Faith and waste in public life

Updated, March 28, The Economist:

The participants were not asked directly how religious they were but, rather, about how they used any religious belief they had to cope with difficult situations by, for example, “seeking God’s love and care”. The score from this questionnaire was compared with their requests for such things as the use of mechanical ventilation to keep them alive and resuscitation to bring them back from the dead.

The correlation was strong. More than 11% of those with the highest scores underwent mechanical ventilation; less than 4% of those with the lowest did so. For resuscitation the figures were 7% and 2%.


___________________

Religious dying patients more likely to get aggressive care reports the Boston Globe:

"These results suggest that relying upon religion to cope with terminal cancer may contribute to receiving aggressive medical care near death," the authors write in today's Journal of the American Medical Association. "Because aggressive end-of-life cancer care has been associated with poor quality of death . . . intensive end-of-life care might represent a negative outcome for religious copers."


Dr. Andrea C. Phelps, the lead author and a senior medical resident at Beth Israel Deaconess Medical Center, said previous research has shown a link between religious coping and preferences for "heroic" measures. But this is the first study to focus on these patients' final days.

Read it all.

The "waste" in the headline to this post comes the conclusions of another recent study:

Terminally ill patients who talk over end-of-life treatments with their doctors spend less money and do not die any sooner but die more peacefully than those receiving aggressive care, researchers said....

Patients who have the discussion tend to opt for cheaper palliative care in a hospice or at home rather than costly treatments like emergency resuscitation, ventilators to breathe for them and movement to a hospital's intensive care unit.
...
One third of expenses in the last year of life are spent in the final month, according to the report, with aggressive treatments in the final month accounting for 80 percent of those costs.

Read all the Reuters article in Cure Today.

No doubt [added: commenters say no to "no doubt"] many hospital chaplains sense this is true. Are they unable to break through to some significant portion of the religious patients or their families?

Addendum: JAMA abstract.

Comments (10)

Actually, this only somewhat conforms to my experience as a chaplain but mostly differs radically from my experience.

I would want to ask of this study what they mean by "religious" and I would want to compare how different hospitals approach the religiosity of their patients and loved ones.

Physicians and nurses generally are not trained to do much more than respect patients ritual needs in a general way, but often don't know how to engage the person of faith with a style and language that can deal with these issues. When well-trained, clinical chaplains can enter the situation early enough then good things happen, but that is much too rare.

In our haphazard, unintegrated healtcare environment, religiosity can become a hindrance not a help, unless a good chaplain or well-trained parish pastor gets involved early.

This study is worrisome to me because it does not appear to me to ask the right questions in the right way about the effect of religiosity on end-of-life care. This will be a set back to those of us working to improve clinical chaplaincy in a profit- and market-driven health care world.

Once, many years ago (around the time, IIRC, of the "Karen Anne Quinlan" case---anybody else remember that?), I heard a certain kind of religiousity described as "If God says 'Tribulate', then tribulate!"

I think this is the type of "religious dying patients" being thought of: those whose brand of religion orders one (or one's relatives!) to "hold on to the bitter end", no matter the cost (mental, physical, emotional, spiritual, financial). Suffering is fetishized as an end in itself, and there's a suspicion of ANYTHING in the direction of "ending suffering", that such efforts are "not pro-life".

In contrast, my faithful Episcopalian mother died (from ALS) in 2007: at home, w/ palliative care only (by her direction).

I thank God for a Church which blessed her way of taking the last part of her earthly pilgrimage. TEC's God---Praise Christ!---orders NO ONE to "tribulate".

JC Fisher

My experience and my questions are more like than different from Andrew Gerns'. I do find that there are those holding out hope for the miracle even to the bitter end. In fact they've been offered "miraculous" medical care; but I have had to say often enough that we don't necessarily get the miracle we want in the time we ask.

I, too, would wonder how they study surveyed "religiosity;" and I'll be looking into that. However, in my experience the greatest "bottleneck" in the process is getting a physician to acknowledge that we've reached the limits of what therapeutic medicine has to offer, and that we need to change our goal for care from "the longest life" to "the most comfortable death." After all, until the Kingdom comes this is what we can expect. When physicians are clear, then chaplains and other professionals can provide support and care for patients and families. Until the accurate medical information has been conveyed, we're all limited in our ability to choose good goals and make good decisions.

Marshall Scott

I also was surprised to find these results, until I looked into the numbers a little more.

Rephrasing exactly from the Boston Globe story, 88.7% of the most religious chose *not* to have mechanical ventilation; 86.4% of the most religious opted *against* intensive life-prolonging care.

That is, the vast majority of both religious and nonreligious were pretty much the same. Plus, the sample size is quite small: only 345 altogether, only 80 "religious." So only NINE individuals among the "religious" wanted ventilation
(88.7% of 80 = 71; 80-71 = 9).

