Jan 26, 2016
The 2015 Palliative Care in Oncology Symposium fostered thoughtful discussion and new insights among faculty and attendees. As part of the ASCO Connection Clinical Conversations series, Symposium leadership have selected questions submitted during sessions by attendees via the electronic question-and-answer system (eQ&A) that could not be addressed in the time available onsite.
Joshua Jones, MD, of the University of Pennsylvania, and Christina K. Ullrich, MD, MPH, of Dana-Farber Cancer Institute, co-chaired Oral Abstract Session B. Other session participants included:
- Pasquale Innominato, University of Warwick
- Amelie Harle, MD, The Christie NHS Foundation Trust
- Dorothy M.K. Keefe, MD, FRACP, FRCP, MBBS, Royal Adelaide Hospital
- Michael Balboni, PhD, Dana-Farber Cancer Institute
- Jonathan Marron, MD, Dana-Farber Cancer Institute
- Karen E. Steinhauser, PhD, Duke University
- Ryan Nipp, MD, Dana-Farber Cancer Institute
- William F. Pirl, MD, Massachusetts General Hospital
- Betty Ferrell, PhD, City of Hope
In the following Q&A, Dr. Balboni addresses some of the unanswered questions posed about his abstract on clergy religious beliefs and ICU utilization during Oral Abstract Session B.
It seems like involving community clergy can lead to undesired health care outcomes and decisions. What do you suggest is the right approach?
MB: The data suggests that nearly half of patients at the end of life have relationships with community clergy. In our survey, 70% of clergy indicated that they had known the patient facing end-of-life medical decisions for whom they provided spiritual care for longer than 3 years. So clergy are involved in the lives of congregational members and not involving them within the process of patient medical decisions does not undermine their influence.
On a systems level, the medical community needs to make greater concerted efforts to engage clergy around the end of life by providing education about medical decisions, explaining the benefits of hospice, and most importantly, suggesting a religiously informed way of thinking about medical decisions within terminal illness.
On an individual case level, the right approach is for the medical team to ask the patient, or family members, whether they would like their minister to be part of the medical decision-making process. If the patient desires this, bring the clergy in, explain the prognosis and the potential limitation of medicine, and uphold how hospice and palliative care offers patients the best of human care, even though the powers of medicine are not able to cure in the case of terminal diagnosis.
Physicians can agree with clergy and patients that the medical team also is hoping for a miracle, if this is the idea being expressed by the patient, family, or faith community. However, the medical team can also indicate that in the case of terminal diagnosis, palliative care might be the best option because not only might a miracle take place in that context, but if it does, it will be demonstration of an even greater miracle. The medical team can also indicate to the clergy member that to the best of your knowledge, medicine has reached its limits, and it would be wise if the patient and family transition to being spiritually, relationally, and materially prepared for death. Most clergy, no matter their background, believe and recognize that spiritual preparation is more important than physical cure.
Did the study control for whether patients seen by clergy had had hospice discussions with medical professionals?
MB: No, our study was not able to control for this because the medical information was gathered from the clergy perspective only. We did not believe that clergy would be so involved in many cases to be able to accurately indicate the nuances of the patient’s experience with the health care team. This is an important limitation in our study methods and it would be extremely interesting to perform a multi-perspective study that includes patients, clergy, and medical professionals.
Regarding clergy theological beliefs, do you have any qualitative or anecdotal information about how clergy interpret the "miracle" statement? For example, "God will cure me of this cancer [...in heaven]," which I have heard from at least one patient/family in the past.
MB: This is another good question. We spent considerable time developing the survey questions, including this item regarding God curing of cancer. During the development phase we used cognitive pre-testing, which evaluates whether clergy understand a survey item in the way it is intended to be understood. We spent time ensuring that this question avoided this very kind of interpretation that inserts an expanded meaning to cure beyond the physical. For example, clergy are more likely to use a broader definition pertaining to the word “heal.”
“Heal” signals to clergy processes involving more than the physical body and illness, expanding to include the relational and spiritual dimensions of the person. However, “cure” signaled to clergy that this question was limited to the physical dimension of cancer. We also inserted “cancer” in the statement to further avoid clergy from applying an expanded meaning beyond physical cure. During the pretesting of the questionnaire, we found that clergy consistently read this statement to be referring to physical cure of cancer, and not an expanded meaning often connected to the word “heal.”
Read more 2015 Palliative Care in Oncology Clinical Conversations: