Psychosomatics 45:119-128, April 2004
© 2004 The Academy of Psychosomatic Medicine
Effects of Religiosity on Patients' Perceptions of Do-Not-Resuscitate Status
Maria A. Sullivan, M.D., PH.D.,
Philip R. Muskin, M.D.,
Shara J. Feldman, B.A., and
Elizabeth Haase, M.D.
Received Nov. 27, 2002; revision received Aug. 1, 2003; accepted Aug. 15, 2003. From New York State Psychiatric Institute, New York City; and the Consultation-Liaison Service, Department of Psychiatry, Columbia Presbyterian Campus of the New York-Presbyterian Hospital. Address reprint requests to Dr. Muskin, Consultation-Liaison Service, Department of Psychiatry, Columbia Presbyterian Campus of the New York-Presbyterian Hospital, New York, NY; prm1{at}columbia.edu (e-mail).
Supported by the K.J. Lee Family Fellowship of the Richard and Hilda Rosenthal Center for Alternative/Complementary Medicine.
The authors thank Robert E. Pollack, Ph.D., and Laura Roberts, M.D., for their comments on this paper.
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ABSTRACT
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Forty-eight oncology inpatients participated in a survey designed to characterize their understanding of and beliefs about do-not-resuscitate (DNR) decisions and to identify dimensions of religiosity associated with moral beliefs about DNR decisions. Seventy-five percent of the patients believed they understood the meaning of "DNR," but only 32% were able to provide an accurate definition. Seventeen percent believed that DNR decisions are morally wrong, and 23% believed that they are equivalent to suicide. Those who lacked an accurate understanding of DNR status were significantly more likely to perceive them as morally wrong. Gender, but not religious denomination, was significantly related to patients' attitudes about the morality of DNR decisions. The belief that DNR decisions are morally wrong was predicted by certain religious practices, including near-daily meditation, near-daily thinking about God, and the current practice of meditation, and by endorsement of the statement, "My faith sometimes restricts my action."
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INTRODUCTION
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The use of the do-not-resuscitate (DNR) order, an explicit intervention to prevent cardiopulmonary resuscitation (CPR), has increased in recent years.1,2 When properly utilized, such a directive clarifies the patient's perspectives on life, death, and medical care. The decision to choose or not to choose DNR status promotes the patient's autonomy and potentially enhances communication between the patient and the health care team. Utilization of DNR orders reduces unwanted life-sustaining treatments.2,3 While the overall use of DNR orders has increased over the past two decades, their use among hospital inpatients is still quite infrequent.4 Only 10%–30% of all hospital inpatients have DNR orders written.5,6 Among patients who are chronically and critically ill, 43% choose DNR orders.7 Only about one-half of patients who do not wish to receive CPR choose DNR orders.8 Persistent disparities in the use of DNR orders on the basis of age, race, gender, and diagnosis have been found.4,5,7–16 Although differences based on religion have received less attention, several studies have indicated associations among DNR status, religiosity, and patients' preferences in medical decision making.2,9,10,11,17
Understanding the sociocultural factors that affect beliefs about DNR status would better enable physicians to guide patients through the course of medical decision making in a manner consistent with their wishes at the end of life. The literature on end-of-life care reveals substantial shortcomings in communication between physicians and patients, particularly with respect to patients' values and preferences. Physicians often dominate discussions about end-of-life care and often fail to provide essential information about resuscitation.18,19 Discussions initiated by physicians concerning patients' religious or spiritual values and goals of care occur in only 10% of cases. 18 In a large-scale, multisite study, only 40% of physicians were aware of patients' preferences with respect to resuscitation.19 Patients whose physicians understand their preference to forgo CPR more often choose DNR orders, choose them earlier, and are significantly less likely to undergo resuscitation.20
In a national survey of dying veterans, patients ranked "coming to peace with God" as second only to pain control in importance at the end of life.21 This ranking was significantly different from that given by physicians (p<0.001). For physicians seeking to practice patient-centered end-of-life care, the need to attend to the spiritual component of patients' illness experiences is clear.22
Most of the literature concerning the informing and decision-making processes involved in DNR planning is reported from the perspective of physicians and nurses. Only a few studies have examined patients' perceptions of DNR status or have explored beliefs about DNR status in the context of patients' religious or spiritual values. On the other hand, the prevalence of religious beliefs and practices among hospital patients is high,23–26 particularly among patients with chronic and life-threatening illnesses.11,25 The literature suggests that patients' preferences regarding medical care are associated with, and are informed by, religious beliefs.3,10,17,27
