Journal of Hospice & Palliative Medical Care Category: Medical Type: Review Article

Catholics and Hospice Choice

Alan Turley1*
1 Austin community college, 5930 Middle Fiskville Rd. Austin, Texas, United states

*Corresponding Author(s):
Alan Turley
Austin Community College, 5930 Middle Fiskville Rd. Austin, Texas, United States
Tel:+ 512-223-7000,
Email:alan_turley@yahoo.com

Received Date: Oct 19, 2022
Accepted Date: Oct 31, 2022
Published Date: Nov 07, 2022
DOI:

Abstract

A database from a large hospice provider with offices in 16 states will be used to examine the impact of religious preference, specifically Catholics, on hospice choice. Little work has been done on this issue, even though religion is the only social institution that specifically addresses the end of life. Hospice work, in particular, has drawn little attention despite it effecting millions of patients and their families. Of all the medical sub specialties, hospice is one of the most effected by society’s views on death and religious views of dying.  It is also the only government funded medical service that requires religious support be made available to patients. Our hypothesis is that Catholics have a predisposition against hospice and will be less likely to utilize hospice. This impacts a multi-billion dollar a year industry that supplies hospice service to millions of patients, and our research points to one major religious group not accessing their hospice benefit at the same rate as other denominations.

Religious Preference and Hospice Choice

Emile Durkheim’s (1897) work on suicide and religion, in which the larger known population is compared to specific groups to determine the impact of religious identity on certain end of life choices is where we begin our examination [1]. Durkheim found evidence that religious identity affects the choice to commit suicide in Germany, with Catholics committing fewer suicides than Protestants.This paper will attempt to determine the impact of one religion on the utilization of hospice during the end of life [2]. Our hypothesis is that certain religious groups, specifically Catholics, utilize hospice less often. The theoretical reasons for this prediction lie in Catholics believing that hospice means “not doing anything” or “hastening death” for the patient and would be against the groups’ Pro-Life theology (a dogmatic stance that includes opposition to abortion service availability and the death penalty.

Background

How does religious identity affect people's choices? In his groundbreaking study done over a century ago, Emile Durkheim [1] found that being Catholic or Protestant affected whether one would be more likely to commit suicide.  Using detailed data from provinces known to be Catholic or Protestant, he compared people from equal backgrounds and similar areas of the country, which left religious identification as the only major discrepancy between the groups. Catholic dogma against suicide condemns it as a deadly sin, while Protestants do not have any special theological reservations about suicide; thus making Protestants more prone to choose it. Theorists today have looked at hospice and religious choice and found that religion still plays an important role in our life [2]. ound that religion is one of the factors effecting hospice choice in their study of 248 patients in Korea.  In 2014, Richardson found that 68% of her 230 patients described religion as very important in their choice of support at the time of diagnosis/hospice decision, with 89% of African Americans listing religion as very important. Modern religious thought has progressed some, since Durkheim’s era, but many religious groups in America have remained very dogmatic on certain issues like abortion and the death penalty. Referred to as Pro-Life, these groups advocate for eliminating abortion service and the death penalty. Their reasoning is that life is sacred and only God can take life. Although Hospice does nothing to hasten death, it does cease aggressive treatments for the patient that are no longer useful, in favor of palliative care and pain care.  Often this course of treatment will include a “Do Not Resuscitate Order;” this allows the cessation of aggressive treatment and attempts to resuscitate the patient, thus allowing natural death to occur.  For some people this may look like giving up on the life of the patient, and those that are Pro-Life may have difficulty with this perspective. Officially, no denomination has a theological stance against hospice care, but common or folk beliefs can be just as powerful as official dogma; and therefore we often find people who feel that hospice is against their religious beliefs (according to their understanding of them).  Ironically, some of the first hospices were started by Irish Catholic nuns , yet many Roman Catholics still feel hospice is an anti-Catholic idea [3]. 

