The Medical Hazards of Spiritual Care

Two studies recently have found a striking association between faith and the medical decisions of terminal cancer patients at the end of life. In both cases, religious faith often led patients to choose more aggressive medical care at the end of life. Michael Balboni, M.Div. Th.M., is a researcher at the Dana Farber Cancer Institute and Ph.D. candidate at Boston University. The research team he belongs to has looked at how people cope with cancer.

What has the Coping with Cancer Study shown?

While I didn’t play a role in the initial paper, published in the Journal of the American Medical Association, it looked at positive and negative religious coping. Positive would be things like being at peace with God and feeling supported by one’s religious community. Negative religious coping would be feeling angry with God or feeling judged by God.

The researchers who worked on that paper split the group in two, high and low religious copers. Those who were in the high group had a strong association with preferring heroic life-prolonging measures. There is a six-fold increase in preference for aggressive measures at the end of life. High religious copers were also less likely to have a living will, a health care proxy, or Do Not Resuscitate orders.

In actual practice, high religious copers ended up being three times more likely to actually receive some type of intensive life-prolonging care, which was defined as things like receiving mechanical ventilation or being in the intensive care unit.

Unfortunately, we do not know the exact religious or spiritual reasons why high religious copers receive aggressive care at life’s end.

The next paper, which you co-authored, found people were better off if they received their spiritual care from medical staff.

There are three findings regarding the last week of life and medical choices that are being made. Among the entire sample, patients whose spiritual needs were largely or completely met by [their] medical team [ … ] were three times more likely to go into hospice, versus those who said their spiritual needs were not supported by the medical team.

Then, looking at the high religious coping group, they were five times less likely to receive aggressive care and five times more [likely] to enter hospice when hospital staff cared for them spiritually. We’re seeing a greater effect among high religious copers.

Do you know what pastors and spiritual caregivers are telling their congregants who are sick with cancer?

We really don’t know what’s going on with clergy. But the kind of support they’re offering is probably leading patients to choose more aggressive care. We can only hypothesize why. I’m guessing it has to do with some misunderstandings about the ability of medicine. Fighting cancer is not necessarily the best thing to do spiritually. When people have metastatic cancer, it would appear that they are not being accompanied in quite the right way regarding their medical decisions.

On the other hand, there are certain doctors and nurses who simultaneously understand and/or share beliefs and practices with the patient, and they understand the complexities of the disease and the disease process. Having an understanding in both areas, they seem to be able to offer spiritual advice when engaging medical decisions.

What is a good end of life outcome? Who’s to say whether these people simply prefer aggressive care? If that’s what they want, why say they have “poor outcomes”?

Part of the study interviewed caregivers after the patient’s death. They asked the caregiver how much physical pain and psychological pain the deceased was in. And they asked about their overall sense of quality of death.

They were able to evaluate based on the caregiver’s perception what the quality of death was. There was internal consistency with how caregivers responded throughout the process. At the original interview there was consistency between a patient’s answer about how they were doing overall and their caregiver’s perception on how the patient was doing. This indicates that the quality of death scores given by caregivers after the patient’s death likely is a good indicator of how the patient felt as they approached death.

In another paper, it was found that among patients who received more aggressive care during the last week of life, there was an association with worse quality of death scores. It implies there is a relationship. If you get aggressive care at the end of life, you’re going to experience more pain, more psychological pain, and you’ll have a worse quality of death.

I think there is a second response. I think most Christian traditions would likely have strong reservations regarding the overuse of technology at the end of life. Within the Christian tradition, at least in theory, there is not favor toward a high dependence on technology. I’m not sure what Christian tradition would want a patient to, despite their terminal illness, turn toward these technologies when their circumstances are futile.

Among many Christians, that’s not the way people envision themselves dying. Perhaps what might be happening, once push comes to shove and they’re dying, things happen quickly and are not fully understood, and the implications of medical decisions are not fully understood. Medical culture is generally trained to provide care unless it’s refused. Given all those factors, there is a tendency toward receiving aggressive care. That would be my guess.