Most of the major religious denominations of the Judeo-Christian tradition support the withholding of life-sustaining treatment for patients regarded as terminally and irreversibly ill and for whom resuscitation would be considered futile.28 Several studies have found strong positive correlations between both internal and external religiosity and the desire for maximally aggressive, life-sustaining medical care.3,10,17 While the reasons for these preferences have remained largely unexplored, people who are highly religiously observant or fundamentalist tend to have an orientation in which the sanctity of life, rather than the quality of life, becomes the primary determinant of care preferences.10,29 These findings suggest the possibility that religious individuals may decline DNR status or experience significant emotional distress surrounding DNR decisions because of a misunderstanding about what such a decision signifies in terms of their religious beliefs. They may suffer from the perception that DNR orders are morally wrong or perhaps tantamount to suicide. In the study reported here, we attempted to examine patients' perceptions of DNR status and beliefs about the DNR decision-making process in order to identify dimensions of religiosity associated with moral objections to DNR status.
A review of the literature on religiosity among medical patients reveals that 42%–44% of hospital patients report that religious belief is the single most important factor in coping with their illness.30,31 Moreover, the value of religious faith appears to increase among chronically and terminally ill patients.22,32,33 Yates and colleagues24 found a positive correlation between illness severity and the use and value of prayer as a coping mechanism. Prayer was reported as helpful by 80% of patients with advanced cancer. In a study examining the cognitive appraisals of 62 cancer patients, Jenkins and Pargament34 found that greater perception that control rests with God was associated with higher self-esteem and lower behavioral upset than was greater perception of personal control. Patients who coped better with their cancer reported a perception of an active process of engagement with God or that God was working through their lives, rather than a perception of passive submission to an external force. Jenkins and Pargament suggested that religious beliefs offer a schema for explaining ambiguous or life-threatening events.
Consistent with these earlier results, McClain et al.35 recently found that among terminally ill cancer patients, depression was highly correlated with a desire for hastened death in participants with low levels of spiritual well-being (r=0.40, p<0.0001) but not in those with high levels of spiritual well-being (r=0.20, p=0.06). Thus, spiritual well-being was found to offer some protection against end-of-life despair for those facing imminent death. Similarly, Nelson et al.36 reported a strong negative association between scores on the FACIT Spiritual Well-Being Scale and scores on the Hamilton Depression Scale among terminally ill patients with diagnoses of cancer and AIDS. The authors concluded that existential or spirituality-based interventions may offer important clinical benefits for those struggling to cope with a grave illness and prognosis.
To our knowledge, controlled studies have not been conducted to determine what kinds of spirituality-based interventions could effectively support or enhance spiritual well-being in terminally ill patients. A prerequisite to any such interventions, however, is the clinician's ability to assess a patient's religious affiliation and spiritual beliefs. One brief spiritual history instrument, developed by Puchalski,37 includes the following questions: 1) What is your faith or belief? Does religious faith or spirituality play an important part in your life? 2) How does your religious faith or spirituality influence your thoughts about health? 3) Do you consider yourself part of a spiritual or religious community? How is the community a source of support for you? 4) Do you have any religious or spiritual concerns that you'd like me to address with you? Is there someone else you would like to speak with about these matters?
The DNR directive, which represents an important medical care decision for all patients, takes on a special salience for oncology inpatients, many of whom are facing a life-threatening illness. In this preliminary investigation, we sought to explore the influence of oncology patients' religiosity on their perceptions of DNR status. This study begins an exploration of how patients' religious beliefs and values influence their perceptions of resuscitation. The investigation highlights dimensions of patients' understandings of DNR status, as well as common attitudes and beliefs relevant to the DNR decision-making process. Such insights may prove critical to physicians' efforts to engage patients in discussing end-of-life care directives.
