This study demonstrates that most advanced cancer patients rely on religion to cope with their illness and that greater use of positive religious coping is associated with the receipt of intensive life-prolonging medical care near death. This association was not attributable to other predictors of aggressive EOL care established in the literature, 28–30
and remained after controlling for advance care planning and other plausible psychosocial confounds. These results suggest that relying upon religion to cope with terminal cancer may contribute to receiving aggressive medical care near death.
To our knowledge this is the first study to examine the influence of any religious factor on medical care received near death, and it is novel in demonstrating that positive religious coping is associated with actual receipt of aggressive EOL care. Positive religious coping was very commonly endorsed within our sample, consistent with other studies that demonstrate it to be the normative mode of religious coping within predominantly Christian patient samples3, 4, 19
(pargament 2004, anos). Adjusting for negative religious coping did not alter the association of positive religious coping with intensive life-prolonging care, suggesting that these findings might not be attributable to religious struggle at the EOL.
In the absence of preexisting outcome data, previous studies support an association of several religious measures and preference for medically aggressive EOL care.1, 10, 31, 32
In a study of 68 ethnically diverse advanced cancer patients, belief in miracles, seeking guidance from God, and spiritual coping were associated with a preference for resuscitation, ventilation, and hospitalization in near-death scenarios.10
In a study from the trauma literature, over half of the respondents believed that God could heal a critically injured patient even when the physician stated that medical futility had been reached9
. Religious copers may choose medically aggressive therapies because they believe God could use the therapy to provide healing. Alternatively, patients may seek aggressive therapies because they hope that God might miraculously intervene while the patient’s life is being prolonged through intensive medical care.
Sullivan et al31
found that religious cancer patients were less likely to understand the definition of a DNR order and were more likely to think a DNR order was morally wrong. Positive religious copers in the CwC sample were less likely than nonreligious copers to have a DNR order or other forms of advance care planning; however, these differences were largely attributable to the effect of race/ethnicity (analysis not presented). Indeed, lower rates of advance care planning did not mediate the relationship between positive religious coping and intensive life-prolonging care. The increased rate of intensive life-prolonging care among religious copers was also not mediated by baseline preference for aggressive care, suggesting a more complex relationship between religious coping and EOL care outcomes. Religious coping may influence medical decision-making rather than directly affecting treatment preferences or orientation toward care. 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.
Intrinsic to positive religious coping is the idea of collaborating with God to overcome illness and positive transformation through suffering. Sensing a religious purpose to suffering may enable patients to endure more invasive and painful therapy at the EOL.11, 12
Alternatively, religious copers might feel they are abandoning a spiritual calling as they transition from “fighting cancer” to accepting the limitations of medicine and preparing for death. Religious patients might thus equate palliative care to “giving up on God [before he has] given up on them.”33
Qualitative studies commonly report spiritual reasons for preferring life-sustaining treatments, including a belief that only God knows a patient’s time to die.11, 34, 35
Finally, high rates of intensive EOL care among religious copers may be attributable to religiously-informed moral positions that place high value on prolonging life.
Taken together, these results highlight the need for clinicians to recognize and be sensitive to the influence of religious coping on medical decisions and goals of care at the EOL. When appropriate, clinicians might include chaplains or other trained professionals (e.g., liason psychiatrists36
[cite Curlin]) to inquire about religious coping during ICU family meetings and EOL discussions occurring earlier in the disease course37
(cite Alexi). Because aggressive EOL cancer care has been associated with poor quality of death and caregiver bereavement adjustment37
[Alexi], intensive EOL care might represent a negative outcome for advanced cancer patients who rely on their religious faith to cope. These findings merit further discussion within religious communities, and consideration from those providing pastoral counsel to terminally ill cancer patients.
Clear associations are often elusive in religiousness/spirituality research because of the complex interactions between religious and other psychosocial factors38
. Because the CwC study included comprehensive assessments of psychosocial measures, we were able to control for demographic confounds as well as more subtle potential explanatory effects. The effects of religious coping may have been confounded by other coping mechanisms; however, controlling for common non-religious coping styles did not alter its relationship with EOL care. Cancer patients with unrealistically optimistic expectations of survival prefer and receive more aggressive EOL care.25, 30
We attempted to account for this by controlling for acknowledgement of terminal illness, which did not alter the relationship between religious coping and the primary outcome. Failure to address the spiritual needs of terminal cancer patients could conceivably contribute to spiritual crisis at the EOL, thereby leading to more aggressive care. Similarly, adjusting for support of spiritual needs did not alter the main findings. Research is needed to determine the mechanisms by which religious coping might influence EOL care preferences, decision making, and ultimate care outcomes.
Strengths of this study include ethnic and socioeconomic diversity among participants, use of validated surveys, and its prospective design. The brief RCOPE is a well-validated research tool that enabled empiric observations about a complex psychosocial construct. Nevertheless, clinicians should appreciate that the effects of religious coping are likely to be moderated by the environment and belief system from which they arise. Our findings should not be misinterpreted as denying the experience of many patients who find peaceful acceptance of death and pursue comfort-centered care because of their religious faith. Although religious coping is a theoretically appealing measure of functional religiousness, we cannot say that positive religious coping rather than other religious factors (e.g. religiously based morals) completely accounts for the associations observed. Given the observational nature of this study, other hidden confounds are possible. Because our study sample was predominantly Christian, the applicability of our findings to non-Christian populations is uncertain. Religious coping is common among patients with a variety of illnesses,2
but attitudes toward EOL care vary substantially across diagnoses with intensive EOL care being much more prevalent among non-cancer populations.2, 29
Future studies are needed to determine the extent to which these findings apply to patients with other terminal illnesses.
Despite these limitations, this study demonstrates that positive religious coping is associated with receipt of more intensive life-prolonging medical care at the EOL. These results suggest that clinicians should be attentive to religious methods of coping as they discuss prognosis and treatment options with terminally ill patients.