Monday, March 23, 2009

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.

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Anonymous Anonymous said...

Response from Terry Rosell of the Center for Practical Bioethics:

The JAMA article by Phelps, et al. has been forwarded to me by 3 different sources in the past 3 days, indicative of research that struck a chord.

A question about whether the research found an association or a cause-effect? seems to me, also, important--and one related to the hypothesis that there are other variables that play a role in this having to do with socio-economic issues and what some call health literacy.

The researchers might need to do another sorting of the data in order to ascertain whether the (clinging to life?) positive correlation is just with religious coping or perhaps more closely correlated to other population variables such as socio-economics, health literacy, etc.

They do note that “patients with a high level of positive religious coping were younger, less educated, less likely to be insured, less likely to be married, and more likely to be recruited from the Texas sites” (p 1143).


And they adjusted for race/ethnicity and age, according to the JAMA article, plus some “potential psychosocial confounders,” and still found positive correlation between use of religious coping and preference for intensive life-prolonging treatments in the last week of life.

However, some folk, religious or not, surely are just ill informed regarding life-prolonging treatments (health literacy), and/or aren’t thinking clearly in the midst of crisis.

My experience with Christian patients and families mostly parallels the JAMA data, in general though not in every case.

I’m not surprised by what they found.

The “waiting for a miracle” rationale comes up frequently. Like Phelps, et al., I suppose that the reasons for this are particular and complex.

Some religious ‘copers’ may not really believe their own after-life doctrines, and therefore cling to what they do know and have in this life.

Others believe the doctrines but fear the dying process or worry about what sort of after-life awaits them.

Family members may believe or doubt, but prefer to have their loved one remain here regardless. This might account for most of it.

In Christianity, there is found the rhetoric of Death as Enemy to be defeated, and the notion of spiritual warfare as a virtuous activity. So perhaps the virtuous patient/proxy fights Death courageously with every “weapon” at our disposal until the last gasp of breath. And so it happens.

I think there is also a strong sense in many Christian copers that faith in God requires faithfulness in doing all we humanly can—collaborating with God—to “save a life.”

This can lead to a sort of vitalism, of course. But it needn’t go that far, being grounded instead in a reasonable respect for the “sanctity of life” and commitment to human flourishing.

So the JAMA data isn’t necessarily indicative of religious behavior that is entirely illogical, inconsistent, or incoherent.

Neither does it show that most persons who use religion for coping will also insist on medically futile life-prolonging measures.

As a clergy caregiver, I once (years ago) suggested to a morally and medically perplexed family that going along with the intensivist doctor’s inclination to stop Grandpa’s mechanical ventilation might actually constitute a greater act of faith on their part than waiting for a healing miracle with medical machinery still in place.

Actually, I think it was more like: “The miracle God might do is that of releasing Grandpa from this life of suffering to something far better for him. But even if it were to be a miracle of making Grandpa well, would God need the doctor’s machinery and medicines to do that? And, whatever happens, might we mistake God’s work for that of humans, unless we get out of the way and make sure that God gets the glory?”

This was a family of relatively low education and health literacy, limited income, religiously (and politically) conservative, with decision-makers in midlife mostly.

I wouldn’t and don’t approach every similar situation or family in precisely this way. But my form of compassionate logic seemed to help in their case, mostly because they trusted me, I suspect.

The family decided to discontinue life-prolonging treatments for Grandpa—a reasonable course of action. He had a quick and peaceful death after being disconnected from machines and tubes, with all of the family and their pastor gathered in prayer around his bedside.

The widow later sent me a beautiful thank you note, which said in part that she experienced God’s loving presence in that dying room.

It was a miracle.

Monday, March 23, 2009  
Blogger Practical Bioethics said...

From Rosemary Flanigan ...

Thanks to all of you who entered into the discussion of the connection between “religious coping” and aggressive end-of-life requests.

No, I see no cause/effect connection in the article—just a description of the replies to some questions by a carefully sorted group.

Of course, the reader could make that connection, but the authors refer only to “associations” of the two.

And here is the place “assumptions” enter our discussion.

Consider the way each of us reads the front page of the page in the morning. Two people can read the same news article, and though we may not disagree with how the other reads it, we may latch onto some significant feature that the other fails to grasp.

Consider a case consult around an incompetent patient in a terminal condition who has never made any advance care plans—maybe couldn’t—and who has no family or close friend (in fact, a guardian has been appointed) and the healthcare team agrees that CPR would be harmful if the patient stopped breathing.

When an ethics committee member asks, “Is there a legal way to do a DNR?” I wonder, “Why?” Why ask it; why think it important or necessary; why do not the physicians (with the guardian’s knowledge and consent) simply write the order?

Those questions—and my response—come out of the assumptions we make when we hear the case.

I want to apply this to “religious coping” but first, does anyone agree with me (and my assumption) that legality is not relevant here?


Tuesday, March 24, 2009  

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