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METHOD
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Study Participants
Participants were recruited from the oncology service at New York–Presbyterian Hospital. All participants provided informed consent in accordance with procedures established by the New York–Presbyterian Hospital institutional review board, which approved the study. To be enrolled, patients had to be age 21 years or older and be under treatment by a medical oncologist. Patients were excluded if they had not received follow-up care from an oncologist for their current cancer diagnosis. This provision ensured that patients might have had some time for consideration and discussion of end-of-life issues with a physician. Patients were also excluded if they demonstrated evidence of cognitive impairment as measured by the Mini-Mental State Examination (score <20). An additional exclusion criterion was medical illness that would interfere with the capacity to participate in the study (e.g., acute pain, side effects of chemotherapy). The sociodemographic characteristics of the participants are presented in Table 1.
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TABLE 1. Demographic Characteristics of Oncology Inpatients (N=48) Who Participated in a Survey About Their Understanding of and Beliefs About Do-Not-Resuscitate (DNR) Decisionsa
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Potential subjects were patients admitted to the oncology service from October 1995 through January 1998. Patients who appeared to be eligible for the study were identified by the primary attending physician or by the oncology fellow providing direct care to these patients. Before the investigators had any contact with a particular patient, the physician primarily responsible for the care of the patient spoke with the patient to determine if he or she was interested in speaking with the investigators. Approximately 10% of eligible patients declined to be interviewed. The patients who expressed an interest in participating in the study were then approached by either of two research psychiatrists (M.S. or E.H.) to secure their written consent. In the course of obtaining patients' informed consent, we made every effort to ensure that patients were comfortable in speaking about the proposed topic. We explained that making a DNR decision was not part of the interview process. We explained that the survey would offer patients an opportunity to think about and discuss issues that could prove either anxiety relieving or, in some cases, anxiety provoking. The patients were assured that if, in the course of the interview, they expressed a wish to speak with a psychiatrist for any reason, we would communicate this wish to their primary oncologist and assist in arranging such a consultation. None of the investigators was providing clinical care to oncology service patients at the time of the study. The patients were assured that their participation, or their decision not to participate, would have no effect on their clinical care.
Data Collection
After signing a consent form, enrolled patients completed a self-report questionnaire. This instrument was developed through a process of conferring with established researchers in the study of religiosity. An interdisciplinary committee comprising medical ethicists, oncologists, and psychiatrists met to review the proposed questionnaire. The revised questionnaire was subsequently pilot-tested in interviews with five patients and found to be both feasible to administer and readily acceptable to patients. The interview instrument consisted of 1) a brief demographic survey; 2) the Hoge Intrinsic Religious Motivation Scale,38 a 10-item instrument that addresses depth of belief and is scored on a 4-point Likert-type scale; 3) the Religious Practices and Beliefs Scale developed by Tonigan and Miller,39 which assesses external religiosity; 4) the Geriatric Depression Scale,40 which was developed to avoid the misidentification of medical symptoms as somatic symptoms of depression; 5) the Denial of Illness Scale, adapted from the Havik and Maeland scale for denial of illness41 and scored on a 5-point Likert-type scale; 6) a quality-of-life scale; 7) items on intrinsic recognition/understanding of "DNR" and spontaneous definitions of "DNR"; and 8) a 6-item original instrument addressing beliefs about medical care and DNR status, which was scored on a 6-point Likert-type scale. For the Likert-type scale questions, patients were asked how much they agreed or disagreed with each statement. Responses ranged from strongly agree to strongly disagree. Examples of the items addressing internal religiosity are "In my life I experience the presence of the Divine," and "My faith sometimes restricts my actions." An example of an item addressing denial of illness is "The less you think about your illness, the better." The external religiosity scale recorded the frequency with which patients had engaged in various religious practices ("prayed," "attended religious services," "read or studied holy writings") in the past year, as well as the consistency with which they had continued these practices during their lifetime.
Statistical Analysis
Gender differences in understandings of DNR orders and attitudes toward medical care and DNR decisions were analyzed with t tests. Differences in response patterns between major religious groups represented among the study participants were also examined with t tests.
Differences in internal and external religiosity were examined between the genders and among religious groups with t test analyses. Both internal and external religiosity self-report scales were transformed into dichotomous variables. Chi-square analyses or Mann-Whitney tests (for samples of nonhomogeneous variance) were then conducted to examine the relationship between internal/external religiosity and several individual items concerning attitudes and beliefs about DNR orders.
