Holly Prigerson, PhD

In a new study of terminally ill cancer patients, researchers at Dana-Farber Cancer Institute found that those who draw on religion to cope with their illness are more likely to receive intensive, life-prolonging medical care as death approaches — treatment that often entails a lower quality of life in patients' final days.

Previous research has shown that more religious patients often prefer aggressive end-of-life (EOL) treatment. The new study — to be published in the March 18 issue of the Journal of the American Medical Association — examined whether these patients actually receive such care. The study's findings suggest that physicians tend to comply with religious patients' wishes for more aggressive care.

"Recent research has shown that religion and spirituality are major sources of comfort and support for patients confronting advanced disease," says the study's senior author, Holly Prigerson, PhD, of Dana-Farber and Brigham and Women's Hospital (BWH). "We focused specifically on positive religious coping, on people who rely on their faith to handle the stresses of serious illness and approaching death. Our findings indicate that patients who turn to religion to cope in times of crisis, such as when facing death, are more likely to receive aggressive care when they die."

The study involved 345 advanced cancer patients at seven hospital and cancer centers around the country. Participants were interviewed about their means of coping with the illness, their use of advance care planning tools such as living wills and durable power of attorney, and their preferences regarding end-of-life treatment. Investigators then tracked each patient's course of care during the remainder of his or her life.

An analysis of the data showed that patients identified as positive religious copers had nearly three times the odds of receiving life-prolonging care, in the form of being on a ventilator or receiving cardiopulmonary resuscitation, in the final week of life. Even after researchers accounted for the influence of important factors such as age, ethnicity, or other coping techniques, the connection between religious coping and aggressive EOL care held up.

The researchers also found that religious copers in the study were less likely to have completed advance medical directives, such as a living will or do-not-resuscitate order, which can limit the extent of such interventions in advance. The effects of religious coping on the use of intensive medical care in the last week of life remained significant even after adjusting for differences in advance care planning.

In interpreting the results, study lead author Andrea Phelps, MD, of Dana-Farber and Beth Israel Deaconess Medical Center (BIDMC), and a clinical fellow in medicine at Harvard Medical School, says that "beyond the significance of religious faith in coping with the emotional challenge of incurable cancer, it is important to recognize how religious coping factors into extremely difficult decisions confronting patients as their cancer progresses and death appears imminent. Beyond turning to doctors for advice, patients often look to God for guidance in these times of crisis."

The study did not explore why religious copers often tend to prefer and receive extensive end-of-life care, the authors note. The researchers hope to examine such questions in future studies.

"Our results highlight how patients' ways of coping, particularly their use of religious coping, factor prominently into the ultimate medical care patients receive. This suggests that clinicians should be attentive to terminally ill patients' religious views as they discuss prognosis and treatment options with them," said Prigerson, who is also an associate professor of psychiatry at Harvard Medical School. "A greater understanding of the basis of patients' medical choices can go a long way toward achieving shared goals of care.

Financial support for the study was provided by grants from the National Cancer Institute, the National Institute of Mental Health, and the Fetzer Institute.

The study's co-authors include Deborah Schrag, MD, MPH, Tracy Balboni, MD, Alexi Wright, MD, Elizabeth Trice, MD, and Matthew Nilsson, of Dana-Farber; Paul Maciejewski, PhD, John Peteet, MD, and Susan Block, of Dana-Farber and BWH; and M. Elizabeth Paulk, MD, of the University of Texas Southwestern Medical Center, Dallas.