April 2009 Article of the Month
Phelps, A. C., Maciejewski, P. K., Nilsson, M., Balboni, T. A., Wright, A. A., Paulk, E. M., Trice, E., Schrag, D., Peteet, J. R., Block, S. D. and Prigerson, H. G. "Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer." JAMA 301, no. 11 (March 18, 2009): 1140-1147.
COMMENT and SUMMARY: This month's research article has received a good deal of press attention lately, probably because it relates to the subject of the utilization of health care resources (though it does not address this directly) and because it carries the imprimatur of the Journal of the American Medical Association. The study may well endure in discourse about spirituality & health, and chaplains may be asked about it. However, the summaries of the article in the popular press have seemed -- to this reader -- to contain some mischaracterizations of the study's findings. Press accounts tended to assert that the study found that religiousness was associated with greater utilization of life-sustaining treatment. This could have been prompted by a particular line in the article commenting that the results "...suggest that relying upon religion to cope with terminal cancer may contribute to receiving aggressive medical care near death" [p. 1145]. Nevertheless, what the study does find is an association between "positive religious coping" (as identified through the Brief RCOPE measure) and intensive life-prolonging care near the time of death in a predominantly Christian sample of patients with advanced cancer.
This research analyzed data from 345 participants who were recruited as part of a larger study of patients with advanced lung, colon, breast, pancreatic and other cancers; and who died a median of 122 days after their baseline assessment for this study. Among the characteristics of these patients:
A total of 272 patients (78.8%) reported that religion helps them cope "to a moderate extent" or more and 109 (31.6%) endorsed the statement that "it is the most important thing that keeps you going." Most patients (n = 193; 55.9%) endorsed engaging in times of prayer, meditation, or religious study at least daily. [p. 1143]Patients completed the 14-item Brief RCOPE, a measure which seeks to identify "positive" and "negative" types of coping involving religion. [For more on the Brief RCOPE, see Related Items of Interest, below.] It is important to note that "positive and negative religious coping are not mutually exclusive" [p. 1141] --individuals can exhibit both. The authors chose to focus on positive religious coping, in particular, as the "primary religious coping variable" [p. 1142], and they assessed the level of such coping in terms of whether patients scored above or below the median on the Brief RCOPE's positive religious coping scale.
Among the findings:
In analyses adjusted for demographic confounders, a high level of positive religious coping at baseline was significantly associated with receipt of mechanical ventilation compared with patients with a low level...and intensive life-prolonging care…in the last week of life. The associations between positive religious coping and cardiopulmonary resuscitation..., death in the intensive care unit..., and hospice care enrollment...were nonsignificant after adjusting for age and ethnicity.... [pp. 1143-1144]
A high level of positive religious coping was significantly associated with use of negative religious coping compared with patients with a low level...and active coping..., a greater acknowledgment of terminal illness..., and a greater support of spiritual needs.... A high level of positive religious coping was significantly associated with preferring heroic measures compared with patients with a low level…and was associated with less advance care planning in all forms: do-not-resuscitate..., living will..., and health care proxy/durable power of attorney.... [p. 1144]
This study demonstrates that most patients with advanced cancer rely 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. This association was not attributable to other predictors of aggressive end-of-life care established in the literature, and remained after controlling for advance care planning and other potential psychosocial confounders.... [pp. 1144-1145]
The increased rate of intensive life-prolonging care among religious copers was…not mediated by baseline preference for aggressive care, suggesting a more complex relationship between religious coping and end-of-life care outcomes. Religious coping may influence medical decision making rather than directly affecting treatment preferences or orientation toward care. [p. 1145]The researchers caution, however:
Our findings should not be misinterpreted as denying the experience of many patients who find peaceful acceptance of death and pursue comfort-centered care because of their religious faith. Although religious coping is a theoretically appealing measure of functional religiousness, we cannot say that positive religious coping rather than other religious factors (e.g., religiously based morals) completely accounts for the associations observed. [p. 1146]For these authors, their work stands out as "the first study to examine the influence of any religious factor on medical care received near death, and it is novel in demonstrating that positive religious coping is associated with receipt of aggressive end-of-life care" [p. 1145]; and their 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" [p. 1145]. Chaplains should note especially the suggestion: "When appropriate, clinicians might include chaplains or other trained professionals (e.g., liaison psychiatrists) to inquire about religious coping during family meetings while the patient is in an intensive care unit and [about] end-of-life discussions occurring earlier in the disease course" [p. 1145].
