Support of cancer patients' spiritual needs and associations with medical care costs at the end of life

Abstract

Background: Although spiritual care is associated with less aggressive medical care at the end of life (EOL), it remains infrequent. It is unclear if the omission of spiritual care impacts EOL costs.

Methods: A prospective, multisite study of 339 advanced cancer patients accrued subjects from September 2002 to August 2007 from an outpatient setting and followed them until death. Spiritual care was measured by patients' reports that the health care team supported their religious/spiritual needs. EOL costs in the last week were compared among patients reporting that their spiritual needs were inadequately supported versus those who reported that their needs were well supported. Analyses were adjusted for confounders (eg, EOL discussions).

Results: Patients reporting that their religious/spiritual needs were inadequately supported by clinic staff were less likely to receive a week or more of hospice (54% vs 72.8%; P = .01) and more likely to die in an intensive care unit (ICU) (5.1% vs 1.0%, P = .03). Among minorities and high religious coping patients, those reporting poorly supported religious/spiritual needs received more ICU care (11.3% vs 1.2%, P = .03 and 13.1% vs 1.6%, P = .02, respectively), received less hospice (43.% vs 75.3% ≥1 week of hospice, P = .01 and 45.3% vs 73.1%, P = .007, respectively), and had increased ICU deaths (11.2% vs 1.2%, P = .03 and 7.7% vs 0.6%, P = .009, respectively). EOL costs were higher when patients reported that their spiritual needs were inadequately supported ($4947 vs $2833, P = .03), particularly among minorities ($6533 vs $2276, P = .02) and high religious copers ($6344 vs $2431, P = .005).

Conclusions: Cancer patients reporting that their spiritual needs are not well supported by the health care team have higher EOL costs, particularly among minorities and high religious coping patients.

Figure 1. Adjusted estimates of ICU admissions in the last week of life and of ICU deaths by provision of patient-reported spiritual care from the health care team in the complete sample, racial/ethnic minorities and high religious coping patients (N=303)^b

^aSample reduced from 339 due to missing data; findings unchanged when analyses repeated with data imputed to mean values. ^bEstimates were adjusted for education, race/ethnicity, baseline existential well-being, baseline social support, advance care planning, end-of-life discussion, health insurance status, patient-physician relationship, degree of positive religious coping, preferences for aggressive care, religiousness, spiritual support from religious communities, Northern versus Southern recruitment site, and terminal illness awareness. Models repeated with cluster analysis by site with findings unchanged.

Figure 2. Adjusted estimates of receiving a week or more of hospice care by patient-reported receipt of spiritual care from the health care team in the complete sample, among non-white race/ethnicity patients and high religious coping patients (N=303)^b

^aEstimates were adjusted for education, race/ethnicity, baseline existential well-being, baseline social support, advance care planning, end-of-life discussion, health insurance status, patient-physician relationship, degree of positive religious coping, preferences for aggressive care, religiousness, spiritual support from religious communities, Northern versus Southern recruitment site, and terminal illness awareness. Models repeated with cluster analysis by site with findings unchanged. ^bSample reduced from 339 due to missing data; findings unchanged when analysis repeated with data imputed to mean values.

Figure 3. Costs of medical care in the last week of life by patient-reported receipt of spiritual care from the health care team in the total sample and among non-white race/ethnicity and high religious coping patients (N=291)^b

^aLeast square mean estimates of costs were adjusted for education, race/ethnicity, baseline existential well-being, baseline social support, advance care planning, end-of-life discussion, health insurance status, patient-physician relationship, degree of positive religious coping, preferences for aggressive care, religiousness, spiritual support from religious communities, Northern versus Southern recruitment site, and terminal illness awareness. Models repeated with cluster analysis by site with findings unchanged. ^bSample reduced from 339 due to missing data; findings unchanged when analysis repeated with data imputed to mean values.