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November 2019 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA


George, L. S., Balboni, T. A., Maciejewski, P. K., Epstein, A. S. and Prigerson, H. G. "'My doctor says the cancer is worse, but I believe in miracles' --when religious belief in miracles diminishes the impact of news of cancer progression on change in prognostic understanding." Cancer (2019): online ahead of print, 10/28/19; 8pp.

[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. References are to manuscript [MS] page numbers.]

SUMMARY and COMMENT: This month's study "is the first to provide direct evidence that religious belief in miracles may limit the impact of prognostic information [about cancer progression], even when that information involves concrete medical data coming from scan results" [MS p. 5]. It is aimed at medical providers but touches upon circumstances relevant to chaplaincy, especially in terms of how this belief may play into patients' coping and potential health care decision-making. Previous literature around this subject has been largely anecdotal.

"Specifically, using patient-report assessments, we examine whether receiving cancer progression news is associated with a previsit to postvisit change in prognostic understanding with respect to patients' baseline level of religious belief in miracles" [MS pp. 1-2]. Data came from a larger study, with the analytic sample for present purposes consisting of 158 patients.

At study entry, patient demographics and disease characteristics were recorded. Before and after clinic visits at which cancer restaging scan results were discussed, trained interviewers assessed patients via structured interviews. At the previsit assessment, religious belief in miracles was measured; at the postvisit assessment, receipt of cancer progression news was measured; and at the pre- and postvisit assessments, prognostic understanding was measured. The median time between pre- and postvisit assessments was 35 days (interquartile range, 16-70 days). [MS p. 2]
The Religious Beliefs in End-of-Life Medical Care (RBEC) scale was used, with belief in miracles assessed with the item: "I believe that God could perform a miracle in curing me of cancer" [MS p. 2; and see Items of Related Interest, §I, below]. Other measures included the Multidimensional Measure of Religiousness and Spirituality Brief Scale, and a four-item measure of patients' prognostic understanding drawn from previous research by some of the current authors and lined out in a table [--see p. 3]. Patients were also "asked what their provider said about their cancer during the discussion of scan results" [MS p. 2], with options being that their cancer condition was worse, stable, better, or other.

Among the results, belief in miracles for the overall sample was: 22.2%, not at all; 9.5%, a little; 15.2%, somewhat; 7.0%, quite a bit; and 46.2%, a great deal [--see Table 3, MS p. 4]. So, "religious belief in miracles was highly prevalent, with approximately 78% endorsing at least some belief and with 46% endorsing the strongest level..." [MS p. 5]. For the majority of patients, who reported moderate to strong belief in miracles, "news of cancer progression was associated with no change in prognostic understanding" [MS p. 5], while patients who reported a weak belief in miracles showed a more accurate prognostic understanding.

The researchers lit upon this predictive association as a function of a significant interaction effect [--see Items of Related Interest, §II, below] between two variables in the data: 1) the patient reporting that provider said their cancer was "worse" and 2) the patient reporting a religious belief in miracles, even though each of the variables by themselves did not show a significant effect. Further analyses "showed that a modifying role was unique to religious belief in miracles and not shown by general religiousness or other religious beliefs..." [MS p. 6].

Thus, there may be something specific about believing in a miracle beyond general religiousness and spirituality and other religious beliefs that limits the impact of receiving news of cancer progression. By definition, religious belief in miracles refers to the expectation that because of some divine intervention, events may unfold in ways that defy the natural or expected order of things to be more in one's favor. This belief may, therefore, be uniquely associated with more favorable expectations of one's prognosis than general religiousness because the latter may manifest in a variety of ways, including unfavorable disease expectations (eg, "if dying from this illness is part of God's plan for me, I am okay with that"). [MS p. 6]
Atop their main results, the authors also note: "Interestingly, younger participants showed stronger religious belief in miracles, and this was a surprising finding because religiousness and spirituality tend to increase with age" [MS p. 6]. They go on to comment: "This counterintuitive association raises questions regarding potential psychosocial processes among younger patients driving such stronger belief in miracles (eg, younger patients may be more likely to hear from others that God will cure them)" [MS p. 6].

