Spiritual care is a key component of palliative care1
that has previously been shown to improve the well-being of dying patients and facilitate their transitioning to less-aggressive, QOL-focused care at the EOL.10
However, spiritual support from the healthcare team remains infrequent in the care of terminally-ill patients.3
This study demonstrates that advanced cancer patients who report that their religious/spiritual needs are insufficiently supported by the healthcare team have increased medical costs in the final week of life. EOL costs among advanced cancer patients reporting low support of their religious/spiritual needs by the healthcare team were $2441 more on average as compared to those well-supported. Notably, low R/S support among racial/ethnic minority patients and high religious coping patients was associated with greater cost differences in the last week of life, on average $4206 more among minorities and $4060 more among high religious coping patients. These findings are robust considering adjustment for multiple potential confounding factors such as EOL discussions and geographic location. Hence, the frequent absence of spiritual care by the medical team3
– culturally-competent care mandated by national guidelines1
– is associated with decreased well-being of dying patients10, 38
and their families,14
and increased costs due to greater futile, aggressive care at the EOL.
Studies indicate that EOL costs are largely driven by aggressive measures, such as ICU care,15
whereas increased hospice is associated with lower healthcare costs.20
Provision of spiritual care appears to influence costs at the EOL by leading to greater hospice-utilization and facilitating earlier referrals to hospice while decreasing ICU care and deaths, particularly among patients known to be at greater risk for aggressive care – racial/ethnic minorities34, 39, 40
and high religious coping patients.11
R/S has been shown to play a key role in the experience of EOL2, 3
and in EOL decision-making,12
particularly among minorities.34, 39, 40
This study's demonstration that low patient-reported support of their spiritual needs is associated with increased aggressive care among minorities beyond the contribution of religious coping and religiousness, highlights the central role that R/S often plays in the experience of terminal illness among African-American40
and Latino patients.34
Attention to patients' R/S as part of medical care appears to assist terminally-ill patients in avoiding burdensome, aggressive medical care at the EOL. Potential causal mechanisms include facilitating resolution of spiritual needs and distress that would otherwise result in more aggressive and QOL-compromising care. Recognition of patient R/S as part of EOL care may also assist patients in transitioning away from a focus on extending life to a focus on spiritual priorities at the EOL, such as finding spiritual peace – a factor of primary importance to patients facing death7
that is associated with less aggressive care at EOL.41
Involving patients' R/S in medical decision-making may assist patients in recognizing less aggressive EOL care options that remain consistent with their R/S beliefs.
The implications of the provision of spiritual care to dying patients are noteworthy given that it represents higher quality EOL care1, 10
that, despite its presence in national care quality standards,1
frequently remains absent at the EOL.3
The projected economic impact is approximately $1.4 billion ($2441 × 562,340 annual cancer deaths42
) for care delivered in the last week of life, or approximately 1.5% of direct cancer costs per year ($1.3 billion of $93.2 billion).42
Furthermore, this study's cost estimates only comprise cancer care in the last week of life; spiritual care could result in greater cost implications if other EOL clinical settings were included and examined over a longer time period. Whereas some hypothesize that ample supply of aggressive technologies creates unnecessary demand,28
our study suggests that medical demand is impacted by medical system engagement of underlying psychosocial issues that mediate EOL decision-making.
This study is limited by the fact that cost calculations were based on estimates present in the literature rather than medical claims data. However, by employing national cost averages that include unaccounted for items such as type of chemotherapy or laboratory costs, these estimates provide a justifiable approximation of the overall impact of spiritual care on US EOL medical care costs. Furthermore, costs calculations solely represent costs to medical payers and do not include costs to patients and their families, such as care-giving costs and lost employment revenue. Another limitation is the unclear content of the spiritual care patients reported receiving from their healthcare team. Data from our prior report assists in characterizing spiritual care, however. First, patients' ratings of support of their R/S needs are significantly associated with receiving pastoral care visits,10
supporting the convergent validity of the spiritual care measure and suggesting that pastoral care is a key aspect of spiritual care. Furthermore, while spiritual care from the healthcare team is associated with less intensive EOL care and reduced costs, receipt of pastoral care visits alone does not predict medical care received at the EOL.10
This finding is consistent with the fact that medical caregivers such as physicians and nurses are the primary health providers assisting patients in medical decision-making, and reinforces the multidisciplinary, collaborative approach to spiritual care outlined in recent guidelines.43
Additionally, patients' ratings of spiritual support from the healthcare team and their associations with EOL outcomes appear distinct from patients' perceptions of their relationships with their providers and of care communication, as the associations of spiritual support with EOL care and costs adjusted for the patient-physician relationship (5-item measure of trust, mutual respect, feeling viewed as a whole person, and comfort asking questions regarding care) and history of an EOL discussion with a physician. Interestingly, in contrast to patients' overwhelmingly positive perceptions of their medical care and care communication,44
a minority (26%) reported high support of their R/S needs by their care providers, further bolstering confidence that patients are identifying spiritual care as absent from their medical care and distinct from other aspects of medical care provision. Future studies are required to describe the specific content of spiritual care from the medical team and its impact on patient and family well-being, medical decision-making, and medical costs.
In conclusion, infrequent spiritual care by the healthcare team is associated with higher medical care costs during the final week of life, particularly among racial/ethnic minorities and high religious coping patients. These findings highlight the importance of spiritual care guidelines1
and of educating healthcare providers in their appropriate role in spiritual care provision.43
The integration of spiritual care into the care of dying patients holds promise to improve patients'10
and bereaved caregivers'14
well-being, while also avoiding healthcare costs due to futile, aggressive care at the EOL.