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June 2011 Article of the Month
Balboni, T., Balboni, M., Paulk, M. E., Phelps, A., Wright, A., Peteet, J., Block, S., Lathan, C., VanderWeele, T., and Prigerson, H. "Support of cancer patients' spiritual needs and associations with medical care costs at the end of life." Cancer 117, no. 23 (December 1, 2011): 5383-5391.
SUMMARY and COMMENT: Over the past several years, a group of researchers based largely out of the Dana-Farber Cancer Center (Boston, MA) has produced an impressive string of studies indicating the importance of spirituality for cancer patients' care near the end of life. Two of these studies have already been featured as Articles-of-the-Month (April 2009 and January 2010). This month's article builds upon that previous work and ventures a dollar assessment of differences in end-of-life care costs when patients do and do not feel spiritually supported by the health care team. The authors' key findings are as follows: This study demonstrates that advanced cancer patients who report that their religious/spiritual needs are insufficiently supported by the health care team have increased medical costs in the final week of life. EOL costs among advanced cancer patients reporting low support of their religious/spiritual needs by the health care team were $2441 more on average as compared with those who reported themselves well supported. Notably, low religious/spiritual support among racial/ethnic minority patients and high religious coping patients was associated with greater cost differences in the last week of life, on average $4206 more among minorities and $4060 more among high religious coping patients. These findings are robust considering adjustment for multiple potential confounding factors such as EOL discussions and geographic location. [p. 5388]The data are from a sample of 339 advanced cancer patients from seven major outpatient clinics in Massachusetts, New Hampshire, Connecticut, and Texas; out of a total of 920 eligible patients approached between September 1, 2002 and August 31, 2007. Participants completed an assessment upon enrollment, and within three weeks after the patient's death medical records were reviewed and a caregiver who was present during the last week of the patient's life was interviewed. Measures included the patients' rating of the "the degree to which their spiritual needs were met by the health care team" [p. 5384] and patients' self-report of positive and negative religious coping (via the Brief RCOPE measure), quality of Life, existential well-being, and social support (via the McGill Quality of Life questionnaire), as well as information about physician relationship and discussion of end-of-life care and Advance Directives. Postmortem chart reviews included referral to hospice, days in the Intensive Care Unit (with and without a ventilator), and receipt of resuscitation or chemotherapy in the last week of life. Results showed that "patients reporting that their religious/spiritual needs were poorly supported were less likely to receive a week or more of hospice care and were more likely to die in an ICU, with the impact being greatest among racial/ethnic minority and high religious coping patients" [p. 5387]. It is important to note that patients' assessment of spiritual support does not distinguish support from chaplains per se but rather refers to perceived support from the whole care team. However, a previous study by these same researchers is cited concerning this limitation: "...patients' ratings of support of their religious/spiritual needs [in the earlier study] are significantly associated with receiving pastoral care visits, ...suggesting that pastoral care is a key aspect of spiritual care" [p. 5389]. That earlier study, by the way, did not find that pastoral visits alone predicted EOL medical care. More research is obviously needed to assess the impact of chaplains in particular, perhaps examining their role both in direct pastoral visitation and in supporting and guiding the whole multidisciplinary team in the spiritual care of patients at the end of life. Further regarding costs and potential savings, the authors extrapolate their findings to the wider context of health care in the US: The implications of the provision of spiritual care to dying patients are noteworthy given that it represents higher quality EOL care that, despite its presence in national care quality standards, frequently remains absent at the EOL. The projected economic impact is approximately $1.4 billion ($2441 x 562,340 annual cancer deaths) for care delivered in the last week of life, or approximately 1.5% of direct cancer costs per year ($1.3 billion of $93.2 billion). Furthermore, this study's cost estimates only comprise cancer care in the last week of life; spiritual care could result in greater cost implications if other EOL clinical settings were included and examined over a longer time period. Whereas some hypothesize that ample supply of aggressive technologies creates unnecessary demand, our study suggests that medical demand is impacted by medical system engagement of underlying psychosocial issues that mediate EOL decision making. [p. 5389]And as to mechanisms by which spiritual care may affect EOL care: Potential causal mechanisms include facilitating resolution of spiritual needs and distress that would otherwise result in more aggressive and QOL-compromising care. Recognition of patients' religion/spirituality as part of EOL care may also assist patients in transitioning away from a focus on extending life to a focus on spiritual priorities at the EOL, such as finding spiritual peace--a factor of primary importance to patients facing death that is associated with less aggressive care