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December 2008 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Van Ness, P. H., Towle, V. R., O'Leary, J. R. and Fried, T. R. [Yale University School of Medicine]. "Religion, risk, and medical decision making at the end of life." Journal of Aging & Health 20, no. 5 (August 2008): 545-559.


SUMMARY and COMMENT: How patients' spirituality/religiosity influences medical decision-making has been a long-standing topic for research and an issue underlying many chaplaincy referrals, especially in end-of-life circumstances. While cases of religiously based refusals of medical treatment are well documented in the health care literature, studies have tended overall to show that religiosity is positively correlated with an interest in life-sustaining therapy. This month's featured article examines particular spiritual/religious dynamics affecting patients' willingness to accept low-burden and high-burden life-sustaining treatments. The findings may have important implications for pastoral assessment as well as for chaplaincy research.

Van Ness, Towle, O'Leary, and Fried present a well-written piece about the complex and varied relationship between religiosity and decision-making. They build largely on previous work led by co-author Terri Fried on treatment preferences by older patients. The article begins with an overview of research and includes speculation on possible explanations of earlier findings that indicate "the apparently greater willingness of relatively religious persons to undertake potentially life-sustaining treatment at the end of life" [pp. 546-547].

The study's participants were 226 community-dwelling older adults with advanced illness (e.g., cancer, congestive heart failure, and chronic obstructive pulmonary disease). They were all initially interviewed in their homes, and subsequently at least every four months for up to two years. "Five dimensions of religiousness were measured and used in the analysis": "attendance at religious services (once a month or more vs. less frequently), religious identity (deeply vs. less religious), and religious comfort (a great deal vs. little or none). Also included were two indicator variables for growing closer to God and growing spiritually" [p. 549]. Participants were asked "whether they would be willing to undergo either low- or high-burden treatment with different likelihoods of a return to current health status vs. dying despite treatment" [p. 549].

The low-burden treatment consisted of brief hospitalization with minor tests such as x-rays and blood draws, and low-burden therapies such as intravenous antibiotics and oxygen. The high-burden treatment consisted of extended hospitalization, invasive tests, and high-burden therapies such as surgery or intubation. Regarding both treatments, people were told that without treatment they would not survive for long.... [p. 550]

Among the findings: "...over time persons reporting growing closer to God...and, to a lesser degree, growing spiritually..., were on average more willing to accept the risk associated with low-burden treatment" [p. 554]. Yet, "with each additional month of follow-up study, participants became less willing to accept risk associated with potentially life-sustaining low-burden treatment," and there was "evidence that persons who reported growing closer to God declined in their willingness to accept risk associated with potentially life-sustaining low-burden treatment more rapidly than others" [pp. 555-556].

Results also showed some indication of a relationship between the two variables of "growing closer to God" and "growing spiritually" and patients' "willingness to accept high-burden treatment," yet "these results did not reach statistical significance" [p. 554].

Though the findings here are limited, for clinical chaplains they focus new attention on the potential importance for assessment of a patient's sense of growth during the experience of illness. Growth themes in pastoral conversation may have practical implications for a patient's approach to decisions entailing risks for treatment burden, and a patient's willingness to risk treatment burden may be telling about the spiritual experience of the course of illness. For chaplain researchers, this study opens up such questions as whether patients' expectations for adversarial growth that are rooted in dogma (e.g., "God tests us to make us strong") predispose patients either to look for growthful experiences during illness or to fix on any perceived lack of those experiences, and whether that in turn plays upon decision-making. Moreover, this study calls for further work on the interplay between patients' personal experience of illness and a sense of the prospects for burdens ahead.


Suggestions for the Use of the Article for Discussion in CPE: 

The complexity of the relationships of the variables in this study seem to defy a simple explanation of the results, but any CPE student should be able to engage well the opening section (pp. 545-548) and the Discussion (p. 556-557). Students interested particularly in research will want to look closely at the Method and Results sections (pp. 548-556), but general discussion can easily revolve just around the findings that patients' experiences of "growing closer to God" and "growing spiritually" may be key to decisions about low-burden treatments. This could lead to talk about how the topic of growth figures into pastoral assessment, how patients experience adversarial growth, and the role of religion/spirituality in health-care decision-making [--see Related Items of Interest, below]. The authors offer speculation not only about possible causes underlying the results of the present research but about why previous research has shown that religiosity is associated with decisions to opt for life-sustaining treatment; and that presents a great deal of material for debate.


Related Items of Interest:

I. On the topic of spiritual growth per se during illness, see the May 2008 Article-of-the-Month: Cole, B. S., Hopkins, C. M., Tisak, J., Steel, J. L. and Carr, B. I., "Assessing spiritual growth and spiritual decline following a diagnosis of cancer: reliability and validity of the Spiritual Transformation Scale," Psycho-Oncology 17, no. 2 (February 2008): 112-121.

II. On the related topic of adversarial growth, see the May 2005 Articles-of-the-Month. These articles, however, deal particularly with post-traumatic growth.

III. Van Ness, et al. added the questions about "growing closer to God" and "growing spiritually" to their measures, based upon Ken Pargament's research into religious coping. Pargament was also instrumental in the development of the Brief RCOPE assessment, which includes seven items on the key function of gaining comfort and closeness to God (i.e., "Looked for a stronger connection with God," "Sought God's love and care," "Asked forgiveness of my sins," "Focused on religion to stop worrying about my problems," "Wondered whether God had abandoned me," "Questioned God's love for me," and "Wondered whether my church had abandoned me." The measure also includes, as one of five items for the key function of finding meaning, "Tried to see how God might be trying to strengthen me in this situation." While the Brief RCOPE has been used largely to study spiritual struggle, it may be a tool for further research in the area of spirituality & decision-making. See: Pargament, K. I., Koenig, H. G. and Perez, L. M., "The many methods of religious coping: development and initial validation of the RCOPE," Journal of Clinical Psychology 56, no. 4 (August 13-27, 2001): 519-543.