What is hospice?  Many people only know a little bit about what hospice entails. There are two parts to answering this question, one is a quick history and the other is a shortened version of how hospice is done today.  Let’s start with the diagnosis; if a patient has been diagnosed with an illness in which the average patient may die within 6 months, and there are no further medical treatment options to cure the disease, then they are referred for a hospice evaluation.  If they are deemed eligible, then the medical focus and treatment plan shifts from aggressive treatment of a disease and moves to diminishing the symptoms and discomfort of the disease. So, often treatments like chemo-therapy and radiation are discontinued, certain medications that have no benefit in symptom management are removed, and the patient themselves may elect to discontinue other services like breathing treatments that may prolong life, but are uncomfortable.  Hospice care as we understand it today, has only been around for a couple hundred years, when patients were sent home to die with no further medical follow up if they had a condition that medical science could not cure at the time.  Slowly, this field has become more informed and includes aggressive pain management, spiritual, psycho-social and even financial health of the patient and their family. Health care and its various funding sources have come on board with hospice as it reduces the trips to emergency rooms that clog services and don’t benefit the patient.  Most terminally ill patients don’t find out about hospice eligibility till it is very advanced in their disease process; this is unfortunate, as it is part of the Medicare benefit that patients can utilize without charge. Also unfortunate is the lack of help religious leaders today feel that they can offer a dying patient at this crucial moment, because they are not sufficiently trained in hospice awareness [4]. What makes hospice different than traditional medicine?  The treatment focus is the main difference, as hospice treats the symptoms, instead of the disease.  When someone gets a life limiting diagnosis they are referred for a hospice evaluation. This is done by a hospice company to see if the patient qualifies.  If they do, then the Medicare hospice benefit becomes their payor usually, and directs the future treatment. Many treatments and medications designed to attack a disease are often discontinued like dialysis, radiation, and chemotherapy. The reason being that they are no longer effective and often have very uncomfortable or even painful side effects.There is also a change in the driving approach of the treatment; before a medical doctor made all the decisions, now a team, composed of a doctor, nurse, volunteer coordinator, social worker, certified nursing assistant, and chaplain, collaborates with the family and /patient about their care. To be considered a hospice, according to Medicare guidelines, a company must offer all these services to the patient.  This team approach and the mandatory inclusion of a religious/spiritual professional is the only area in medicine where public funds, in the form of Medicare/Medicaid, pay for religious support.

Theory

There have been several studies that have successfully linked religious involvement to health indicators that show a positive correlation between religious and spiritual participation and positive health outcomes. Reductions in high blood pressure, anxiety, and stress have all been associated with religious involvement [5, 6]. From this we can glean that religion is not just in one's head, rather, it seems to help across a measurable spectrum of health outcomes. In our case, we are trying to determine the impact of religion on decision-making, and again, Durkheim’s study points us in a definitive direction - that religion does color one’s opinions and decisions regarding certain issues. All religious viewpoints on death are ultimately tied to viewpoints on life and the sanctity of life. Examining how religions deal with an end of life issue, like abortion, can illustrate how diverse the opinions are between religious groups. For instance, Buddhists believe, according to the 14th Dalai Lama (Dreifus, 1983), abortion is an act of killing generally speaking, but it depends on the circumstances of an abortion.  If a pregnancy will cause serious health problems for the parent, then exceptions can be made.  Hinduism, as interpreted by Mohandas Gandhi (1929), may consider abortion as always being a criminal act, as it is the taking of a life (and life is sacred). Islam is more complicated on this issue of abortion.  There's a school of thought that abortions are permitted if the mother's life is in danger.  However, there's another school of thought, which stipulates that at the end of the third period of development (at four months), the human body is filled with the soul or spirit, and at that point abortion is absolutely forbidden. 

The Southern Baptist Convention Churches, Church of Jesus Christ of Latter-Day Saints and Assembly of God all oppose elective abortion. These churches also feel that there are few, if any, exceptions to this stance; some oppose abortion even in cases of rape, incest, or danger to the mother’s health. These views would be considered Pro-Life with the no exceptions stance being an extreme of that view. The perceived timeline of when life begins according to the above mentioned religious groups seem to be associated with extreme views on the sanctity of life and the steps needed to preserve life. The earlier life is believed to begin, the more extreme the views, in general a religious sect has towards abortion. For example, if a group believes that life begins at conception, then they are more likely to believe that there are few exceptions to their anti-abortion view. This is where the application of Pro-Life terminology is usually similar between denominations.  The end of life seems to be where specific denominations part ways on what is Pro-Life; with Catholics tending to extend this thinking to end of life issues and Conservative Protestants being less likely to do so. For end of life issues, Catholics tend to favor expending all medical remedies to prolong life. Protestants tend to believe in “natural death,” one unencumbered by medicine or human interference. These varying beliefs concerning abortion and end of life issues contribute to difficulties encountered in the hospice field. Hospice is then further complicated by the view on what qualifies as what qualifies as “allowing natuaral death,” denying care, or euthanasia [2]. For example, the Roman Catholic Church in the US Conference of Catholic Bishops (2012), believe that palliative and psychological care should be increased at the end of life, not decreased, as to honor the life of the patient.  In addition, there is also the moral option to refuse extraordinary treatment; at this point, the question becomes “Does the treatment have a reasonable chance of benefiting the individual?” However, foregoing feeding or the removal of life support is not acceptable under Catholic dogma.Yet, the Mormon Church feels that allowing natural causes, including the foregoing of extraordinary therapy and the removal of life support, does not fall into the definition of euthanasia (2016).  Many Conservative Protestants, who would characterize themselves as being Pro-Life, feel that at the end of life allowing “nature” or God to take over in place of medicine is not contradictory to their Pro-Life stance. The Conservative Protestants’ support for the death penalty is more difficult to understand, as well, because it does not seem to follow any philosophical course from Pro-Life.  In this case, the sanctity of life seems to hinge on the level of perceived sin in the individual, with infants having none and adults having some.  These issues concerning life, death, and mortality have to be dealt with during a loved one’s hospice journey [7, 8].

