The One Death This Doctor Can’t Forget

How physicians' religious views may affect end-of-life talks

In over 30 years of being a doctor, I’ve participated in many end-of-life events. But one stands out.

She was an elderly woman I had known for years; I’ll call her “Tessie” (not her real name). On the last evening of her terminal illness, I was in her home, standing at her bedside with her large extended family. I felt their glistening eyes yearn for me to harness both a spiritual presence and medical expertise. As they prayed the rosary out loud, I directed the administration of morphine drops on her tongue. She exuded peace. The family wept with gratitude. I never felt more like a doctor. It was the best end of life I’ve ever witnessed.

That experience was many years ago; today, I wonder why it was so good. Was it the palpable faith of a loving family? Was it the respect associated with palliative care? Was it the unification of medicine and spirituality? I wonder if it was something simpler.

A Step in the Right Direction

Medicare announced in July 2015 its plans to reimburse health professionals for end-of-life counseling and advance care planning. (The initiative took effect Jan. 1.) I herald this step, but the reality is complex.

An advance directive, documenting a person’s wishes for end-of-life care ahead of time, has limitations. When end of life is imminent, the document may be inaccessible; its language may be imprecise for nuanced medical decisions; patients may change their minds. Even with an updated document, challenges exist in implementation. Defining end of life and treatment futility can be difficult and subjective. A spiritual preference — of a patient, family or doctor — can be expected to impact these subjective views; we’re all human.

I often wonder about my own interactions with patients. In 2005, a survey reported that most doctors believe in God. I’m a doctor, and I also believe in God. However, as with many beliefs, doubt creeps in. Core beliefs, like advance directives, can evolve.

The reality is that during discussion of my patients’ spiritual preferences, I fear exposing my own.

A Difficult Subject

As an infectious disease consultant, I commonly advise about antibiotic treatment for patients with infections complicating chronic terminal illness — metastatic cancer, late stage HIV, severe dementia. Medically, I recognize the end of life and, in many circumstances, the futility of antibiotic therapy. But I always pause before mentioning the idea of palliative care. Patients, and families, can seem surprised by the suggestion. Acknowledging the end of life is hard.

I sometimes take notice of my patients’ spiritual preferences before initiating end-of-life discussions. However, I hesitate to discuss goals of care issues in the context of spiritual beliefs — and a recently published study suggests I’m not alone.

The reality is that during discussion of my patients’ spiritual preferences, I fear exposing my own. To maintain an unbiased professionalism, I evolve into a bedside equivalent of “Don’t ask, don’t tell.” My instinct is to be less intrusive; I shun the potential loss of trust.

But something’s changing.

A Pew Research Center report in May of last year described the rise in religiously unaffiliated American adults to almost 23 percent in 2014; the proportion was higher than mainline Protestants or Catholics. Will this impact end-of-life decisions if fewer patients and fewer doctors believe in God?

How Doctors Differ

It might.

A survey of doctors in the UK reported in 2010 that doctors self-described as “very or extremely non-religious” were more likely than “very or extremely religious” doctors to discuss and report decisions related to accelerating the end of life.

Perhaps non-religious doctors find it easier to discuss end of life, define futility and suggest palliative care unburdened by spiritual dogma.

Maybe patients, evolving to less religious lives, will welcome end-of-life decisions based on scientific and moral grounds, rather than spiritual ones.

Today, I wonder how my own life will end: whether it will be sudden or prolonged; whether it will matter if my doctor believes in God.

Can my end of life combine scientific-based palliation and spirituality? My experience votes yes. Does it matter? My instinct votes maybe not. Despite advance planning, I expect some uncertainty. Despite disparate core beliefs, I know there can be a common vision.

In the end, what I want is what Tessie had — trust. It just may be the thing that matters most.

By Vincent Quagliarello, M.D.
Vincent Quagliarello, M.D., is professor of medicine and clinical chief of infectious diseases at Yale University School of Medicine.

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