Strong religious faith associated with aggressive end of life care

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Patients with advanced cancer who used their religious faith to help them cope with their disease were more likely to receive intensive and aggressive treatment during their last week of life, a new study has found.

Intensive life-prolonging care, defined as receipt of mechanical ventilation or resuscitation in the last week of life near death, was about 3 times more likely to occur in patients with a high level of religious coping than in patients with a low level of religious coping. The results suggest that a reliance on religion to cope with terminal cancer may contribute to aggressive medical care in the last days of life, the authors conclude in the March 18 issue of the Journal of the American Medical Association.

The authors used the term "religious coping" to describe how patients make use of their religious beliefs to understand and adapt to stress. They note that religiousness and religious coping have been associated with an increased preference for aggressive measures, such as cardiopulmonary resuscitation, mechanical ventilation, hospitalization near death, and heroic end-of-life measures. Some data also suggest that lower rates of advanced-care planning among minority patients may be partially due to spiritual appraisals of illness and healing, such as the belief that "only God knows when it is one's time to die."

Corresponding author Holly G. Prigerson, PhD, director of the Center for Psychooncology and Palliative Care Research at the Dana-Farber Cancer Institute, in Boston, Massachusetts, explained that there are not enough data at this point to make any recommendations to clinicians.

"These data point to clinicians and patients recognizing what the factors are that are driving end-of-life treatment preferences and care so that both parties can come to a mutual understanding," she told Medscape Oncology.

"The important issue is the recognition by both patients and clinicians that religious coping is driving a desire for and the ultimate receipt of intensive, life-prolonging care," she added.

The 345 patients included in the analysis were recruited between January 1, 2003 and August 31, 2007, and were part of the Coping With Cancer Study, a multi-institutional investigation of patients with advanced cancer and their informal caregivers. Both patients and caregivers participated in baseline interviews, and within 2 to 3 weeks of the patient's death, the caregiver was contacted to provide information regarding the patient's care and quality of death. Additional information was obtained from the patient's medical charts during the last week of life.

When asked about how much they rely on religion to cope with illness, a total of 272 patients (78.8%) reported that religion helps them cope "to a moderate extent" or more, and 109 (31.6%) agreed that "it is the most important thing that keeps you going." More than half of all patients (55.9%) endorsed engaging in prayer, meditation, or religious study at least daily.

The researchers also observed that positive religious coping was significantly associated with being black or Hispanic, and that those with a high level of positive religious coping tended to be younger, less educated, less likely to be insured, less likely to be married, and more likely to have been recruited from sites in Texas than those with low levels of religious coping.

After adjustment for confounders, they also found that a high level of positive religious coping at baseline was significantly associated with the receipt of mechanical ventilation (11.4%) during the last week of life, compared with patients with a low level (3.6%). There was also a significant association with intensive life-prolonging care (13.6% vs 4.2%).
Associations between positive religious coping and cardiopulmonary resuscitation (7.4% for a high level vs 1.8% for a low level), death in the intensive-care unit (10.7% vs 4.2%), and hospice-care enrollment (71.3% vs 73.5%) were nonsignificant after the data were adjusted for age and patient ethnicity.

A preference for heroic measures was also associated with a high level of positive religious coping, compared with a low level (38.3% vs 8.6%). A high level was also associated with less advanced-care planning in all forms, including do-not-resuscitate orders (33.9% vs 49.4%), living wills (29.4% vs 68.1%), and healthcare proxies/durable powers of attorney (34.1% vs 63.9%).

"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," the authors conclude. "Because aggressive end-of-life cancer care has been associated with poor quality of death and caregiver bereavement adjustment, intensive end-of-life care might represent a negative outcome for religious copers."