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RESULTS
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Patient Characteristics
Fifty-two percent (N=25) of the 48 patients who participated in the study were women. The mean age of the entire study group was 55.0 years (SD=14.2, range=26–82). As Table 1 shows, 8% of the subjects were Asian, and the majority (83%) were white. Catholics represented 50% of the subjects, and Protestant and Jewish patients each accounted for about 23% of the subjects. Most patients were married (75%); 17% had never been married. The subjects were highly educated, with 40% having completed some graduate studies and another 21% having completed college. The overrepresentation of white patients in this study precluded data analyses based on stratification by race.
Compared with all patients treated in the same oncology service over the past 3 years, the study subjects did not differ significantly in gender distribution ( 2=0.53, df=1, p=0.47). With respect to the distribution of ethnicity, whites (83.3% versus 56.8%) and Asians (8.3% versus 2.2%) were overrepresented in the study group, relative to the overall population of oncology service patients, and African Americans (4.1% versus 21.4%) and Hispanics (4.1% versus 31.0%) were underrepresented (2=28.14, df=6, p<0.01). The religious affiliation of oncology service patients is not regularly recorded and thus the religious affiliation of the study subjects could not be compared with that of the larger patient population.
Understanding the Meaning of DNR Status
Since DNR decisions represent one important dimension of end-of-life care, we felt it was important to understand whether patients felt confidence and trust in the medical care they were currently receiving. Patients expressed high levels of confidence that their physicians had considered all treatment options in their best interest (mean=5.4 on a 6-point scale, SD=1.0). There were no significant differences between genders or among religious groups on this question. Patients were also asked whether anyone (staff member, family member, or friend) had ever spoken to them about the term "DNR" during the current or a previous hospitalization. Approximately one-half of the subjects (48%) reported that they had discussed the topic of DNR status with someone during a hospitalization.
Participants were asked whether they believed they understood the meaning of the term "do-not-resuscitate (DNR)." Seventy-five percent of the respondents indicated that they believed they could define this term. Participants were then asked to provide, either orally or in written form, a spontaneous definition of the term "do-not-resuscitate/DNR." A definition was judged to be accurate if it contained a description of either cardiac resuscitation (e.g., CPR, defibrillation) or pulmonary resuscitation (i.e., intubation). Responses that contained at least one of these elements were deemed accurate, even if other forms of support (oxygen, nutrition) were also included. Women were more likely than men to report knowing the meaning of DNR (88% of women versus 61% of men; 2=4.70, df=1, p=0.03). However, the genders did not differ significantly in the percentage of subjects who actually provided an accurate definition. Thirty-two percent of patients demonstrated an accurate understanding of DNR, mentioning either cardiac resuscitation or intubation in the event of cardiac or pulmonary arrest. After eliciting patients' own conceptions of DNR status, the interviewer then read to the patient a standard accepted definition of DNR status. This description is contained in patient orientation materials designated for distribution by hospital staff at the time of admission. The standard definition was provided in an effort to ensure that participants were interpreting "DNR" in as similar a manner as possible when answering the subsequent questions.
Preferences for Consulting With Others
Women were significantly more likely than men (2=9.00, df=1, p=0.003) to express the wish to speak with a family member before making a DNR decision. However, men and women did not differ significantly in their wish to speak to a member of the clergy before making such a decision. We also examined the influence of religious identity (Catholic versus Protestant versus Jewish) on the wish to confer with family members or clergy. The religious groups did not differ with respect to their intention to consult a family member; most individuals in each group (63%–74%) wished to do so. When asked if they would wish to speak to a member of their religious community, both Catholic (42%) and Protestant (36%) patients endorsed this item more frequently than did Jewish (27%) patients. This difference did not reach statistical significance.
Patients' self-identified degree of religiosity (ranging from atheist/agnostic/unsure to spiritual/nonpracticing to religious/practicing) predicted differences in one dimension of making a DNR decision. Higher degrees of self-ascribed religiosity were associated with greater likelihood of wishing to speak with a clergy member (2=5.04, df=1, p=0.03). In addition, 69% of those scoring high on the measure of external religiosity (dichotomized total score), compared to 26% of those with lower scores, reported wishing to speak with a member of the clergy before making a DNR decision (2=7.66, df=1, p<0.01).