This study highlights "the value of integrating patients' spirituality into their medical care" [MS p. 5] and attending to the process by which patients' translate new information about their disease progression into a changed understanding of their situation affecting their sense of the future and decisions before them. The authors conclude with guidance for oncologists:

During discussions of prognostic relevance, mere provision of medical information is likely not enough; assessing and addressing personal beliefs that limit the impact of provided information may provide added utility. When appropriate, openly discussing relevant beliefs in miracles and other patient beliefs may improve the impact of prognostic information provided, such that patients have a more accurate understanding to guide their treatment decisions. Oncologist training and competency in addressing patient beliefs during prognostic discussions may be important. [MS p. 7]
The article put this reader in mind of the potential role of chaplains as resources for the development of particular educational programming for providers, for assessment of patients' beliefs in miracles as part of a larger spiritual assessment, and for referral in those cases where miracles have come up in provider-patient conversations. The authors do comment on the need for research into "patients' receptivity to having discussions with their medical providers regarding their belief in miracles" [MS p. 7], so while belief in miracles could be clinically significant, there may be others -- like chaplains -- who could be in an optimal position to engage patients on the subject.

Variability of findings is noted for geographic and certain demographic differences, but it is not analyzed according to specific religious traditions. That would seem to suggest a factor for future research. And, then there's the idea of "nonreligiously based" [MS p. 7] beliefs in miracles. Moreover, it is possible that even in light of the current results, there could also be some types of belief in miracles that enhance rather than limit patients' accuracy in understanding information about disease progression, like a belief that a miracle would come through medical processes. This article provides a quantitative baseline by which much additional research might proceed.

The bibliography of 23 references is adequate for the immediate purpose (with the most recent citations coming from 2016), and the Author Contributions note [MS p. 7] nicely lays out the individual roles of the authors. The research was supported by the National Cancer Institute and the National Institutes of Health.


Suggestions for Use of the Article for Student Discussion: 

The article should be quite readable for all levels of CPE students, with technical/statistical aspects covered in clear terms in the Discussion section. It would be a useful entree to a broad discussion of miracles, with the first question to the group being how they have encountered patients' beliefs in miracles. Do the results about the percentages of participants who hold such beliefs [--see especially Table 3, MS p. 4] surprise anyone? What of the finding that younger participants showed stronger beliefs in miracles [--see MS p. 6]? The authors comment briefly about how belief in miracles may be special among religious beliefs in terms of an effect upon hearing news of disease progression, but students might discuss a variety of theological understandings of miracles and consider some potential subtleties of influence upon patients' coping with bad news. Do the students themselves believe in miracles, and how have they found their own beliefs influencing their work with patients who believe differently? Have they ever been involved in helping clinicians understand the religious perspective of patients' decision-making? Have they ever been involved in helping patients understand clinicians' perspective on disease? The article does not mention chaplains, but how might a chaplain participate in a patient-provider conference about disease progression? Does the group have any speculation about unmeasured variables that the study does not take into account but that may affect patients' understanding of information about disease progression? How have students witnessed patients coping with bad news in general, and how have they seen religious beliefs play into decision-making? Is there an opportunity to have an oncologist join in the discussion?


Related Items of Interest:

I.  For more on the Religious Beliefs in End-of-Life Medical Care (RBEC) scale, see:

Balboni, T. A., Prigerson, H. G., Balboni, M. J., Enzinger, A. C., VanderWeele, T. J. and Maciejewski, P. K. "A scale to assess religious beliefs in end-of-life medical care." Cancer 125, no. 9 (May 1, 2019): 1527-1535. [(Abstract:) BACKGROUND: Studies postulate that certain religious beliefs related to medical care influence the end-of-life (EOL) medical decision making and care of patients with advanced cancer. Because to the best of the authors' knowledge no current measure explicitly assesses such beliefs, in the current study the authors introduced and evaluated the Religious Beliefs in EOL Medical Care (RBEC) scale, a new measure designed to assess religious beliefs within the context of EOL cancer care. METHODS: The RBEC scale consists of 7 items designed to reflect religious beliefs in EOL medical care. Its psychometric properties were evaluated in a sample of 275 patients with advanced cancer from the Coping With Cancer II study, a National Cancer Institute-funded, multisite, longitudinal, observational study of communication processes and outcomes in EOL cancer care. RESULTS: The RBEC scale proved to be internally consistent (Cronbach alpha, .81), unidimensional, positively associated with other indicators of patients' religiousness and spirituality (establishing its convergent validity), and inversely associated with patients' terminal illness understanding and acceptance (establishing its criterion validity), suggesting its potential clinical usefulness in promoting informed EOL decision making. The majority of patients (87%) reported some ("somewhat," "quite a bit," or "a great deal") endorsement of at least 1 RBEC item and a majority (62%) endorsed >=3 RBEC items. CONCLUSIONS: The RBEC scale is a reliable and valid tool with which to assess religious beliefs within the context of EOL medical care, beliefs that frequently are endorsed and inversely associated with terminal illness understanding.]