This is clearly an important study, and it uses a valuable measure (the Brief RCOPE), but for this reader, it deserves several cautions be kept in mind. First, the population was predominantly Christian --a caution addressed explicitly by the authors (see esp. p. 1146). Since coping is a multidimensional concept connected to a complex of variables, generalization of the present study's findings, especially beyond a Christian population, appears highly risky. Second, the conceptualizations of "positive" and "negative" religious coping are here functions of a particular instrument, and while the Brief RCOPE has received a good deal of psychometric testing, it is not above challenge. Indeed, from various theological perspectives, its implicit evaluation of what is marked as "positive" or "negative" may well be disputed. And third, this study's focus on positive religious coping leaves open questions about the relevance of negative religious coping. The authors describe negative religious coping as "uncommon" [p. 1140 and 1142], but that is not to assert that it is insignificant, and it could even be a phenomenon that is not fully captured by the measure at hand. The findings here about positive religious coping should not be read as a dismissal of the potential effects of negative religious coping, nor understood as a presentation of a simpler view of religious coping than is assumed by the Brief RCOPE. After all, 43% of the study's population endorsed at least one negative religious coping item on the Brief RCOPE [see p. 1142].
Given the recent press about the article, and the gravity of any study published in JAMA, chaplains are encouraged to read this research carefully. For chaplain researchers, the high-profile use of the Brief RCOPE here is another major reason to explore this instrument for use in spirituality studies.
Suggestions for the Use of the Article for Discussion in CPE:
Some CPE students may find that, in spite of the article's clear organization, it may be somewhat difficult to read. The authors at points appear to blur differences between the specific concept of "positive religious coping" and the broader one of "religious coping," and while the tables present a great amount of information, it is information that tends to require knowledge of statistics. Also, students may become confused by the differentiation between high and low positive religious coping, which is not a differentiation between positive and negative religious coping. However, if students are offered some preparation around the concepts of positive and negative religious coping, the article should be very manageable. This study obviously evokes issues of connections between patients' religious beliefs/views/culture and end-of-life care, and students may want to examine their own assumptions and experiences about this. They may also want to debate the general idea of positive/negative religious coping. Since the authors suggest to clinicians that chaplains may play a role in inquiring about religious coping during family meetings, discussion could delve into just how that sort of pastoral intervention might occur.
Related Items of Interest:
I. The authors of our featured article note that the Brief RCOPE "assesses 14 methods of coping" [p. 1142], addressing the "extent to which patients engage in 7 types of positive religious coping…and 7 types of negative religious coping" [p. 1141]. The items of this measure are taken from a longer RCOPE instrument, which is described in detail by Kenneth I. Pargament, Harold G. Koenig, and Lisa M. Perez in "The many methods of religious coping: development and initial validation of the RCOPE" [Journal of Clinical Psychology 56, no. 4 (April 2000): 519-543]. For a tabular summary of 12 religious coping methods (not 14 methods) and 5 key religious functions upon which the 14 items of the Brief RCOPE are said to be based, click HERE.
II. Much of the popularity of the Brief RCOPE in spirituality & health research may be attributable to the following two highly influential articles that report separate analyses of a single project:
III. For studies using the Brief RCOPE that were carried out in part by chaplains, see:
IV. For articles that look at religious coping vis-à-vis non-religious coping, using the larger RCOPE measure, see:
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