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Koss SE, Weissman R, Chow V, Smith PT, Slack B, Voytenko V, Balboni TA, Balboni MJ. Training Community Clergy in Serious Illness: Balancing Faith and Medicine. J Relig Health 2018; 57:1413-1427. [PMID: 29876716 PMCID: PMC6281818 DOI: 10.1007/s10943-018-0645-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Sarah E Koss
- Harvard Divinity School, Cambridge, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ross Weissman
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Graduate School of Education, Cambridge, MA, USA
| | - Vinca Chow
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Patrick T Smith
- Harvard Medical School Center for Bioethics, Boston, MA, USA
- Gordon-Conwell Theological Seminary, S. Hamilton, MA, USA
| | | | | | - Tracy A Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Initiative on Health Religion and Spirituality within Harvard, Boston, MA, USA
| | - Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
- Initiative on Health Religion and Spirituality within Harvard, Boston, MA, USA.
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Wooster M, Stassi A, Hill J, Kurtz J, Bonta M, Spalding MC. End-of-Life Decision-Making for Patients With Geriatric Trauma Cared for in a Trauma Intensive Care Unit. Am J Hosp Palliat Care 2018; 35:1063-1068. [PMID: 29366336 DOI: 10.1177/1049909117752670] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The geriatric trauma population is growing and fraught with poor physiological response to injury and high mortality rates. Our primary hypothesis analyzed how prehospital and in-hospital characteristics affect decision-making regarding continued life support (CLS) versus withdrawal of care (WOC). Our secondary hypothesis analyzed adherence to end-of-life decisions regarding code status, living wills, and advanced directives. MATERIALS AND METHODS We performed a retrospective review of patients with geriatric trauma at a level I and level II trauma center from January 1, 2007, to December 31, 2014. Two hundred seventy-four patients met inclusion criteria with 144 patients undergoing CLS and 130 WOC. RESULTS A total of 13 269 patients with geriatric trauma were analyzed. Insurance type and injury severity score (ISS) were found to be significant predictors of WOC ( P = .013/.045). Withdrawal of care patients had shorter time to palliative consultation and those with geriatrics consultation were 16.1 times more likely to undergo CLS ( P = .026). Twenty-seven (33%) patients who underwent CLS and 31 (24%) patients who underwent WOC had a living will, advanced directive, or DNR order ( P = .93). CONCLUSIONS Of the many hypothesized predictors of WOC, ISS was the only tangible independent predictor of WOC. We observed an apparent disconnect between the patient's wishes via living wills or advanced directives "in a terminal condition" and fulfillment during EOL decision-making that speaks to the complex nature of EOL decisions and further supports the need for a multidisciplinary approach.
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Affiliation(s)
- Meghan Wooster
- 1 Department of Surgery, Indiana University, Indianapolis, IN, USA
| | - Alyssa Stassi
- 2 Department of Surgery, Palmetto Health Richland, Columbia, SC, USA
| | - Joshua Hill
- 3 Department of Surgery, Grant Medical Center, Columbus, OH, USA
| | - James Kurtz
- 4 Heritage College of Osteopathic Medicine, Ohio University, Doctors Hospital, Columbus, OH, USA
| | - Marco Bonta
- 5 Department of Surgery, Riverside Methodist Medical Hospital, Columbus, OH, USA
| | - M Chance Spalding
- 3 Department of Surgery, Grant Medical Center, Columbus, OH, USA
- 4 Heritage College of Osteopathic Medicine, Ohio University, Doctors Hospital, Columbus, OH, USA
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Balboni MJ, Sullivan A, Smith PT, Zaidi D, Mitchell C, Tulsky JA, Sulmasy DP, VanderWeele TJ, Balboni TA. The Views of Clergy Regarding Ethical Controversies in Care at the End of Life. J Pain Symptom Manage 2018; 55:65-74.e9. [PMID: 28818632 PMCID: PMC5735011 DOI: 10.1016/j.jpainsymman.2017.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/19/2017] [Accepted: 05/09/2017] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA.
| | - Adam Sullivan
- Department of Biostatistics, Brown University, Providence, Rhode Island, USA
| | - Patrick T Smith
- Harvard Medical School Center for Bioethics, Boston, Massachusetts, USA
| | - Danish Zaidi
- Harvard Medical School Center for Bioethics, Boston, Massachusetts, USA
| | | | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Tyler J VanderWeele
- Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Departments of Epidemiology and Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; and Brigham and Women's Hospital, Boston, Massachusetts, USA
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Piccoli GB, Sofronie AC, Coindre JP. The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions. BMC Med Ethics 2017; 18:61. [PMID: 29121886 PMCID: PMC5680775 DOI: 10.1186/s12910-017-0219-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/31/2017] [Indexed: 12/16/2022] Open
Abstract
Background Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions. Case presentation Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy). In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”. Conclusions An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy. .,Nephrology, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
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