II.  The idea of an "interaction effect" [--see especially pp. 3, 5, and 6 of our featured article] is quite well explained in the following entry by Rafa M. Kasim for that term in Lavrakas, P. J., ed., Encyclopedia of Survey Research Methods, Vol. 1 (Thousand Oaks, CA: Sage Publications, Inc., 2008): 339-342:

An interaction effect is the simultaneous effect of two or more independent variables on at least one dependent variable in which their joint effect is significantly greater (or significantly less) than the sum of the parts. The presence of interaction effects in any kind of survey research is important because it tells researchers how two or more independent variables work together to impact the dependent variable. Including an interaction term effect in an analytic model provides the researcher with a better representation and understanding of the relationship between the dependent and independent variables. [p. 339]


III.  One of the contributions of the present research is that it captures some data about the incidence of belief in miracles. The Pew Research Center on Religion and Public Life published their U.S. Religious Landscape Survey on Religious Beliefs and Practices in 2008, and this included an analysis of Miracles and the Supernatural (in chapter 1 of the full report). And, for a more recent and wide-ranging report of American's religious beliefs, see Pew's 2018 survey, When Americans Say They Believe in God, What Do They Mean?.


IV.  Note the following articles that our authors cite regarding physicians interacting with patients who express a belief in miracles. These are not reports of research, though the article by Rhonda S. Cooper, et al. raises research questions about their proposed approach.

Cooper, R. S., Ferguson, A., Bodurtha, J. N. and Smith, T. J. "AMEN in challenging conversations: bridging the gaps between faith, hope, and medicine." Journal of Oncology Practice/American Society of Clinical Oncology 10, no. 4 (July 2014): e191-195. [All health care practitioners face patients and families in desperate situations who say, "We are hoping for a miracle." Few providers have any formal training in responding to this common, difficult, and challenging situation. We want to do our best to preserve hope, dignity, and faith while presenting the medical issues in a nonconfrontational and helpful way. We present the acronym AMEN (affirm, meet, educate, no matter what) as one useful tool to negotiate these ongoing conversations.]

DeLisser, H. M. "A practical approach to the family that expects a miracle." Chest 135, no. 6 (June 2009): 1643-1647. [When a patient is extremely ill and/or dying, and the family expects a miraculous recovery, this situation can be very challenging to physicians, particularly when there is certainty that the miracle will occur through divine intervention. A practical approach is therefore provided to clinicians for engaging families that anticipate the miraculous healing of a sick patient. This strategy involves exploring the meaning and significance of a miracle, providing a balanced, nonargumentative response and negotiation of patient-centered compromises, while conveying respect for patient spirituality and practicing good medicine. Such an approach, tailored to the specifics of each family, can be effective in helping a family come to a place of acceptance about the impending death of their loved one.] [NOTE: DeLisser revisits the topic of miracles in a subsequent and broader piece: DeLisser, H. M. "How I conduct the family meeting to discuss the limitation of life-sustaining interventions: a recipe for success," Blood 116, no. 10 (September 9, 2010): 1648-1654; see p. 1652; and then again specifically in: DeLisser, H. M., "When a miracle is expected: allowing space to believe," American Journal of Bioethics 18, no. 5 (May 2018): 52-53.]

Widera, E. W., Rosenfeld, K. E., Fromme, E. K., Sulmasy, D. P. and Arnold, R. M. "Approaching patients and family members who hope for a miracle." Journal of Pain and Symptom Management 42, no. 1 (July 2011): 119-125. [(Abstract:) A clinical problem may arise when caring for patients or their surrogates who prefer continued aggressive care based on the belief that a miracle will occur, despite a clinician's belief that further medical treatment is unlikely to have any meaningful benefit. An evidence-based approach is provided for the clinician by breaking this complex clinical problem into a series of more focused clinical questions and subsequently answering them through a critical appraisal of the existing medical literature. Belief in miracles is found to be common in the United States and is an important determinant of how decisions are made for those with advanced illness. There is a growing amount of evidence that suggests end-of-life outcomes improve with the provision of spiritual support from medical teams, as well as with a proactive approach to medical decision making that values statements given by patients and family members.]

