A new study published in the Journal of the American Medical Association (JAMA) Internal Medicine raises a provocative question: can patients’ religious faith — and the spiritual support given to them by their caregivers — influence their decisions on end-of-life medical services and health care spending? The short answer, according to researchers’ findings, is yes — with some caveats.
Dr. Tracy Balboni of Dana-Farber Cancer Institute in Boston led the new study, which tracked 343 Americans with advanced cancers from its launch in 2002 up through their deaths. The results were striking. Compared to those who reported a lower level of spiritual support, the 43 percent of study participants who reported “high spiritual support” from religious communities were about a third as likely to receive end-of-life (EoL) hospice care, over two and half times more likely to to receive some form of aggressive — and expensive — EoL service (like being put on a ventilator or pursuing additional chemotherapy), and five times more likely to die in a hospital ICU in their last week of life.
Furthermore, patients who self-reported the highest levels of “religious coping” during their final days were 11 times as likely to receive aggressive EoL treatments and 22 times more likely to die in the ICU compared to those with lower levels of religious coping. Those numbers were also elevated for minority populations, particularly African Americans, who are among America’s most religious ethnic groups.
So what’s at the root of these notable trends — and what lessons do they hold for doctors who want to provide their patients with the best care while also reducing the number of unnecessary procedures they must undergo in their last days? Researchers speculate that the numbers may have something to do with religious Americans’ belief in a higher power and the prospect of God working through medical professionals. “One possibility is that religious people consider medicine to be a primary means of divine intervention,” wrote Balboni and her colleagues. They also mused that strong religious community support could foster the desire to “persevere” through “hope found within suffering” — in essence, the mettle to refuse to call it quits.
But as the study’s findings on these religious community-supported patients’ ICU death rates shows, channeling that faith-based will to live into aggressive medical care isn’t necessarily effective — and, to be blunt, it contributes to wasteful health care spending by Americans and public entitlement programs such as Medicare. EoL hospice care isn’t a huge proportion of total health care spending — but aggressive medical interventions for chronically ill elderly Americans on the cusp of death is, with the top five percent of such patients accounting for over $600 billion in health spending every year.
Given those numbers — and Dr. Balboni’s findings on the influence of religious community support in medical decision-making — a shift towards more prudent, less costly EoL care may depend on how doctors approach their patients about terminal illness and their various medical options. On a recent segment of NPR’s Talk of the Nation radio program, surgeon Dr. Pauline Chen discussed the challenges surrounding these delicate conversations, and the choices available to Americans who don’t have long to live:
CHEN: [You] know, for a long time people thought that it was a decision between going forward with aggressive care, whether that was chemotherapy or, you know, a ventilator, a breathing machine or whatever, versus no care at all, which meant to patients giving up or choosing death, or going to hospice was considered the alternative. But what’s been interesting in the last couple of years, there have been studies that have shown that people who go to hospice with metastatic cancer, incurable cancer, they actually – they have better outcomes than if they stayed in, quote-unquote, “aggressive therapy.” [...]
[We're] in a new gray zone, I think, in terms of how we deal with end-of-life care, how we deal with terminal – these discussions, which I think is really – it’s sort of bringing together all of the social, cultural, and medical advances all into one moment in the doctor-patient relationship and sort of putting it in a very different light.
Chen’s recommendations about encouraging a more holistic doctor-patient relationship are also borne out in the new JAMA study. Among the paper’s most surprising — and suggestive — findings was the fact that patients with robust religious community support who also had medical teams that gave them similar spiritual comfort chose to pursue less aggressive EoL services. And those people were more than two times as likely to receive hospice care and one-fifth as likely to die in an ICU, as compared to religious patients who did not receive religious support from their doctors. That suggests that personal, intimate relationships between doctors, patients, and their families, bolstered by a common support system, could go a long way in establishing trust between Americans and their physicians — and reduce the unnecessary human and financial costs of aggressive EoL care along the way.
Dr. Balboni’s study is by no means perfect. As one colleague noted, it includes few criteria for evaluating the types of religious “support” received by patients and given by doctors, and doesn’t probe trends in African American communities as much as it should. A more detailed examination of those aspects might shed light on the influence that different religious groups’ financial capacities have on their EoL care consumption (for instance, would a rich, religious white Baptist male be more inclined to seek expensive EoL care compared to a poor, religious Catholic black woman?). But in the meantime, as doctors care for their terminal patients, they might want to keep this study’s lessons in the back of their minds.