Moral Dimensions and Religious Influences
Several questions surveyed patients' attitudes toward medical care or DNR decisions. These results are shown in Table 2. No significant differences were found among the major religious traditions (Catholic versus Protestant versus Jewish) with respect to any of the examined attitudes. When patients were asked whether religious beliefs would influence their decision about DNR status, nearly one-half the patients (46%) answered in the affirmative. Of those who scored high on the measure of internal religiosity (computed by using a dichotomized total score), 58% stated that religious beliefs would affect their DNR decision, compared with only 24% of those who scored low on total internal religiosity (2=5.27, df=1, p=0.02).
Patients were asked to what degree they would endorse the statement, "It is morally wrong to choose DNR." A 6-point Likert-type scale was transformed into a binary variable of agree or disagree. The vast majority of respondents (82%) reported that they do not believe that DNR decisions are morally wrong. The proportions of men and women endorsing this statement were not significantly different (p=0.16, Fisher's exact test). Religious affiliation was not a significant variable in response to this statement (2=1.17, df=3, p=0.76). In addition, a higher self-ascribed degree of religiosity was not significantly related to endorsement of DNR decisions as "morally wrong" or as "suicide." It is noteworthy that patients with a high degree of denial about their illness (as measured by dichotomized total scores on the denial of illness scale) were significantly more likely to agree with the statement, "Choosing DNR is equivalent to suicide" (p=0.02, Fisher's exact test).
Mann-Whitney tests (for samples of nonhomogeneous variance) were performed to examine the relationship between patients' understanding of the meaning of the term "DNR" and their beliefs about the moral status of DNR decisions. Those who could not accurately define DNR status were significantly more likely to invoke moral arguments against choosing DNR orders (U=114.0, p<0.01). This finding points to the potentially direct effects of patients' education on end-of-life medical decisions.
Men were significantly more likely than women to agree with the statement, "DNR is equivalent to suicide" (2=6.57, df=1, p=0.01). Catholic and Protestant respondents (21% and 18%, respectively) endorsed, "It is morally wrong to choose DNR" to the same degree that they endorsed, "DNR is equivalent to suicide." While only 9% of Jewish respondents believed DNR decisions to be morally wrong, a substantially greater number (27%) regarded the DNR decision as equivalent to suicide. This finding highlights the complexities of the moral reasoning that individuals bring to bear in considering end-of-life issues. For example, some patients perceive a DNR decision to be equivalent to suicide, yet do not perceive the DNR decision to have a negative moral valence.
External Religiosity and Perceptions of DNR Status
External religiosity refers to both private (e.g., prayer, scripture reading) and public (e.g., service attendance) behaviors associated with religious belief. Chi-square tests were performed to examine the relationship between a composite measure of external religiosity and patients' attitudes and beliefs about medical care and DNR decisions. Past-year external religiosity was found to exert a significant influence on the extent to which individuals agreed with the statement, "My religious beliefs would influence my decision about DNR." Of those scoring high on past-year religiosity, 88% reported that religious beliefs would influence their DNR decisions; by contrast, only 38% of those with lower past-year external religiosity scores felt that their religious beliefs were relevant to a DNR decision (2=5.27, df=1, p=0.02).
Those who had meditated on a daily or near-daily basis in the past year were significantly more likely than those who meditated less frequently to perceive DNR decisions to be morally wrong (U=179.5, p=0.02). Similarly, those who had meditated in the past year, compared to those who had meditated only in the past or never, were more likely to believe that DNR decisions are morally wrong (U=86.5, p=0.02).
We next considered the effects of lifetime history of religious practices (composite measure of external religiosity) on the same set of attitudes and beliefs about medical care and DNR decisions. A higher lifetime external religiosity score was found to predict stronger endorsement of 1) wishing to speak with a member of one's religious community before making a DNR decision (F=16.67, df=1, 46, p<0.001), 2) believing that one's religious beliefs would influence one's decision about DNR status (F=10.64, df=1, 46, p<0.01), 3) believing that DNR decisions are morally wrong (F=7.08, df=1, 46, p=0.01), and 4) believing that DNR decisions are equivalent to suicide (F=4.13, df=1, 46, p=0.05).