IV. Regarding whether generally patients use their religious/spiritual beliefs in health care decision-making:

Ai, A. L., Park, C. L. and Shearer, M. "Spiritual and religious involvement relate to end-of-life decision-making in patients undergoing coronary bypass graft surgery." International Journal of Psychiatry in Medicine 38, no. 1 (2008): 113-132. [(From the abstract:) ...One hundred seventy-seven CABG patients completed the pre-operative and post-operative follow-up one month after surgery, while 96 offered information regarding their engagement in settling end-of-life affairs. ...Multiple regression analyses revealed that private religiousness increased the likelihood of having engaged in end-of-life decision planning by nearly half again...and that experiencing reverence in secular contexts nearly doubled the likelihood.... The reduced likelihood of having made plans was observed among those who scored higher on experiencing reverence in religious contexts...and among patients using petitionary prayer.... These effects manifested after controlling for age, impacted functioning, and number of diseased arteries. Therefore, faith factors appear to have independent but complex effects on end-of-life decision making in middle-aged and older cardiac patients.]

Curlin, F. A., Lantos, J. D., Roach, C. J., Sellergren, S. A. and Chin, M. H. "Religious characteristics of US physicians: a national survey." Journal of General Internal Medicine 20, no. 7 (July 2005): 629-634. [Among the findings of this report of a national survey was that "patients and physicians are likely to differ in their reliance upon God as a means of coping and making decisions in the context of major illness." "While most patients will 'look to God for strength, support, and guidance,' most physicians will instead try to 'make sense of the situation and decide what to do without relying on God.'" (p. 632)]

Ehman, J. W., Ott, B. B., Ciampa, R. C., Short, T. H. and Hansen-Flaschen, J. "Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill?" Archives of Internal Medicine 159, no. 15 (August 9/23, 1999): 1803-1806. [Among the findings of this study of 177 pulmonary outpatients was that 45% reported having spiritual/religious beliefs that would influence their medical decisions if they became gravely ill.]

Gibson, L. M. and Hendricks, C. S. "Integrative review of spirituality in African American breast cancer survivors." ABNF [Association of Black Nursing Faculty] Journal 17, no. 2 (2006): 67-72. [This integrative review of seven studies (1994-2004) on spirituality in African American breast cancer survivors identified the key themes of [--from the abstract:) spirituality provided the strength to cope; the need to care for others and receive care; beliefs that God is the healer and in control; God assists in decision-making; and closeness to God.]

McCord, G., Gilchrist, V. J., Grossman, S. D., King, B. D., McCormick, K. E., Oprandi, A. M., Schrop, S. L., Selius, B. A., Smucker, D. O., Weldy, D. L., Amorn, M., Carter, M. A., Deak, A. J., Hefzy, H. and Srivastava, M. "Discussing spirituality with patients: a rational and ethical approach." Annals of Family Medicine 2, no. 4 (July-August 2004): 356-361. [In this research involving 921 participants (798 patients and 123 accompanying adults), 267 indicated that they had spiritual or religious beliefs that would influence their medical decisions (29%), and 235 offered examples of this (--see p. 359).]

Silvestri, G. A., Knittig, S., Zoller, J. S. and Nietert, P. J. "Importance of faith on medical decisions regarding cancer care." Journal of Clinical Oncology 21, no. 7 (April 1, 2003): 1379-1382. [(From the abstract:) One hundred patients with advanced lung cancer, their caregivers, and 257 medical oncologists were interviewed. Participants were asked to rank the importance of the following factors that might influence treatment decisions: cancer doctor's recommendation, faith in God, ability of treatment to cure disease, side effects, family doctor's recommendation, spouse's recommendation, and children's recommendation. RESULTS: All three groups ranked the oncologist's recommendation as most important. Patients and caregivers ranked faith in God second, whereas physicians placed it last (P <.0001). Patients who placed a high priority on faith in God had less formal education (P <.0001). CONCLUSION: Patients and caregivers agree on the factors that are important in deciding treatment for advanced lung cancer but differ substantially from doctors. All agree that the oncologist's recommendation is most important. This is the first study to demonstrate that, for some, faith is an important factor in medical decision making, more so than even the efficacy of treatment....]

White, M. and Verhoef, M. "Cancer as part of the journey: the role of spirituality in the decision to decline conventional prostate cancer treatment and to use complementary and alternative medicine." Integrative Cancer Therapies 5, no. 2 (June 2006): 117-122. [This study looked at a subset of 10 participants from a larger study who indicated spirituality as an important theme in their cancer experience. (From the abstract:) ...Spirituality appeared to influence all aspects of the cancer experience. Most participants intensified their use of spiritual practice after a diagnosis of prostate cancer. These practices included spiritual ceremonies, indigenous healing, prayer, meditation, and use of spiritual imagery. Themes related to the role of spirituality in cancer management include beliefs about Western medicine, the role of spiritual beliefs in treatment decision making, the use of spiritual imagery and metaphor in healing, and the impact of cancer on spirituality. The discussion of these themes draws on quotes and case examples, illustrating how spirituality influenced study participants' response to diagnosis, treatment decision making, and cancer care. Two case examples provide a more in-depth understanding of how some participants incorporated spiritual imagery and metaphor into treatment decision making and cancer care.]


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