Thursday, March 19, 2009

Study Examines Religion's Impact on End-of-Life Care Choices

A study appearing in the most recent edition of The Journal of the American Medical Association asked 345 advanced cancer patients how much they relied on religion to cope with illness. Researchers from Boston's Beth Israel Deaconess Medical Center and Dana-Farber Cancer Institute found that patients who identified themselves as more deeply religious, chose more aggressive end-of-life care. Compared to patients who were less religious, they were less likely to have done advanced care planning, and were three times more likely to use a mechanical ventilator during the last week of life.

Religions specified in the study were Catholic, unspecified Protestant, Baptist and other. According to WebMD Health News, the researchers stated that the association between religious belief and aggressive medical treatment:
. . . persisted after other factors such as race, coping styles of patients, and advance medical care planning were considered.

But Duke University Medical Center psychiatrist Harold Koenig, MD, is not convinced that race did not influence the findings. He says that earlier studies have shown that blacks and Hispanics are more likely to have aggressive medical interventions at the end of life than whites.

From the New York Times:
“People think that spiritual patients are more likely to say their lives are in God’s hands — ’Let what happens happen’ — but in fact we know they want more aggressive care,” said Holly G. Prigerson, the study’s senior author and director of the Center for Psychosocial Oncology and Palliative Care Research at the Dana-Farber Cancer Institute in Boston.

“To religious people, life is sacred and sanctified,” Dr. Prigerson said, “and there’s a sense they feel it’s their duty and obligation to stay alive as long as possible.”

Aggressive life-prolonging care comes at a cost, however, in terms of both dollars and human suffering. Medicare, the government’s health plan for the elderly, spends about one-third of its budget on people who are in the last year of life, and much of that on patients at the very end of life.

Aggressive end-of-life care can lead to a more painful process of dying, researchers have found, and greater shock and grief for the family members left behind.

Last year, HFA interviewed Gloria Thomas Anderson, MSW, an African-American international author and motivational speaker. Anderson teaches cultural diversity and social work practicum integration courses,and has written The African American Spiritual and Ethical Guide to End of Life Care. The interview touched on the role spirituality plays in the African-American community at the end of life.
Q. Why do you think that African-Americans have traditionally not used hospice care?

A. My answer is based on research and my own observation and experience. There is limited awareness of hospice care in the African-American community, and hospice has not been actively promoted within many African-American communities. But for those families who have experienced hospice, it can be a real revelation to learn about the kind of support hospice offers not just for the dying person, but also for the caregivers.

As we discussed, for many older African-Americans, there is a general mistrust of the healthcare system. They still remember the Tuskegee experiments and the heart-breaking impact. Unfortunately in our society, especially for older African Americans, the message conveyed to many was, “Why would anyone care if I lived or died?” Because of this mistrust, some African Americans traditionally have not gone to the doctor regularly and often don’t get treated in the early stages of an illness. So when they do finally arrive at the ER or the hospital, often in the later stages of an illness, it can be a great challenge for healthcare personnel to treat them and provide the full range of services available.

One important cultural consideration in the African-American community is the issue of spirituality and faith. Many African Americans believe strongly that God will heal them. But doctors play an important role, too; in many ways, they are seen as God’s “instrument” for that healing. So when faced with making decisions about end-of-life care, there’s a spiritual component—if you decide to stop treatment, are you somehow “playing God?” This dilemma can cause a great deal of spiritual anguish to patients and their families. And I think there’s a feeling that’s universal in times of illness—I’m not going to “give in” and I’m not going to “give up.”

For coverage of the JAMA study: see WebMD Health News; New York Times; USA TODAY; and Reuters.