U.S. Clergy Religious Values and Relationships to End-of-Life Discussions and Care

Faith and fate: Religious leaders' Bible, heaven, hell beliefs and end-of-life choices

Controversies surrounding end-of-life choices may be due to differences in congregational affiliation and beliefs about the Bible, heaven, and hell. Focusing on religious leaders (N = 1541), this study investigated how these factors are associated with attitudes toward physician-assisted suicide, allowing a patient to die by withholding treatment, and withdrawing treatment in favor of pain relief. Religious leaders affiliated with White liberal or moderate denominations were more supportive of these end-of-life choices compared to those affiliated with Roman Catholic; White conservative, evangelical, or fundamentalist; and Black Protestant congregations. Literalist view of the Bible and belief in hell were significantly associated with less support across the three choices, whereas belief in heaven was significantly associated with less support for only physician-assisted suicide. This study highlights the varying significance of religious beliefs in understanding variations in views on end-of-life choices and sheds light on the moral distinction associated with various choices.

Improving access to palliative care clinical pastoral education

Palliative care is interprofessional care for seriously ill people. Many clergy, religious leaders, and hospice and palliative care chaplains of color and minority religious backgrounds desire clinical palliative care education. This manuscript presents findings from a three-year quality improvement project which included the development of a palliative care specialty ACPE: The Standard for Spiritual Care and Education (ACPE) accredited program at an academic medical center. The program was designed to improve spiritual care provision in palliative care at the institution and to facilitate the participation of clergy and spiritual leaders of color and minority religious groups. Forty-six students participated in 53 400-h clinical pastoral education units. Strategies from medical education literature were employed to address obstacles to CPE participation including a racially and religiously diverse CPE advisory group, financial assistance, flexible learning (e.g. hybrid, asynchronous), and clinical placement agreements at places of employment. Upon completion of the program students provided written feedback, participated in a structured exit interview and completed a survey. Data were reviewed for common themes and results report student perceptions about the strategies utilized.

Paternalism, Evangelism, and Power

In medicine and pastoral care, there are parallel struggles with paternalism and evangelism, each exertions of power in the setting of privilege. While striving to avoid abuses of power, well-intentioned professionals may unwittingly abjure providing guidance. This can result in threats to patient care: professional abdication and patient abandonment. In The Healer's Power, Howard Brody conceptualizes an approach to the use of power in therapeutic relationships. In this essay, we invoke Brody's framework to consider the place of evangelism and paternalism in the fields of chaplaincy and medicine in order to promote healing amidst power differentials.

The influence of religious beliefs and practices on health care decision-making among HIV positive adolescents

It is unknown if religiousness/spirituality influences end-of-life treatment preferences among adolescents. Investigators assessed whether religiousness/spirituality moderates the relationship between an advance care planning intervention and end-of-life treatment preferences among 85 primarily African-American adolescents living with HIV/AIDS in outpatient-hospital-based HIV-specialty clinics in the United States. Adolescents aged 14-21 years living with HIV/AIDS and their families were randomized to three-weekly-60-minute sessions either: advance care planning (survey, goals of care conversation, advance directive); or control (developmental history, safety tips, nutrition/exercise). At 3-months post-intervention the intervention effect (decreasing the likelihood of choosing to continue treatments in all situations) was significantly moderated by religiousness/spirituality. Highly religious/spiritual adolescents were four times more likely to choose to continue treatments in all situations. Thus, intensive treatments at end-of-life may represent health equity, rather than health disparity. The belief believed that HIV is a punishment from God at baseline (15%, 14/94) was not associated with end-of-life treatment preferences. Twelve percent (11/94) reported they had stopped taking HIV medications for more than 3 days because of the belief in a miracle. Religiousness moderates adolescent's medical decision-making. Adolescents who believe in miracles should receive chaplaincy referrals to help maintain medication adherence.

The Spiritual Event of Serious Illness

Thought leaders in palliative care have long recognized the spiritual implications of illness, including Dame Cicely Saunders' groundbreaking concept of suffering as comprising physical, emotional, social, and spiritual sources of pain. However, despite such recognition, spirituality remains an oft-neglected component of the biopsychosocial spiritual model of caregiving in serious illness. We aim in this article to highlight, through an in-depth account of patients' experiences and attitudes, the concept of illness as a spiritual event.

