The Role of Religion in End of Life Decisions Part Deux

Rosemary Flanigan
March 30, 2009

Promise I’ll get off this subject, but Lorell gave me an interesting online article by Dr. Kate Scannell, contributing columnist for Inside Bay Area.com about the article in JAMA on religious coping and the desire for more aggressive medical care at the end of life.

She pointed out that in the study, “the vast majority—more than 86 percent—of high scorers did not receive mechanical ventilation or CPR during the last week of life. Thus, we could envision a headline or sound byte that might have alternatively offered, “Cancer patients using high levels of religious coping are unlikely to receive intensive medical care and CPR during the last week of life.”

As she says, same data, different analytic lens. I call those “analytic lens” “assumptions”—and as we sift facts through our assumptions, we certainly skew the data.

What do you think?

Faith, hope, and clarity at the end of life
Dr. Kate Scannell
Inside Bay Area.com
March 29, 2009

We should take a deep breath and critically analyze this study before it becomes dogma etched in stone. The danger is that broad comments characterizing behaviors of an enormous and diverse group of people — here, patients who rely on religious coping under stress — are destined to prove undependable, dehumanizing and misleading.

Podcast: Caring Conversations for Young Adults

Barbara Bollier, MD

Lauren Douville

March 27, 2009

The Center for Practical Bioethics offers a booklet called Caring Conversations to help individuals and their families make practical preparations for end-of-life decisions.

Now the Center has tailored a version of Caring Conversations for use by young adults.

Dr. Barbara Bollier and Lauren Douville talk about it in this edition of the Bioethics Channel.

Religion + End of Life Does Not = Reduced Requests for EOL Treatment

Rosemary Flanigan
March 23, 2009

I have been flattened!!!

Dear colleague John Carney sent me a Journal of the American Medical Association article (“Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients with Advanced Cancer” JAMA, March 18, 2009. 1140-47) over the week-end that dashed my preconceptions.

All this time I have presumed, assumed, that those who call themselves “religious” would set aside requests for life-sustaining treatment and simply allow death to occur.

How wrong I was.

Read this précis of the conclusion of the article: “Positive religious coping in patients with advanced cancer is associated with receipt of intensive life-prolonging medical care dear death. Further research is needed to determine the mechanisms for this association.” (italics mine)

Note that the “intensive life-prolonging care = receipt of mechanical ventilation or resuscitation in the last week of life”!!!

It was borne in on me with a whoosh that our assumptions need special attention, especially in our case consults, a point I’ve been making to groups but NOT making to myself!!!! Just because I think of myself as “religious” and my long-held belief that I want nothing that will prolong my dying, in no way can I wriggle that belief into others, even those who share my particular brand of “religiosity.”

My desire to universalize from my own experience was FLATTENED!

And not just the assumptions of us who are doing the analysis but of those others who are involved need to be opened up and examined.

Assumptions are far from facts—yet they color the way we interpret facts. Another hole dug to bury hurried case consults!!!!!

Any stories??? Any remarks??? THANKS.

Alas! America's healthcare system is not the best

Rosemary Flanigan
March 20, 2009

Maybe reading all those articles on vulnerability has affected me, but yesterday I went to visit a friend who was sent home from a hospital two days after surgery on her foot (plus receiving two units of blood) wearing one of those casts where the screws screw into the bone from outside.

Note on door: BACK TO THE HOSPITAL. It was pain that drove her back—in an ambulance, of course, to be re-admitted.

And I wondered: At discharge, was it known that she would be home alone? Who talks to patients being discharged about home health nurses—and couldn’t home health nurses be expected to handle her pain which everyone must have known would be a problem?

The May 16, 2007 Journal of the American Medical Association had an article by Ezekiel Emmanuel entitled, “What Cannot Be Said on Television About Health Care,” in which “rationing” was one such word, but he went on to lambaste the perceptions of U.S. healthcare delivery as the “best,” as “special,” and the phrase “New is Better.”

Rather, he said, “The US health care system is considered a dysfunctional mess”—which is not news to any of you.

I thought of that article when I stood at the locked door, clutching two fish sandwiches.

Alas!

Cambridge Quarterly and Ethics Committees

Rosemary Flanigan
March 16, 2009

I let my subscription of Cambridge Quarterly expire, and just renewed it. I have long treasured CQ because it targeted ethics committees—and still does, I guess, though I have found this current issue rather thin.

The main section features revisiting vulnerability. The lead article defines it as “To be vulnerable means to face a significant probability of incurring an identifiable harm while substantially lacking ability and/or means to protect oneself,” and then goes on with articles about different kinds of vulnerability and different sites (research sites, especially) where different groups are especially vulnerable.

Yes.

But it was an article by a trio of Australian women discussing “Developing ‘Ethical Mindfulness’ in Continuing Professional Development in Healthcare” that I especially enjoyed—it’s the issue of ongoing education in one’s competence to recognize an ethical moment and to analyze it.

That sums up the 25 year history of the Center’s work—but the women’s approach is especially through the use of narratives. Still, it is not enough to do a superb job of educating well if the receivers of all that good learning do not practice what they’ve learned.

Nothing new there, but it’s good to be reminded.

Have you had "The Talk"?

Rosemary Flanigan

March 12

We had our Ethics Committee Consortium on March 5 and among the discussion it was announced that National Healthcare Decisions Day is going to be celebrated April 16 here in KC.

Funding is scarce and so all the groups in the Consortium were urged to do what was successfully done last year. It is important to keep the momentum going.

I hope we shall continue to push people to talk with loved ones about end-of-life. I went to a funeral this week-end; again, it was a fall, a brain aneurysm, and decision time to withdraw life-sustaining treatment. Wishes had been expressed; desires made known—sad but simple.

So let us do whatever we can do for National Healthcare Decisions Day, each in our own part of the woods.

Link: Have “The Talk” -- Kansas City Healthcare Decisions Day

Ethics Committees and Pain Policy

Is there a fit?

Rosemary Flanigan
March 6, 2009

All of you who are members of the Center for Practical Bioethics have received our latest publication, a policy brief entitled "Balance, Uniformity and Fairness: Effective Strategies for Law Enforcement for Investigating and Prosecuting the Diversion of Prescription Pain Medications While Protecting Appropriate Medical Practice."

Long title but a join effort of the Federation of State Medical Boards, the National Association of Attorneys General and the Center.

As research leading up to the report indicated, fewer than 0.1% of practicing physicians were charged between 1998-2006 with criminal and/or administrative offenses related to prescribing opioid analgesics (Pain Medicine. 2008:9(6) 737-47).

Contrast that figure with the Journal of American Medical Association conclusion that 40% of the 2.2 million nursing home residents in this country who live with "moderate" to "excruciating" pain daily (JAMA. 2001: 285(16): 208l).

I wondered about the atmosphere concerning adequate pain management at the hospitals in which most of you serve--and I thought that our ethics committees could do a remarkable job of education within those hospitals concerning the strategies suggested to reduce diversion and to encourage physicians to prescribe what is best for their patients without fear.

Anybody have a comment??????

Links:

New policy brief aims for balance in pain investigations

Law enforcement, medical and bioethics communities come together in search of “strategies” to balance competing interests

A new policy brief suggests several key strategies to aid law enforcement faced with the complicated case of a doctor suspected of illegal conduct related to prescription drugs. The document is a key step in the Center’s Balanced Pain Policy Initiative.

Links:

News Release, February 19, 2009

Podcast, The Bioethics Channel, with Bill Colby

Balance, Uniformity and Fairness policy brief