March 23, 2009

The "Cancer Faith" Study

ResearchBlogging.orgAn interesting study released earlier this week attracted the attention of many bloggers and commentators. It's basic premise is that religious patients with advanced cancer are more likely to opt for aggressive end-of-life treatment. In other words, the more religious they are, the more likely it is that they will place less faith in God and more faith in medical treatment and technology. Let's analyse:

Andrea Phelps and colleagues acknowledge that religion and beliefs account for a high amount of coping strategies employed by patients with advanced cancer, as it affords them a sense of "meaning, comfort, control, and personal growth while facing life-threatening illness." Rather understandably, positive strategies are employed that highlight God's "loving care" rather than the negative strategies that view the condition as "divine punishment", which are said to be uncommon. Aside from simply coping with disease, faith is said to be a major factor in medical decisions; Other research in similar areas found that after oncologist recommendations it was faith that was said to be the second most important factor in deciding the course of the treatment, and also that 68% of a sample of a thousand individuals explicitly stated that their faith would guide their medical decisions if they experienced a critical injury, with 57% believing that a divine cure could be obtained in the case of medical incapability to resolve the issue. So while there is evidence that religion is associated with a preference for receiving intense treatment, Phelps and her colleagues wanted to find out whether patients who relied heavily on their religious faith were more likely to receive intensive medical care, such as cardiopulmonary resuscitation or being placed on a mechanical ventilator, before death.

The study was longitudinal, and recruited 345 patients (out of a total of 941 eligibles) from 2003 up till 2007, and were interviewed (at baseline) in either English or Spanish by Yale students, with follow-ups until their deaths. Demographic (ethnic) considerations were accounted for due to the diversity of religious beliefs, and typical measures were undertaken in order to code beliefs accordingly. To avoid selection bias, patients were not told that religion/spirituality was the focus of the study. Other measures of coping strategy were employed; most curiously, patients were asked to rate how much their religious beliefs were supported by the medical staff (doctors, nurses, even hospital chaplains!) and those who rated it highly were coded as having support for their spiritual needs. I can understand chaplains, but what are doctors and nurses doing to support patient beliefs? Did this occur in a sympathetic/empathising context just to keep the patients' spirits up? The study doesn't mention.

Here come the brief stats: 79% stated that religion helped them to cope to a moderate extent, while 32% endorsed the statement that it was the "most important thing that kept them going". 56% engaged in daily prayer or meditation. Positive coping strategies were correlated highly with being black or Hispanic (p < .001). Patients with higher levels of religious coping were younger, less educated, less likely to be insured, less likely to be married, and were more likely to be recruited from Texas (!!) than those who had negative styles of coping. Overall, patients with 'high' religion preferred medical interventions such as being put on a ventilator, resuscitation, transport to the Intensive Care Unit, approved 'heroic' measures by doctors to save lives, than those with 'low' religion. They also didn't think much of advance care planning, Do-Not-Resuscitate orders, making a will or giving anyone power of attorney over their affairs. Even after controlling for other alternatives, 'high' religion remained a significant predictor of preference for life-prolonging measures.
This appears to be the first study to directly examine the influence of religious beliefs on medical care, and although the authors acknowledge that further research ought to be undertaken in order to understand why they wield such a strong influence, this is still an interesting collection of facts. Among the usual disclaimers about the drawbacks of the study, Phelps et al. say something quite interesting: "Religious copers may choose aggressive therapies because they believe that God could use the therapy to provide divine healing, or they hope for a miraculous cure while intensive medical care prolongs life." And again, "religious copers may decide to undergo therapies with high risks and uncertain benefits because they trust that God could heal them through the proposed treatment." Huh? Does this make sense to you? It strikes me that the hope for a divine intervention and it's timely arrival would occur at a time convenient for both medical staff and the patient, instead of leaving it to literally the last minute? The authors haven't submitted the RCOPE scale with their paper that was used to define beliefs, but I'm guessing that it didn't include any questions about fear of death? Perhaps that is an idea for future research: analyse patients' preference for intensive medical care at end-of-life and find out the extent to which it is mediated by fear of death! Duh.

I'm not trying to be deliberately sarcastic because I know that this is a sensitive issue that is especially painful for those who have experienced cancer, or know someone who has suffered it and died etc., but those were really silly things Phelps said. It may be that patients themselves articulated such things in their interviews, but we can never know unless we look through the data. Sensibility returns when other research is cited suggesting that patients do not seem to understand what a DNR is (perhaps due to cultural/language barriers) or thought that it ws morally wrong to institute one (if they think it is God's decision for their "time to die"). It is also noted that believers tend to think illness as a "trial" from God, and it is possible that they deliberately opt to endure further suffering and this might explain their enlisting of life-saving measures.

However, at the end of the day, the study is clear on one thing: terminally patients with high religiosity prefer intensive life-saving care over and above all other forms of coping strategies or medical treatment, and that the decision to opt for this type of care is influenced and mediated by religiosity. The authors pre-empt criticism of misinterpreting their findings as evidence of religiosity accounting for insecurity and/or crises of faith which may lead to the opting for aggressive care, by saying that it cannot "completely account" for the observed associations. Why not? By their own admission they controlled for other eventualities including self-acknowledgement of having a terminal illness and it made no difference at all to the overall results, and only further research can look deeper into the reasons as to why this takes place, but it is understandable if people look to the obvious inference.

For more on this topic, please visit Respectful Insolence.

Phelps, A., Maciejewski, P., Nilsson, M., Balboni, T., Wright, A., Paulk, M., Trice, E., Schrag, D., Peteet, J., Block, S., & Prigerson, H. (2009). Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients With Advanced Cancer JAMA: The Journal of the American Medical Association, 301 (11), 1140-1147 DOI: 10.1001/jama.2009.341

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