Presenter: T. A. Balboni Affiliation: Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
Previous studies have shown that religion/spiritual (R/S) concerns are important to the majority (76-88%) of patients dealing with a life threatening illness (Balboni et al. JCO, 2007).
R/S care during end of life care has been associated with reported improvements in patient coping and quality of life (Tarakeshwar et al. J Palliative Med, 2006)
Support of patient's R/S needs by the medical team (Physicians, Nurses, and Chaplains) has been associated with less intensive care at the end of life, and better quality of life near death.
Guidelines from the National Consensus Project for Quality Palliative Care recommend that attention to R/S needs should be incorporated into medical care.
R/S support is often provided by religious communities rather than by the medical team.
There are no prospective data comparing the provision of R/S support by religious communities with R/S care provided by medical teams in their relationship to advanced cancer patients' medical care at the end of life (EOL).
This study sought to compare EOL care endpoints for cancer patients receiving R/S support from either religious communities or their medical team.
Based on observed patterns of care associated with provision of R/S care from the medical team, the authors hypothesized that R/S care provided by a religious community would lead to even lower rates of aggressive care at the EOL for these patients.
This study was conducted as part of the NCI sponsored Coping with Cancer study, which was a prospective multi-site cohort study of advanced cancer patients and their care providers conducted from 9/2002 - 8/2008.
Study patients included individuals with advanced cancer which was defined as the presence of distant metastases and/or disease refractory to first line chemotherapy with an estimated life expectancy of < 6 months.
Patients were interviewed at baseline and subsequently followed until death.
At baseline, patients rated support of their R/S needs by religious communities and by their medical team, with 5 available response options ranging from "not at all," to “completely supported"
Measured study endpoints of EOL care (defined as the last week of life) included: receipt of hospice care, number of aggressive EOL measures such as care in an intensive care unit (ICU), resuscitation, and/or mechanical ventilation, and death in an ICU.
Multivariate regression analyses were used to examine associations of religious community and medical team R/S support to the EOL care outcomes, controlling for confounding variables.
The multivariate models were adjusted for:
Race, advance care planning, patient EOL care preference, history of an EOL discussion with a physician, recruitment site, physician/patient relationship, religiousness, and positive religious coping.
343 patients of the 670 patients enrolled were followed until death which was a median of 117 days from baseline interview.
89% of patients surveyed reported that R/S care was at least somewhat important to them.
26% of patients reported that their R/S needs were largely or completely supported by their medical team
43% of patients reported that their R/S needs were largely or completely supported by their religious communities
Patients reporting their R/S needs were largely or completely supported by their medical team were more likely to receive hospice care [OR = 2.99 (95% CI = 1.45-6.17), p=.003], were less likely to receive aggressive EOL care measures [OR= 0.38 (95% CI 0.15-0.98), p = 0.04], and were less likely to die in an ICU [OR = 0.26 (95% CI = 0.07-0.92), p=0.04].
In contrast, patients reporting their R/S needs were largely or completely supported by religious communities were less likely to receive hospice [OR = 0.38 (95% CI = 0.20-0.72), p = 0.003], were more likely to receive aggressive EOL care measures [OR =2.55 (95 % CI 1.10-5.93), p=0.01], and were more likely to die in an ICU [OR = 4.69 (95% CI = 1.51-14.56), p=0.008].
In contrast to the association of R/S support from medical teams with less aggressive EOL care, R/S support from religious communities predicts greater aggressive care at the EOL.
These findings suggest that EOL decision-making may be influenced by the content or source of R/S care provided to patients.
Improved collaboration with and education of religious communities may be viable strategies to reduce aggressive care at the EOL.
The majority of patients report that R/S is important to them, and this is important for clinicians in every field to recognize.
The provision of R/S care by the medical care team is associated with improved patient QOL, and less aggressive EOL care for patients with advanced cancer.
This study was a prospective cohort study comparing provision of R/S care by the medical team or by religious communities and their association with EOL care outcomes.
The study results were unexpected to the authors, and demonstrated that patients with advanced cancer who report receiving R/S care through their religious community were more likely to receive aggressive EOL care, die in an ICU, and were less likely to receive hospice care than those who received R/S care from the medical team.
There was no clear explanation as to why spiritual support from the religious community was associated with more aggressive care. Potential explanations may include lack of understanding about prognosis and potential adverse effects of aggressive EOL care, or inadequate communication with the medical team.
Potential limitations of the study include:
The study is not a randomized study and it is possible that important confounders were not included within the multivariate model.
The majority of study patients were Christian (85%) which may limit the applicability of the study findings in other cultures.
The study highlights an important aspect of patient care that is often overlooked by medical teams and underscores the influence that patient religious/spiritual beliefs can have on treatment decisions near the end of life.
Future studies may work to further characterize the content of R/S care and its influence on patient end of life outcomes
May 13, 2013 - Terminally ill patients who are well supported by religious communities use less hospice care and receive more aggressive medical interventions near death, according to a study published online May 6 in JAMA Internal Medicine.