These data suggest that there is a difference, not between the "religious" and the "nonreligious," but between *some* of the religious and others, and between some of the nonreligious and others, and that there's where the really interesting data wait to be discovered.

You can't extrapolate very far from correlational data, nor from samples of such small size. So in itself, this study doesn't mean nothing, exactly, but nearly nothing.

Andrew and Marshall bring real experience. I am glad to retract the "no doubt" editorial comment I made in writing this post which was purely speculative. Scott Elliott's insight is helpful both in explaining the disconnect between Andrew and Marshall's experiences and the study findings.

I, too, shared the question of how they measured religiosity, which a question is more and more being asked in broader contexts. The abstract which I've added to the post as an addendum doesn't help clarify how "positive religious coping" was measured. Was it something observed? Something asked about in a survey?

I went and looked at the comments to the Boston Globe article -- interesting that no one questioned the measurement of religiosity.

A video on the JAMA article is here,
http://jama.ama-assn.org/current.dtl

I have now had a chance to read the article closely, and have two further comments to make. First, the Globe headline is simply inaccurate. The study used a specific instrument to measure religious approaches used by patients in coping with terminal illness. The insturment incorporated techniques labeled by those who developed the tool (good people, by the way) as either "positive" or "negative" - as either helpful or not helpful in coping. This study did not look at people who were "more" or "less" religious. It looked at people who used more or fewer of the "positive" coping techniques (to no small extent, because almost no participant used "negative" techniques). So, it was not whether participants were "more" or "less" religious, but whether religious participants did or did not use particular techniques. The authors themselves wrote,

Our findings should not be misinterpreted as denying the experience of many patients who find peaceful acceptanceof death and pursue comfort-centered care because of their religious faith. Although religious coping is a theoretically appealing measure of functional religiousness, we can not say that positive religous coping rather than other religious factors (e.g. religiously based morals) completely accounts for the association observed.

Moreover, in the study article the authors acknowledge that, while the study is technically multicenter, a large concentration of patients came from two centers in Dallas, while other participants were from four centers in the Northeastern US. They also note that "Positive religious coping was significantly associated with being black or Hispanic," two groups with significant distrust of the intent and content of the health care they receive. The authors do not discuss these considerations, although they imply in the abstract that these were accounted for.

I'm going to be writing more about this, but this is an initial response.

Marshall Scott

Good stuff, Marshall! If this is just your initial response I'm definitely looking forward to more.

I've added The Economist link to the original post as an update. It describes how religiosity was measured. It also describes the correlation as strong.

Looking forward to Marshall's essay.

My analysis of the Globe and Economist articles, and of the JAMA article behind them, is complete. You can find it here.

Marshall Scott

Marhsall, I went to your follow-up article via the lin. Thanks for a thorough and quite comprehensible guided tour of the research, what they actually asked, who they asked it of, and thanks for the significant nuance that careful reading brings to press-reported 'findings.'

I appreciate you holding this up as an example of the ongoing press (especially first report and headline) vs. actual science dilemma.

It cuts both ways- exaggerated confidence on very provisional findings and groundless skepticism in solid scientific discovery. So both an instance like this of even respectable press reporting research findings as fact when they're quite provisional and the flip side of the press hanging doggedly to skepticism when research has come to a solid conclusion.

In San Francisco in the early days of the AIDS crisis I heard a reporter with a respectable news source grilling one of the University of California San Francisco pioneering AIDS researchers about the safety of public transit. What if the person sitting next to you was infected with HIV virus? Can you offer us 'certainty' that there is no such thing as airborne transmission and infection? The researcher kept saying, "within the limits of what scientists mean by certain, we've reached the clear certainty that this disease is not transmitted by sitting next to someone on the transit bus who sneezes. You won't get it from touching a door handle. The amount of these kinds of exposures doesn't matter. They are not the risk - it takes direct body fluid to body bluid contact."

Again and again the interviewer kept asking, "But you say 'within the limits of what scientists mean by certainty' so you're saying you don't really know." Every response the researcher replied the same way, elaborating with practical things like - "I don't hesitate to ride the bus. If a stranger coughs on me I worry about flu but not about HIV." And the researcher repeated the demand for 'complete certainty.' Finally the interviewer gave up, stuck in his sheer incomprehension of scientific method - when provisional (but massively documented) experimental knowledge has no demonstrable exceptions, you've gotten as close as science ever gets to certainty.

The frequency of us hearing these opposites drives some people to reading science as 'just a belief system like any other.' Obviously we see people doing that with global warming and biological evolution. For some people finding a Ph.D. researcher who disagrees with whatever they don't like hearing, proves that 'scientific theories' are marketplace commodities, and we get to choose which theory to buy and which to leave on the shelf. Across our culture this gives us people believing they've heard settled conclusions when all the research offers is an emerging plausible hypotheses needing a lot more challenge and research. And just as often we get a broad group proud of their skepticism in the face of conclusions solid as any scientific conclusion or fact can possibly be.

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