March 18, 2009 -- Having entered hospice care, Ruth Holt, 81, said her faith will not motivate her to seek more aggressive treatment for her terminal colon cancer.
"I think I'm more realistic than that," Holt said. "I'm a firm believer. I'm a true Presbyterian. What is to be will be."
While most patients, religious or not, avoid aggressive end-of-life therapy to prolong their time on Earth, a new study shows that religious patients may seek it out at three times the rate of non-religious patients, a finding that leads some to question why doctors don't address the issue of religion with their patients more often, when it informs so many medical decisions, particularly in end-of-life care.
"We're a very religious country, and patients, when they get sick and when they're suffering, many of them turn to religious faith to make sense of their illness," said Dr. Harold Koenig, director and founder of the Center for the Study of Religion/Spirituality and Health at Duke University, who was not involved with this particular study, but has looked at the issue of doctor-patient religion discussions through his own research.
"This is just something that is totally ignored by the medical profession," he said. "When you try to tell [physicians] about it, there's very little interest."
Relying on Religion at End of Life
The new study, published in the Journal of the American Medical Association, was led by researchers from the Dana Farber Cancer Institute in Boston. Researchers used 45-minute surveys from 345 patients.
Patients were asked about how much they relied upon religion to cope with illness, and researchers found that nearly 80 percent used it at least a moderate amount.
Researchers separated positive religious coping ("seeking God's love") and negative religious coping ("wondering whether God has abandoned me") and found that the extent of positive religious coping was a good predictor of which patients would seek aggressive end-of-life care.
While patients who sought positive religious coping requested aggressive end-of-life care 13.6 percent of the time, those who were not as religious sought it out just 4.2 percent of the time.
"It seems like those patients ... they would hold on as long as possible to give God every opportunity to grant them a miracle and save them," said Holly Prigerson of the department of psycho-oncology and palliative care at Dana Farber.
In the end, she noted, aggressive care did not lead to a more pleasant end.
"We find that those who get more aggressive care have decrements in their quality of life," she said. "The more aggressive care did not predict survival differences."
Doctors and Patients Address Faith
While there is some concern about a reluctance among patients and doctors to discuss religious beliefs, Prigerson noted that for patients who are willing to talk about religion, the study does give some encouraging news.
"The take-home from this study is actually that doctors are highly responsive to patient preferences," she said. "Religious patients wanted more aggressive care ... and they got it."
That has not alleviated everyone's concerns, however.
Dr. Andrea Phelps, an internal medicine physician and another of the study's authors noted that the researchers separately asked patients if they felt their spiritual needs were supported by the medical system.
"To a huge extent, patients said no," she said. "Probably, they just weren't being addressed."
Phelps sees that as a missed opportunity.
"I think being open and sensitive to patients with spiritual and religious questions may lead to better understanding between patients and doctors," she said.
Koenig, who regularly speaks to physicians about addressing patients' religious needs, said that for a patient, bringing up religion can be uncomfortable.
"Many patients are scared to talk to their doctors, to bring this subject up, and many doctors are uncomfortable with it," he said, noting that medical schools and continuing medical education often don't broach the topic.
"There's no other way than for patients to be bold, if it's important to them, and bring it up," he said, adding that if the patient doesn't feel the doctor is sensitive, they should get another doctor.
"If religion is important to you, then a lot of your health care is going to touch on it," Koenig said.
Let Doctors Know Your Religious Beliefs
He said it is important to let doctors and nurses know about your religious beliefs in a nice way, and to ensure that if a patient's and a doctor's ethical beliefs conflict, to know that this is OK with the doctor.
In addition, Koenig said, religious organizations can play a role in teaching congregants about medical issues.
"What I would hope ... is that there would be an effort through churches to help to educate members of the congregation about some of these things," he said, giving do-not-resuscitate orders and living wills as examples.
"It's an ideal setting to educate people about these issues. They've found that it works," he said.
While he said the study's results are not surprising, Koenig said there may be some complications. While the study accounted for race in determining religious preference and how it factored into end-of-life decisions, he said it may be difficult to factor that out entirely.
And minorities, who were far more likely to be religious, may have other reasons for wanting end-of-life care.
"One of the reasons why many minorities want everything at the end of life is because they don't trust the doctor and the health care system," he said, noting that patients without that trust will often request anything available to them.
And it will often be granted.
"It may not be medically beneficial, in the eyes of physicians, to treat someone who is dying with these expensive regimens, but if they demand it, they get it," said Paul Simmons, an adjunct professor of philosophy at the University of Louisville, noting that public policy tends to show deference to religious beliefs.
However, Simmons noted that there tends to be a divide among religious people when it comes to end of life.
"I know of many religious people who would say, 'no, my faith says death is a transition, it's not an absolute evil,'" he said.
"Those who say, 'yes, I would choose aggressive care,' would say, 'I have different beliefs: Death is an absolute evil; people cannot choose death over life at any cost,'" he said.
Religious Comfort: Finding Common Ground
In 2007, Holt went into the hospital for observation and received a medication that lowered her blood pressure. When her blood pressure fell too quickly, she was given further tests, which showed she should have a colonoscopy.
She had colon cancer, and had a resectioning of the colon to remove it. In January of this year, she went in for further testing and doctors found the cancer had moved to the liver.
"They told me that it would be terminal," Holt said. "They would do all they could, but they couldn't operate."
Last week, Holt entered Alive Hospice in Nashville, Tenn., to spend her remaining time.
During the course of treatment, Holt said, knowing that a doctor operating on her had religious faith brought her comfort.
While her regular physician of more than 30 years knew her religious preferences, Holt said she merely wanted to know that other doctors had some level of faith.
"The doctor that operated on me for the colon cancer, I asked him, did he pray before he did his operating?" Holt said. "I wanted to know his connections with the Lord.
"He said that he did not, but he prayed all during an operation," she said. "I was very comfortable with that."
But specific beliefs or faiths are not important to her, Holt said, and she does have religious discussions with all of her doctors.
"To a lot of people, your religious beliefs are very private -- I think they leave it up to the patient," she said. "They know I'm a strong believer and I've expressed that."
But despite a lifetime of religious faith, Holt is not holding out for a miracle.
"After trying chemo, it just seems to actually make things worse," she said.
"I accepted what's happening quite some time ago and I can deal with that. I've had 81 beautiful years," Holt said.
She said she is content to spend her final days surrounded by her "beautiful children and grandchildren. You can't ask for anything more than that."