Negotiating religious beliefs in a medical setting

Patterns of care in Jehovah's Witnesses patients with solid tumours and lymphoma

BACKGROUND

Supportive care of Jehovah's Witnesses (JWs) diagnosed with cancer can be challenging, as they do not accept red blood cell (RBC) transfusions.

AIM

The study was designed to determine treatment preferences and pattern of care offered to JWs diagnosed with cancer and its impact on cancer management.

METHODS AND RESULTS

A retrospective cohort study of JWs with solid malignancies or lymphoma in our institution between 2005 and 2015 was conducted. Survival statistics were estimated using Kaplan Meier survival curves and Cox proportional regression model. A total of 63 JWs were identified with a median age of 70 years. At diagnosis, 34% (n = 22) had anaemia. All 63 declined RBC transfusion, including 19 patients who later developed transfusion threshold during anti-cancer treatment. Forty-three percent (n = 27) JWs had advanced (stage 4) disease, and 76% (n = 48) had Eastern Cooperative Oncology Group of 0 to 1. JWs were willing to accept surgery and radiation rather than chemotherapy. Treatment was deemed to be suboptimal in 22% (n = 14) JWs due to early treatment discontinuation, administration of non-standard chemotherapy regimen, or dose reduction due to anaemia and denial of blood transfusion. Twenty-seven percent (n = 17) received hematopoietic growth factors (erythropoiesis-stimulating agents and pegfilgrastim). There was no mortality directly attributed to anaemia or refusal of blood transfusion in the entire cohort.

CONCLUSION

Jehovah's Witnesses declined RBC transfusion at diagnosis and during cancer therapy even if medically indicated. Management pathways need to be prospectively defined for this group of patients.

Ethics of End of Life Decisions in Pediatrics: A Narrative Review of the Roles of Caregivers, Shared Decision-Making, and Patient Centered Values

Background: This manuscript reviews unique aspects of end of life decision-making in pediatrics. Methods: A narrative literature review of pediatric end of life issues was performed in the English language. Results: While a paternalistic approach is typically applied to children with life-limiting medical prognoses, the cognitive, language, and physical variability in this patient population is wide and worthy of review. In end of life discussions in pediatrics, the consideration of a child’s input is often not reviewed in depth, although a shared decision-making model is ideal for use, even for children with presumed limitations due to age. This narrative review of end of life decision-making in pediatric care explores nomenclature, the introduction of the concept of death, relevant historical studies, limitations to the shared decision-making model, the current state of end of life autonomy in pediatrics, and future directions and needs. Although progress is being made toward a more uniform and standardized approach to care, few non-institutional protocols exist. Complicating factors in the lack of guidelines include the unique facets of pediatric end of life care, including physical age, paternalism, the cognitive and language capacity of patients, subconscious influencers of parents, and normative values of death in pediatrics. Conclusions: Although there have been strides in end of life decision-making in pediatrics, further investigation and research is needed in this field.

Refusal of Medical Blood Transfusions Among Jehovah's Witnesses: Emotion Regulation of the Dissonance of Saving and Sacrificing Life

This study focuses on the requirement of JWs to refuse medical blood transfusions. We identified a life-death cognitive dissonance among JWs, with the opposing cognitions of being willing to sacrifice life by religious standards, while being unwilling to do so. Using a theory that connects cognitive dissonance with the need to regulate difficult emotions to analyze our qualitative data material, we identified two sets of dissonance reduction strategies among the JWs. Set 1 was tied to the individual-group: selective focus on eternal life, a non-blood support and control system, and increased individualization of treatment choices. Set 2 was in the religion versus medicine intersection: denial of risk combined with optimism, perception of blood as dangerous, and use of medical language to underscore religious doctrine.

An Approach to Establishing International Quality Standards for Medical Travel

The number of individuals traveling abroad is increasing annually. The rising popularity of medical travel and the absence of clear minimum quality requirements in this area urgently call for the development of international standards to ensure good practice and patient safety. The aim of this study is to identify the key domains in medical travel where quality standards should be established. Drawing from the evidence-based OECD framework and an extensive literature review, this study proposes three critical areas for consideration: minimum standards of health-care facilities and third-party agencies, financial responsibility, and patient centeredness. Several cultural challenges have been introduced that may pose a barrier to development of the guidelines and should be taken into consideration. Establishing international quality standards in medical travel enhances benefits to patients and providers, which is an urgent necessity given the rapid growth in this industry.

"Big Momma Had Sugar, Imma Have It Too" Medical Fatalism and the Language of Faith Among African-American Women in Memphis

This essay offers a theological exploration of the relationship between medical fatalism and religious belonging among African-American women in Memphis. Drawing on the work of black and womanist theologians and on conversations with participants in a diabetes intervention program administered by a faith-based community health provider, I argue that how we narrate the meanings of our bodies is irreducibly religious. The language we use to interpret and communicate the meaning of our bodily existence emerges from a set of assumptions, often unarticulated, about what is of ultimate value to us. The essay focuses on three interlocking features that link faith with fatalism or hope: (1) The idea that if "I don't claim that" disease cannot enter my body; (2) the role of faith-based clinics in re-establishing trust with marginalized communities; and (3) how nuanced attention to the social location of health seekers can re-frame our understanding of patient compliance. Disrupting fatalism can only be done from within a health seeker's own narrative, and therefore, healthcare providers who learn these narratives and respect their holiness will develop more effective interventions.

Religion, Spirituality, or Existentiality in Bad News Interactions: The Perspectives and Practices of Physicians in India

A qualitative study was conducted to identify the role of religion, spirituality, or existentiality in clinical interactions. Grounded theory design was used to generate narrative data from 27 physicians working in four teaching hospitals in Karnataka, India, using a semi-structured interview schedule. Physicians reported that they explored religious, spiritual, and existential beliefs and practices of patients, along with other psychosocial and disease aspects, to assess their tolerance to bad news, to make decisions about delivering it, and to address the distress that might emerge from receiving bad news. They also reported taking recourse to religious or spiritual practices to cope with their own stress and feelings of failure.