants may emphasize and support a belief in potential miraculous healing, and medicine may be the means for divine intervention.
The emphasis placed on perseverance through and hope found within suffering by religious communities was the second possible explanation for aggressive end-of-life care among those with high levels of spiritual support from religious communities. While the study found that these patients had higher QoL at baseline, patient QoL was not affected by high levels of support from a religious community near death. The authors suggested that the emphasis on perseverance and endurance may aid patients' QoL earlier in an advanced illness, but that it “may become increasingly incongruent or even in conflict with the patients' spiritual needs as death becomes imminent.”1