Pilot Data

Our pilot data comes from a large hospice organization with over 50 offices nationwide and from the survey of religious preferences done in 2013.  A specific area of the country (Nebraska) was chosen to do this pilot study, due to the comprehensive level of hospice data available for this area from the organization.  The hospice data collected includes religious preference given to the hospice team by the patient themselves on admission to hospice service. The religious preference phone survey was conducted by a different organization with 1000 respondents in Nebraska in 2013, and they asked for the respondents’ religious affiliation in that interview. A Pew Survey of 35,000 US adults (2008) regarding views on abortion listed several groups as progressive or conservative [9]. We labeled the groups in our study accordingly, with Presbyterian Church (1.1 million members) listed as progressive Mainline Protestant, Methodist Church (5.1 million members) listed as progressive or Mainline Protestant, Lutheran Church Missouri Synod (1.4 million members) listed as conservative, Catholic Church (23.9 million members) listed as conservative, Southern Baptist Convention (6.7 million members) listed as conservative, and the Assembly of God (1.4 million members) listed as conservative. A pool estimate was used for the population standard deviation and a z-score was computed to construct the critical value that was tested. Since the samples were both quite large and were used as percentage values, this test makes the most sense. 

A Pew Survey of 35,000 US adults (2008) regarding views on abortion listed several groups as progressive or conservative [10].  We labeled the groups in our study accordingly, with Presbyterian Church (1.1 million members) listed as progressive Mainline Protestant, Methodist Church (5.1 million members) listed as progressive or Mainline Protestant, Lutheran Church Missouri Synod (1.4 million members) listed as conservative, Catholic Church (23.9 million members) listed as conservative, Southern Baptist Convention (6.7 million members) listed as conservative, and the Assembly of God (1.4 million members) listed as conservative. A pool estimate was used for the population standard deviation and a z-score was computed to construct the critical value that was tested. Since the samples were both quite large and were used as percentage values, this test makes the most sense. A special note on the issue of Lutheran denominational membership, the ECLA Lutheran Church is coded for our study as a progressive or mainline Protestant church, while the Lutheran Church - Missouri Synod is listed as a Conservative Protestant denomination, due to their very strong dogmatic stances on biblical interpretation, religious activity, and Pro-Life beliefs.  This is consistent with the Pew Study’s classification of denominations. The findings in (table1) are illuminating; as one can see the mainline Protestant religions were found to have more hospice participation than Conservative Protestant Christians, but there was not a statistically significant lack of Conservative Protestant hospice participation. Consistent with our hypothesis, we find that Catholics select hospice service far less often than their population percentage in Nebraska would predict.  This seems fairly constant in smaller pilot data searches in other states, where Catholics aredo not accessing hospice services.  Again, this seems primarily based on the myth that hospice either hastens death, or that somehow choosing hospice equates to “giving up” on your loved ones.  Our last category is “Other Christian” denominations, and here we find their participation to be as predicted was not found to be statistically significant for hospice selection. What could be making mainline Protestants choose hospice so consistently, since this is not the a large group of denominations declaring a religious affiliation in Nebraska? One would have to assume that since no theological or ideological reason for not using hospice can be found in any mainline doctrine/belief system, they have no prohibition to choosing hospice. 