Internal Religiosity and Perceptions of DNR Status
Internal religiosity refers to the role that religious beliefs and attitudes play in an individual's perceptions of self and others. Mann-Whitney tests were performed to examine the relationship between internal religiosity and beliefs about medical care and DNR decisions. These results are shown in Table 3. Patients with high levels of internal religiosity, compared to those with low levels of internal religiosity, were more likely to indicate that religious beliefs would affect their DNR decisions. Beliefs about the morality of DNR decisions or their perceived equivalence to suicide were not significantly different for those with high versus low levels of internal religiosity. One item on the internal religiosity scale did show a significant association with the belief that DNR decisions are morally wrong. Those who strongly agreed with the statement, "My faith sometimes restricts my actions," were more likely than all other respondents to agree with the statement, "It is morally wrong to choose DNR" (U=209.5, p=0.04). The relationship between religious belief and the risk of mortality is complex. While church attendance has been associated with a reduced risk of mortality, certain forms of religiousness have been linked to a greater risk of mortality. For instance, specific dimensions of religious struggle (i.e., feeling unloved or abandoned by God or attributing one's illness to the Devil) have been found to be associated with an increased risk of death, after the investigators controlled for baseline health, mental health status, and demographic factors.42
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TABLE 3. Scores on Measure of Internal Religious Beliefs of Oncology Inpatients Who Did and Did Not Believe That the Do-Not-Resuscitate (DNR) Decision Is Equivalent to Suicide
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DISCUSSION
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This study represents an initial exploration of the effect of patients' spiritual beliefs on DNR decisions. Future studies conducted in a larger and more diverse population will be needed to confirm these findings. Ethnic differences in the use of DNR orders have recently become a focus for studies in this field. An earlier investigation suggested that African American patients are more likely to choose CPR and more likely to change a DNR order to preferring CPR.43 Further studies are needed to explore the roles of ethnic and religious background in patients' end-of-life care decisions.
We found that the majority of medical patients were unfamiliar with the meaning of a DNR order. A significant number of the subjects (75%) believed they understood the meaning of DNR status, yet less than one-third of the subjects could give an accurate definition. To our knowledge, no other studies have surveyed patients to determine the frequency with which they are able to offer accurate definitions of DNR status. A related finding, however, has been that a majority of those surveyed in a large group of outpatients (N=728) were unfamiliar with end-of-life care options, such as the right to refuse or withdraw life-saving treatments.44 The discrepancy between patients' confidence in their ability to define DNR status and their demonstrated inability to do so is a striking finding. It is noteworthy that women were more likely than men to believe incorrectly that they understood the meaning of DNR status.
Approximately one-half of the patients in this study had discussed DNR decisions with someone during hospitalization; this finding suggests that physicians and other health care providers need to develop more effective strategies for educating patients about DNR decisions. The Patients' Bill of Rights contained within the New York State Hospital Code requires that patients entering the hospital be provided with information about DNR orders. The data from this study suggest that distributing brochures is not a substitute for a thoughtful discussion between health care providers and patients. A large majority of patients were unable to define DNR status. It is thus essential that physicians offer patients a full opportunity to express their understandings and misunderstandings about DNR directives. Informed consent relies on rational beliefs, and physicians involved in end-of-life care have a responsibility to elicit and clarify misperceptions held by their patients about this critical issue.
A particular focus of this study was consideration of the moral dimensions of DNR decisions. The data demonstrate that patients' spiritual beliefs and religious practices play an important role in end-of-life decisions. In this study, men were more likely than women to believe that the DNR decision is equivalent to suicide. It would be important to learn if this gender difference results in men being more likely to refuse to sign a DNR form. It is also possible that individuals espousing this view would sign a DNR form but would experience psychological conflict related to concerns about the moral implications of their decision. At the request of the oncology service physicians, we were not permitted to ask patients if they would consent to sign a DNR form. This limitation points to the difficulty many physicians still have in discussing end-of-life decisions.