Plus, see the following more recent article:

Shinall, M. C. Jr., Stahl, D. and Bibler, T. M. "Addressing a patient's hope for a miracle." Journal of Pain and Symptom Management 55, no. 2 (February 2018): 535-539. [(Abstract:) Ill patients may make decisions to continue aggressive life-prolonging care based on hope for a miraculous recovery, and clinicians can find goals of care discussions with these patients extremely challenging. Thus, palliative care providers may be asked to help in these discussions. The concept of "miracle" can express a multitude of hopes, fears, and religious commitments. Effective, sensitive engagement requires the palliative care provider to attend to these variegated hopes, fears, and commitments. This case presents a typology of ways patients express hope for a miracle along with analysis of the motivations and beliefs underlying such hopes and suggestions for tailored responses by palliative care providers.] [The authors also published at about the same time: Bibler, T. M., Shinall, M. C. Jr. and Stahl, D., "Responding to those who hope for a miracle: practices for clinical bioethicists," American Journal of Bioethics 18, no. 5 (May 2018): 40-51; and in relation to that article, there was a comment made: McCarthy, M. and Wasson, K., "Shouldn't chaplains be handling cases with miracle language?" American Journal of Bioethics 18, no. 5 (May 2018): 58-60.]


V.  The following recent study out of the Department of Psychology at North Dakota State University used an undergraduate population to establish "the first experimental test of the relation between meaning and belief in miracles" [p. 781]. It may be interesting and thought-provoking in light of the context of our featured article.

Routledge, C., Roylance, C. and Abeyta, A. A. "Miraculous meaning: threatened meaning increases belief in miracles." Journal of Religion and Health 56, no. 3 (June 2017): 776-783. [(Abstract:) For many, religious belief is a source of meaning and a resource for coping with life stressors that have the potential to undercut meaning. In the present study, we sought to further probe the connection between religion and meaning by focusing on the potential for threatened meaning to inspire belief in miraculous testimonials. We threatened meaning with a meaninglessness manipulation and then had participants read testimonials in which people described miraculous experiences involving supernatural agents and rate the extent to which they believed these testimonials to be credible and true. Meaning threat, relative to a control condition, increased belief in miraculous stories.]


VI.  Authors of our featured article have been significant contributors to the religion & health literature. One of their own studies that they cite is the following, which was our 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. [(Abstract:) BACKGROUND: Although spiritual care is associated with less aggressive medical care at the end of life (EOL), it remains infrequent. It is unclear if the omission of spiritual care impacts EOL costs. METHODS: A prospective, multisite study of 339 advanced cancer patients accrued subjects from September 2002 to August 2007 from an outpatient setting and followed them until death. Spiritual care was measured by patients' reports that the health care team supported their religious/spiritual needs. EOL costs in the last week were compared among patients reporting that their spiritual needs were inadequately supported versus those who reported that their needs were well supported. Analyses were adjusted for confounders (eg, EOL discussions). RESULTS: Patients reporting that their religious/spiritual needs were inadequately supported by clinic staff were less likely to receive a week or more of hospice (54% vs 72.8%; P = .01) and more likely to die in an intensive care unit (ICU) (5.1% vs 1.0%, P = .03). Among minorities and high religious coping patients, those reporting poorly supported religious/spiritual needs received more ICU care (11.3% vs 1.2%, P = .03 and 13.1% vs 1.6%, P = .02, respectively), received less hospice (43.% vs 75.3% >=1 week of hospice, P = .01 and 45.3% vs 73.1%, P = .007, respectively), and had increased ICU deaths (11.2% vs 1.2%, P = .03 and 7.7% vs 0.6%, P = .009, respectively). EOL costs were higher when patients reported that their spiritual needs were inadequately supported ($4947 vs $2833, P = .03), particularly among minorities ($6533 vs $2276, P = .02) and high religious copers ($6344 vs $2431, P = .005). CONCLUSIONS: Cancer patients reporting that their spiritual needs are not well supported by the health care team have higher EOL costs, particularly among minorities and high religious coping patients.]



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