 

Percentage of Hospice Users

Percentage in NE Population*

Z score Statistically Significant

Mainline Prot

42.6%

19%

Yes

Conserv Prot

24.3%

21%

NO

Other Christian

19.2%

21%

NO

Catholic

13.9%

28%

Yes

Table 1 Pilot Study  According to 2013 Phone survey and 10% reporting no religious affiliation. 

A special note on the issue of Lutheran denominational membership, the ECLA Lutheran Church is coded for our study as a progressive or mainline Protestant church, while the Lutheran Church - Missouri Synod is listed as a Conservative Protestant denomination, due to their very strong dogmatic stances on biblical interpretation, religious activity, and Pro-Life beliefs. This is consistent with the Pew Study’s classification of denominations. The findings in (table 1) are illuminating; as one can see the mainline Protestant religions were found to have more hospice participation than Conservative Protestant Christians, but there was not a statistically significant lack of Conservative Protestant hospice participation. Consistent with our hypothesis, we find that Catholics select hospice service far less often than their population percentage in Nebraska would predict.  This seems fairly constant in smaller pilot data searches in other states, where Catholics aredo not accessing hospice services. Again, this seems primarily based on the myth that hospice either hastens death, or that somehow choosing hospice equates to “giving up” on your loved ones. Our last category is “Other Christian” denominations, and here we find their participation to be as predicted was not found to be statistically significant for hospice selection. What could be making mainline Protestants choose hospice so consistently, since this is not the a large group of denominations declaring a religious affiliation in Nebraska? One would have to assume that since no theological or ideological reason for not using hospice can be found in any mainline doctrine/belief system, they have no prohibition to choosing hospice.

Discussion

As we can see in (table 2.1 & 2.2) from our larger survey of 16 states and 8,600 respondents in 2014, Catholics are underrepresented as hospice patients in almost every state; including a few Southern states, where their numbers are dramatically smaller. [10] This is consistent with our hypothesis. When examining official Catholic doctrine on this issue though, there should be no conflict with choice in hospice service, yet many families may feel the need to try ever more aggressive treatment (even with slim chances of the treatment’s success).  Their understanding of Catholic dogma and faith translates to trying absolutely everything medically possible (even long shots), before allowing natural death to occur. 

 

Protestant

Conservative Protestant

Catholic

Orthodox

Other

Total

Alabama

128

232

43

0

116

519

California

192

71

140

3

241

647

Georgia

29

16

50

2

23

120

Indiana

125

130

76

2

145

478

Massachusetts

50

21

82

1

57

211

Minnesota

11

21

23

0

10

65

Mississippi

34

34

13

0

33

114

Nebraska

565

238

247

6

410

1,466

North Carolina

62

117

12

0

76

267

Ohio

63

53

54

2

39

211

Pennsylvania

639

352

401

12

485

1,889

South Dakota

7

36

2

0

15

60

Tennessee

195

137

48

0

70

450

Texas

46

70

29

0

36

181

Virginia

27

53

8

0

33

121

Wisconsin

46

29

17

0

12

104

X

648

645

14

3

466

1,776

Total

2,444

1,835

1,259

31

2,267

8,679

Table 2.1 Patients Religious Preference in this Hospice Organization. 

 However, Conservative Protestants appear to be adequately represented in hospice participation. What could be the difference between Catholics and Conservative Protestants, who are seemingly on the same page with regards to Pro-Life? The difference could be an Evangelical and Conservative Pprotestant belief in natural death; allowing the “higher power” to take a patient without human intervention at the end. This view seems to be more consistent with Conservative Protestant Pro-Life belief than with the Catholic Pro-Life belief.  It appears that many Catholics interpret their role in the patient’s life/death as more of an intervention in the possibility of dying, rather than accepting death as a natural outcome of living; and their view is that the faith calls them to do everything to stave off passing on. A chi-square test was performed on the data from 16 states and the results are in (table 2.2) A statistical significance was found in the data with some of the more significant discrepancies between predicted and observed outcomes represented in the column of Catholic participation. One can see a similar discrepancy in the table 2. 1 of percentages between state Catholic participation and in hospice Catholic participation.  Our initial interpretation was that these are regional differences, but the results cannot be attributed to only regional differences.  When we examine Massachusetts, for example, (whose general rate for Roman Catholic affiliation is 44% we find less than 24% of hospice choice being made by Catholics. This is a dramatic difference and can only be attributed to religious affiliation, as regional and class differences seem to be equally accounted for amongst the denominations; a caveat being that Urban Irish Catholics are more likely to be working class [11-13]. When we apply the Chi-square test to these results, we find statistically significant differences in all but three (The Association of Religious Data Archives 2013) of the 16 cells for Roman Catholic affiliation [14]. 