An important and unexpected finding was that the practice of meditation is significantly associated with the belief that DNR decisions are morally wrong. We found that near-daily meditation, as well as any current practice of meditating, is strongly linked to the belief that DNR decisions are morally wrong. This finding suggests that a simple inquiry by physicians about patients' meditation practices might serve as a useful screening tool to identify patients who are likely to experience moral conflicts about DNR orders. Such patients would clearly benefit from an opportunity to explore their concerns with their physician and, in some cases, with a chaplain or other representative of their religious community.
We found that the patients who were least knowledgeable about their religious traditions were also the least likely to consult a clergy member. This finding predicts a bimodal distribution of patient knowledge, with persons who were least informed religiously also being least likely to be informed by others about what is at stake with a DNR choice. Since physicians are not providing this information in the majority of cases, the second source of information would likely be one's own religious knowledge, either held in advance or learned in the hospital from clergy.
Conflicts about treatment usually result from an inadequate understanding of the frame of reference in which the patient is making medical decisions. This investigation highlights the salience of patients' moral and religious beliefs in their decisions about DNR orders. We speculated that a substantial percentage of the patients we surveyed would refuse to sign a DNR form because they believe it to be morally wrong and/or the equivalent of suicide. Our data reveal that Christian patients were twice as likely as Jewish patients to consider DNR decisions morally wrong. Such differences in perspective between religious groups may also animate the encounter between physician and patient. When a physician addresses the subject of DNR with a patient, this clinical encounter should include inquiry about the patient's religious beliefs. Obtaining information about the patient's spiritual background is an important but often overlooked component of the history. Neglecting to obtain this information may limit how a patient will respond to the physician's introduction of the topic of signing a DNR form. During discussions with patients about DNR wishes, it would be useful for physicians to point out that the DNR procedure does not actively end life, as does the act of suicide. Rather, DNR status reflects the recognition that resuming basic physiological processes may not restore any meaningful quality of life. Patients should be offered a realistic view of CPR and its consequences.45 Attention should be given to the individual's educational, ethnic, and religious background to ensure that he or she has the opportunity to render an effective and meaning-centered autonomous decision.
In cases in which an initial discussion of the DNR decision reveals that the patient has particular moral or religious concerns, the physician should consider including a hospital chaplain or outside member of the clergy in the treatment team. This inclusion is not an endorsement of religion, but it is an affirmation of the patient's beliefs and of what is important to him or her.45 In a previous study involving medically ill elderly patients, religious struggle with an illness was found to predict an increased risk of mortality.42 A useful model for the role of the clergy in such clinical settings may be that of a religious "interpreter" who would serve several important functions, including 1) convincing the physician of the validity of strongly held religious beliefs that merit consideration, 2) dissuading patients from requests if the faith community believes that the requests are incorrect, and 3) counseling patients when the doctrines in question may be flexible or may be understood differently.27
This study had several limitations. First, the number of subjects was small, and the study group was ethnically unbalanced. In particular, whites and Asians were overrepresented, relative to the larger hospital population, while African Americans and Hispanics were underrepresented. Further research should be conducted to focus on these issues in a larger and more diverse population. Future investigations are needed to explore the role of ethnic and cultural differences in interpretations of DNR status. It would be informative to explore the influence of such factors on attitudes toward DNR decisions among both patients and physicians. For instance, we might expect that physicians who are more religious would be more likely to discuss with their patients the spiritual dimensions of making a DNR decision, but no data yet exist to confirm this hypothesis. Second, we did not know whether the patients surveyed would actually consent to sign a DNR form, as this study did not include provisions for directly obtaining consent for DNR. This research, however, represents one of only a small number of studies that have investigated the influence of religious beliefs and practices on end-of-life decisions. This work provides some early guidelines for the provision of clinical care to critically ill patients and suggests directions for future investigations.
It is important to note that the subjects in this study did not constitute a random sample. White patients were overrepresented, as were those with a college or higher level of education. The limitations on our sampling frame derived from difficulty in securing the permission of attending oncologists for their patients to participate in this survey. A number of staff oncologists expressed the fear that exploring attitudes toward DNR decisions would prove anxiety provoking for their patients. Since this study was intended as a preliminary exploration of an important aspect of DNR decision making, we elected to proceed with the research with the patients who were available. While the generalizability of the findings awaits confirmation from larger studies involving randomly selected patient groups, we believe that these data offer insights into the possible influences of patients' spiritual beliefs on their end-of-life care decisions.
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