at EOL. Involving patients' religion/spirituality in medical decision making may assist patients in recognizing less aggressive EOL care options that remain consistent with their religious/spiritual beliefs. [pp. 5388-5389]Any attempt to discern the relationship between spiritual care and medical expenses is risky, because it pairs the fuzziness of spirituality with the controversial subject of health care economics. This study concerns just one subset of patients, does not break out chaplains as care providers, and assesses patients' sense of spiritual support only in the baseline interview; but it nevertheless thoughtfully establishes some basic figures against which future data may be compared as research continues. The authors line out well their methodology, present several very clear tables to illustrate results, and provide a thorough bibliography. For chaplains in the US, this work offers an intriguing quantification of the effect of spiritual support. [See also: Related Items of Interest §III and subsequent NOTE (below).] As such, it surely plays into chaplains' arguments that spiritual care is -- in addition to being a good idea on the basis of principle and valuable for patients' well-being -- potentially advantageous to hospitals focused on their bottom line. However, arguments about the costs and benefits of spiritual care need not be simply utilitarian, and chaplains usually bristle at the thought of an instrumental view of spirituality. What the authors here conclude isn't that spiritual care is a means to suppress expenses but that it may help in "avoiding" futile and unnecessarily aggressive treatments [see p. 5389]. If spiritual care is conceived first and foremost as an essential element in the optimal care of patients, then the issue isn’t about justifying the cost of spiritual care but realizing the various costs that may follow from its absence. Suggestions for the Use of the Article for Discussion in CPE: What do students think about any association of spiritual support with medical cost savings? What might be the attraction of such a line of thought, and how might it be problematic? While this study does not evaluate chaplains in particular, how do students feel that their work could affect reductions in excessive end-of-life treatment and/or transitions to hospice? Do chaplains ever feel pressed to pursue such outcomes as an agenda for their pastoral interaction? Also, what are the various ways that patients might feel spiritually supported by the care team as a whole, and what roles might a chaplain play as part of the team (e.g., improving referral processes or encouraging and guiding other providers in offering spiritual support), in addition to direct patient interaction. Finally, since the article notes that spiritual care by the medical team is "culturally competent care mandated by national guidelines" [p. 5388], students might want read and discuss the report of the National Consensus Project for Quality Palliative Care [--see: Related Items of Interest §I (below)]. Related Items of Interest: I. This month's article references the report of the National Consensus Project for Quality Palliative Care (www.nationalconsensusproject.org). The report mentions spirituality throughout, but see specially the section on "Spiritual, Religious and Existential Aspects of Care," on p. 49 of the Clinical Practice Guidelines for Quality Palliative Care.
II. Other recent articles by members of the team who produced our featured study:
III. The argument from published literature for the cost effectiveness of hospital chaplains continues to be an indirect one, based either upon the assumption that chaplains can be a key link or catalyst for the widely evidenced benefits of spirituality to health or upon a calculation of the very modest cost of chaplains in light of an overall sense of their potential value to an organization (e.g., patient satisfaction). For some examples, see:
NOTE: Regarding the cost savings benefit of hospital chaplains in particular, the following is often cited: Bliss, J. R., McSherry, E., and Fassett, J., "Chaplain intervention reduces costs in major DRGs: an experimental study," in Hefferman, H., McSherry, E. and Fittgerald, R. (eds), Proceedings of the NIH Clinical Center Conference on Spirituality and Health Care Outcomes, March 21, 1995. Findings from this research seem to have been distributed widely on September 20, 1996, through a report by Terese Hudson Thrallon on the Hospitals and Health Network's website for the HHN Magazine, titled "Measuring the results of faith":
However, in spite of these citations, the study by Bliss, McSherry and Fassett was never actually published, nor apparently were any formal proceedings published of the 1995 meeting at which Dr. McSherry made an oral presentation. The popularized details of the study seem to have come from individual recollections and notes of meeting attendees. In a personal communication (with John Ehman, 3/16/05), Dr. McSherry indicated that she believed the original data were valid and relevant but that final analysis and publication had been delayed for a variety of reasons, with the project eventually becoming sidelined. It should be noted that in the 1980s, Dr. McSherry was one of the early and strong voices for the economic importance of chaplains: for example, McSherry, E., "Economic impact of chaplaincy on the hospital environment," The Caregiver Journal (Journal of the College of Chaplains) 4, no 1 (August 1987): 28-43; in which she offers data from her own work and from others, concluding, "So, whenever it has been carefully studied, chaplaincy has been shown to have significant favorable impact on hospital economics" [p. 34].
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