 

Protestat

Conservative Protestant

Catholic

State’s Avg Catholic

Orthodox

Other

Total

Alabama

23.77%

44.67%

8.28%

6%

0%

22.35%

100%

California

29.67%

10.97%

21.63%

37%

.4%

37.24%

100%

Georgia

24.16%

10.83%

41.66%

13%

1.6%

19.16%

100%

Indiana

26.15%

27.19%

15.89%

20%

.4%

30.33%

100%

Massachusetts

23.69%

9.95%

38.86%

44%

.2%

27.61%

100%

Minnesota

16.92%

32.30%

35.38%

25%

0

15.38%

100%

Mississippi

29.82%

29.82%

11.40%

7%

0

28.94%

100%

Nebraska

38.54%

16.23%

16.84%

28%

.4%

27.99%

100%

North Carolina

23.22%

43.82%

4.49%

10%

0

28.46%

100%

Ohio

29.85%

25.11%

25.59%

24%

.9%

18.48%

100%

Pennsylvania

33.82%

18.63%

21.22%

29%

.6%

25.67%

100%

South Dakota

11.66%

60.00%

3.33%

25%

0

25.00%

100%

Tennessee

43.33%

30.44%

10.66%

9%

0

15.55%

100%

Texas

25.41%

38.67%

16.02%

32%

0

19.88%

100%

Virginia

22.31%

43.80%

6.61%

14%

0

27.27%

100%

Wisconsin

44.23%

27.88%

16.34%

29%

0

11.53%

100%

X

36.48%

36.31%

.78%

NA

.16%

26.23%

100%

Total

32.71%

25.70%

14.51%

24% NATL

3.57%

26.12%

100%

Table 2.2 16 State Religious Preference in this Hospice Organization these are the percentages above the state average.

Conclusion

In conclusion, the data gained from the hospice offices in these 16 states compared to the data from the religious preference phone survey shows that hospice selection does vary depending on religious preference.  This would likely be predicted by social scientists [15], whose work clearly demonstrates the impact of group identification and religious preference on personal choices. Principle among those differences is the lack of participation by Catholics nationally in hospice choices. Further study is needed to identify all of the factors that may be contributing to this lack of hospice participation. For palliative medicine and hospice, reaching patients that vary in their religious identification is definitely needed by a more aggressive campaign to eliminate the myths surrounding hospice service for parishioners, clergy and even some doctors.

References

  1. Durkheim É (1951) Suicide: A study in sociology. New York.
  2. Park C, Lee J, Juyoung M (2012) Choice intention regarding hospice care based on the theory of reasoned action. J of Hospice and Palliative Nurs 14: 34-44.
  3. Roman Catholic Church and the US Conference of Catholic Bishops (2012) Assisted suicide and euthanasia beyond terminal illness.
  4. Euthanasia and Prolonging Life. 2018 February 27.
  5. Garrett M (2013 July 26) Hospice and religion at the end of life.
  6. Hummer RA, Rogers RG, Ellison CG, Nam CB (1999) Religious involvement and US adult mortality. Demography 36: 273-285.
  7. Idler AL, Kasl SV (1992) Religion, disability, depression, and the timing of death. American J of Socio 97: 1052-1079.
  8. McCullough ME, Hoyt WT, Larson DB, Koenig HG, Thoresen C (2000) Religious involvement and mortality: A meta-analytic review. Health Psychol 19: 211-222.
  9. Musick MA, House JS, Williams DR (2004) Attendance at religious services and mortality in a national sample. J of Health and Soc Behav 2: 198-213.
  10. Richardson P (2014) Spirituality, religion and palliative care. Ann of Palliat Med 3: 150-159.
  11. Pew Forum on Religious and Public Life (2008) US religious landscape survey.
  12. Pew Forum on Religious and Public Life (2015) US religious landscape survey: Boston metro area. November 2016.
  13. The Association of Religious Data Archives (2013) The membership report for 2013.
  14. United States Census, (2015) Quick facts.
  15. Weber M (1921) The protestant ethic and the spirit of capitalism in America. Free Press: New York, NY.

Citation: Alan Turley (2022) Catholics and Hospice Choice. J Hosp Palliat Med Care 4: 016.

Copyright: © 2022  Alan Turley, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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