Training Community Clergy in Serious Illness: Balancing Faith and Medicine

Community-based clergy are highly engaged in helping seriously ill patients address spiritual concerns at the end of life (EOL). While they desire EOL training, no data exist in guiding how to conceptualize a clergy-training program. The objective of this study was used to identify best practices in an EOL training program for community clergy. As part of the National Clergy Project on End-of-Life Care, the project conducted key informant interviews and focus groups with active clergy in five US states (California, Illinois, Massachusetts, New York, and Texas). A diverse purposive sample of 35 active clergy representing pre-identified racial, educational, theological, and denominational categories hypothesized to be associated with more intensive utilization of medical care at the EOL. We assessed suggested curriculum structure and content for clergy EOL training through interviews and focus groups for the purpose of qualitative analysis. Thematic analysis identified key themes around curriculum structure, curriculum content, and issues of tension. Curriculum structure included ideas for targeting clergy as well as lay congregational leaders and found that clergy were open to combining resources from both religious and health-based institutions. Curriculum content included clergy desires for educational topics such as increasing their medical literacy and reviewing pastoral counseling approaches. Finally, clergy identified challenging barriers to EOL training needing to be openly discussed, including difficulties in collaborating with medical teams, surrounding issues of trust, the role of miracles, and caution of prognostication. Future EOL training is desired and needed for community-based clergy. In partnering together, religious-medical training programs should consider curricula sensitive toward structure, desired content, and perceived clergy tensions.

The Views of Clergy Regarding Ethical Controversies in Care at the End of Life

CONTEXT

Although religion often informs ethical judgments, little is known about the views of American clergy regarding controversial end-of-life ethical issues including allowing to die and physician aid in dying or physician-assisted suicide (PAD/PAS).

OBJECTIVE

To describe the views of U.S. clergy concerning allowing to die and PAD/PAS.

METHODS

A survey was mailed to 1665 nationally representative clergy between 8/2014 to 3/2015 (60% response rate). Outcome variables included beliefs about whether the terminally ill should ever be "allowed to die" and moral/legal opinions concerning PAD/PAS.

RESULTS

Most U.S. clergy are Christian (98%). Clergy agreed that there are circumstances in which the terminally ill should be "allowed to die" (80%). A minority agreed that PAD/PAS was morally (28%) or legally (22%) acceptable. Mainline/Liberal Christian clergy were more likely to approve of the morality (56%) and legality (47%) of PAD/PAS, in contrast to all other clergy groups (6%-17%). Greater end-of-life medical knowledge was associated with moral disapproval of PAD/PAS (adjusted odds ratio [AOR], 1.51; 95% CI, 1.04-2.19, P = 0.03). Those reporting distrust in health care were less likely to oppose legalization of PAD/PAS (AOR 0.93; 95% CI, 0.87-0.99, P < 0.02). Religious beliefs associated with disapproval of PAD/PAS included "life's value is not tied to the patient's quality of life" (AOR 2.12; 95% CI, 0.1.49-3.03, P < 0.001) and "only God numbers our days" (AOR 2.60; 95% CI, 1.77-3.82, P < 0.001).

CONCLUSION

Most U.S. clergy approve of "allowing to die" but reject the morality or legalization of PAD/PAS. Respectful discussion in public discourse should consider rather than ignore underlying religious reasons informing end-of-life controversies.

Seeking and Accepting: U.S. Clergy Theological and Moral Perspectives Informing Decision Making at the End of Life

BACKGROUND

People with serious illness frequently rely on religion/spirituality to cope with their diagnosis, with potentially positive and negative consequences. Clergy are uniquely positioned to help patients consider medical decisions at or near the end of life within a religious/spiritual framework.

OBJECTIVE

We aimed to examine clergy knowledge of end-of-life (EOL) care and beliefs about the role of faith in EOL decision making for patients with serious illness.

DESIGN

Key informant interviews, focus groups, and survey.

SETTING/SUBJECTS

A purposive sample of 35 active clergy in five U.S. states as part of the National Clergy End-of-Life Project.

MEASUREMENT

We assessed participant knowledge of and desire for further education about EOL care. We transcribed interviews and focus groups for the purpose of qualitative analysis.

RESULTS

Clergy had poor knowledge of EOL care; 75% desired more EOL training. Qualitative analysis revealed a theological framework for decision making in serious illness that balances seeking life and accepting death. Clergy viewed comfort-focused treatments as consistent with their faith traditions' views of a good death. They employed a moral framework to determine the appropriateness of EOL decisions, which weighs the impact of multiple factors and upholds the importance of God-given free will. They viewed EOL care choices to be the primary prerogative of patients and families. Clergy described ambivalence about and a passive approach to counseling congregants about decision making despite having defined beliefs regarding EOL care.

CONCLUSIONS

Poor knowledge of EOL care may lead clergy to passively enable congregants with serious illness to pursue potentially nonbeneficial treatments that are associated with increased suffering.