November 2013 Article of the Month
Garrido, M. M., Idler, E. L., Leventhal, H. and Carr, D. "Pathways from religion to advance care planning: beliefs about control over length of life and end-of-life values." Gerontologist 53, no. 5 (October 2013): 801-816.
SUMMARY and COMMENT: This month's article was chosen for the richness and explication of its involved concepts, hypotheses, and methodology as thought-provoking for future research. It attempts a fairly big-picture consideration of connections between religion and Advanced Care Planning (ACP), and in the process it illustrates both the significant sophistication of current spirituality & health research as well as the still-nascent state of the field overall. The findings are also a contribution to discussions within pastoral care about patients' sense of control in end-of-life care decision-making.
This research emerges, in part, from studies suggesting that "[s]elf-identified religious importance... religious service attendance, and positive religious and spiritual coping are negatively associated with ACP likelihood," raising the following question: "Why are highly religious people less likely to engage in ACP, particularly when ACP may specify treatment preferences consistent with one's religious beliefs, including preferences for intensive medical intervention?" [p, 802].
Data were analyzed from 305 outpatients (from a total sample of 575), aged 55 years and older, receiving treatment in New Jersey for colorectal cancer, type 2 diabetes, or congestive heart failure. Face-to-face interviews between 2006-2008 assessed for informal discussion of ACP, formal completion of a Living Will or other Advance Directive, self-rated health, sociodemographics, religious affiliation, importance of religion/spirituality and the degree of influence on medical decision-making, values about "physical and mental functioning, family and social functioning, and spirituality" [p. 805] around the end-of-life; and beliefs about God control [GC] and natural death [ND]. Regarding the latter: the GC score was assessed by three original items (i.e., "It is God's will when one's life will end"; "The length of one's life is determined by God"; and "I believe in turning my health problems over to God"); and the ND score by two items taken from the Death Attitude Profile-Revised (i.e., "Death should be viewed as a natural, undeniable and unavoidable event"; "Death is simply a part of the process of life") [p. 805, and see Related Items of Interest, §II (below)].
Results are given in detail in the narrative and in extensive tables. These express complex and varied relationships and require close reading. Among the findings:
Strong bivariate associations between religious affiliation and ACP were largely accounted for by beliefs and values about control in multivariate models. Beliefs about God's control over life length differed by affiliation, but...many values about control over the EOL were equally important across religious groups. Overall, beliefs in God's control over life length were associated with lower likelihood of ACP (either informal or formal), whereas valuing individual control over EOL circumstances was associated with greater ACP likelihood. [p. 809]The authors build upon a myriad of other research, well cited, to contextualize their findings. They also offer a good deal of speculation about larger dynamics at play. For instance: "Because conservative Protestants are more likely to believe that an outside entity controls life length, they may feel less of a need to plan for the EOL," and "Persons who do not believe that God controls life length might feel a need to appoint a specific person to take control in case they are incapacitated" [p. 814]. However, for this reader, the most practical and overarching proposition is that "individuals are more likely to engage in health-related actions when they perceive control over an illness or scenario" [p. 809]. This idea is guided by the Common Sense Model (CSM) of Illness Representations:
The CSM states that individuals' perceptions of their own health and illnesses affect the decisions they make when seeking health care... Illness perceptions include perceived controllability of an illness or a scenario (here, EOL in general); those who believe their illness is controllable are more likely to seek treatment. Similarly, those who believe that the timing and nature of death are beyond one's own control may be less likely to engage in ACP. [p. 802, and see also Related Items of Interest, §III (below)]
The authors acknowledge the heterogeneity of beliefs within religious groups and the complexity in relationship between a religion's teachings and an individual's beliefs and how those beliefs are translated into decisions and actions. For some chaplain readers, the article might still seem to make too many assumptions about groups as a whole (e.g., "conservative Protestants"), but Garrido, Idler, Leventhal, and Carr bring considerable erudition to this study. If the article is a mix of both broad conceptualizations and minute statistical details, this may illustrate the state of the field of spirituality & health at this point, as the particulars of accumulated research are building a sense of connections but still require a wide view for interpretation.
There is much to stimulate thinking and debate in this article, especially for chaplain researchers, but there are practical implications as well. The authors conclude [p. 815] by encouraging educational initiatives in congregations to empower religious leaders to promote ACP (like the Robert Wood Johnson Foundation's "Compassion Sabbath" initiative), and this should resonate with chaplains in the frequent role as liaison between hospitals and community clergy. The authors also propose that some types of Advance Directives (like the Five Wishes document, which provides for statements about religious beliefs) could be more acceptable to some patients. Chaplains can, of course, also bring sensitivity to religious values -- and potentially "God control" beliefs in particular -- to the facilitation of Advance Directive completion and care plan decision-making for inpatients. In fact, chaplains may be ideally placed to help people better understand ACP as a process to ensure the consonance of one's beliefs and one's medical care and not a means merely to limit treatments [--see p. 803].
One final observation: The authors are exceptionally thorough in defining the key terms used in the study. This reader would note, however, the absence of the term locus of control, which is so much in the parlance of the control literature; perhaps because that literature tends to be focused on health and not specifically on the end of life.
Suggestions for the Use of the Article for Student Discussion:
The article is geared for researchers and may be more difficult than usual for students without a solid sense of the spirituality & health literature, as the relationships between the study's variables are complex, and there is a concentration analytical details. The opening paragraphs, moreover, have an outsider-looking-in tone that may not entice chaplaincy students. Nevertheless, like any good article, this one should be accessible for thoughtful dialogue in CPE, and the Discussion section [pp. 809, 814-815] offers many intriguing ideas regarding the connection between beliefs about control and Advanced Care Planning. Students might think about the specific questions used here to assess for "God control" [--see p. 805]. They may want to talk about associations between "God control" and different theological/denominational traditions, especially in light of the finding that "many values about control over the EOL were equally important across religious groups" [p. 809]. Students might also be asked if they personally have Advance Directives and whether anything in the article touched upon their reasons for having or not having one. Finally, they should be interested in the authors' conjectures about the causes and mechanisms behind their findings, for instance, regarding beliefs about "natural death": "Individuals who believe that death is a natural part of life may engage in ACP because they want to ensure that they have an opportunity to die when nature -- not medicine -- intended…. Alternatively, individuals who believe that death is a natural event may be less fearful of discussing death, making them more likely to engage in ACP." [p. 814]
Related Items of Interest:
I. A related study by co-author Deborah Carr, analyzing a variation of the same overall patient sample:
II. While the three "God control" assessment items are original to the study, the two "natural death" items are taken from the 32-item Death Attitude Profile-Revised, available through its developer's website. For more, see Wong, P. T., Reker, G. T. and Gesser, G., "Death Attitude Profile-Revised: a multidimensional measure of attitudes toward death," in Neimeyer, R. A., ed., Death Anxiety Handbook: Research, Instrumentation and Application (Washington, DC: Taylor & Francis, 1994): 121-128.
III. Co-author Howard Leventhal was a principal developer of the Common Sense Model (CSM) of Illness Representations [--see p. 802], which guided this month's study. Our article gives as a reference for the CSM:
However, a couple of other basic introductions to the CSM can be found in:
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