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Original Investigation |

Provision of Spiritual Support to Patients With Advanced Cancer by Religious Communities and Associations With Medical Care at the End of Life

Tracy A. Balboni, MD, MPH; Michael Balboni, PhD; Andrea C. Enzinger, MD; Kathleen Gallivan, PhD; M. Elizabeth Paulk, MD; Alexi Wright, MD; Karen Steinhauser, PhD; Tyler J. VanderWeele, PhD; Holly G. Prigerson, PhD
JAMA Intern Med. 2013;173(12):1109-1117. doi:10.1001/jamainternmed.2013.903.
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Importance Previous studies report associations between medical utilization at the end-of-life (EoL) and religious coping and spiritual support from the medical team. However, the influence of clergy and religious communities on EoL outcomes is unclear.

Objective To determine whether spiritual support from religious communities influences terminally ill patients' medical care and quality of life (QoL) near death.

Design, Setting, and Participants A US-based, multisite cohort study of 343 patients with advanced cancer enrolled from September 2002 through August 2008 and followed up (median duration, 116 days) until death. Baseline interviews assessed support of patients' spiritual needs by religious communities. End-of-life medical care in the final week included the following: hospice, aggressive EoL measures (care in an intensive care unit [ICU], resuscitation, or ventilation), and ICU death.

Main Outcomes and Measures End-of-life QoL was assessed by caregiver ratings of patient QoL in the last week of life. Multivariable regression analyses were performed on EoL care outcomes in relation to religious community spiritual support, controlling for confounding variables, and were repeated among high religious coping and racial/ethnic minority patients.

Results Patients reporting high spiritual support from religious communities (43%) were less likely to receive hospice (adjusted odds ratio [AOR], 0.37; 95% CI, 0.20-0.70 [P = .002]), more likely to receive aggressive EoL measures (AOR, 2.62; 95% CI, 1.14-6.06 [P = .02]), and more likely to die in an ICU (AOR, 5.22; 95% CI, 1.71-15.60 [P = .004]). Risks of receiving aggressive EoL interventions and ICU deaths were greater among high religious coping (AOR, 11.02; 95% CI, 2.83-42.89 [P < .001]; and AOR, 22.02; 95% CI, 3.24-149.58 [P = .002]; respectively) and racial/ethnic minority patients (AOR, 8.03; 95% CI, 2.04-31.55 [P = .003]; and AOR, 11.21; 95% CI, 2.29-54.88 [P = .003]; respectively). Among patients well-supported by religious communities, receiving spiritual support from the medical team was associated with higher rates of hospice use (AOR, 2.37; 95% CI, 1.03-5.44 [P = .04]), fewer aggressive interventions (AOR, 0.23; 95% CI, 0.06-0.79 [P = .02]) and fewer ICU deaths (AOR, 0.19; 95% CI, 0.05-0.80 [P = .02]); and EoL discussions were associated with fewer aggressive interventions (AOR, 0.12; 95% CI, 0.02-0.63 [P = .01]).

Conclusions and Relevance Terminally ill patients who are well supported by religious communities access hospice care less and aggressive medical interventions more near death. Spiritual care and EoL discussions by the medical team may reduce aggressive treatment, highlighting spiritual care as a key component of EoL medical care guidelines.

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Figures

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Figure 1. Spiritual support from religious communities. Rates of hospice care (A), aggressive medical interventions (B), and intensive care unit (ICU) death (C) in the full sample (N = 343), patients with high religious coping (n = 175), and racial/ethnic minority patients (n = 128). *Hospice is inpatient or home hospice care in the last week of life, and aggressive medical interventions include receipt of ventilation, resuscitation, or care within an ICU in the last week of life. Full sample rates of hospice care, aggressive medical interventions, and death in an ICU are 73.2%, 13.1%, and 7.3%, respectively. †Religious coping is a patient's reliance on their religious/spiritual beliefs to cope with and understand illness and was measured using Pargament's validated RCOPE (religious coping) instrument (score range, 0-21). Patients with high religious coping were those who scored at or above the median, and of these patients, 63% (n = 109) reported high spiritual support from religious communities and 37% (n = 66) reported low spiritual support from religious communities.

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Figure 2. Comparison of sources of spiritual support and their adjusted associations with end-of-life medical care in the full sample, patients with high religious coping, and racial/ethnic minority patients. ICU indicates intensive care unit; Rel Com Spirit Support, Religious Community Spiritual Support; Med Team Spirit Support, Medical Team Spiritual Support. *Sample size reduced from 343 (total sample), 175 (patients with high religious coping), and 128 (racial/ethnic minority patients) owing to missing data (<3% for all variables). †Odds ratios and 95% confidence intervals are shown. Models adjusted for race, positive religious coping, religious tradition, northeast vs southern region, health insurance status, Med Team Spirit Support, end-of-life treatment preferences, terminal illness awareness, advance care planning, and end-of-life discussions. Sex was included in models examining receipt of hospice and death in an ICU. ‡Hospice is inpatient or home hospice care in the last week of life and aggressive medical interventions include receipt of ventilation, resuscitation, or care within an ICU in the last week of life. §Wald χ2 for comparison of odds ratios.

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Figure 3. End-of-life (EoL) medical care among 147 patients receiving high spiritual support from religious communities according to receipt of EoL discussions and high spiritual support from the medical team. *Hospice is inpatient or home hospice care in the last week of life, and aggressive medical interventions include receipt of ventilation, resuscitation, or care within an intensive care unit (ICU) in the last week of life.

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