Religion and end-of-life decisions in critical care: where the word meets deed.

‘‘Inhisthoughtsandhisattributes,mankindatlargeiscontrolled by inherited beliefs and impulses, whichcountless thousands of years have ingrained likeinstinct.…indays ofillness many millions…stillseektheir gods rather than the physicians.’’Sir William Osler [1].The 19th and 20th centuries saw a scientiﬁc revolutionand the establishment of ‘modern medicine.’ The explo-sion in medical knowledge, therapies, and technologies islargely attributable to increased focus on the scientiﬁcmethod and empirically demonstrable outcomes. In the21st century many clinicians consider the use of evidence-based medicine synonymous with good clinical care.However, as the report from Bu¨low and colleaguesreminds us [2], the human condition is complex and noteasily reduced to mere empiric decision-making. This isparticularly true in the context of life-altering decisionsabout end-of-life care or value laden concepts such aspatient autonomy, both of which the authors explore [2].Bu¨low et al. build on the original ETHICATT study bySprung and colleagues [3] and add greater granularity tothe complex topic of end-of-life decision-making byexploring differences between doctors, nurses, patients,and families self-reporting they are ‘religious’ as opposedto simply ‘afﬁliated’ with a religion. One of the mainﬁndings is that, in general, religious individuals favormore aggressive treatment than religion-afﬁliated indi-viduals. These self-reported preferences are congruentwith actual treatments received among patients dying inEuropean intensive care units (ICUs) [4]. These obser-vations may be partially attributable to religious doctrineviewing life as having paramount value, a commonly heldview in most religions, yet there is probably greatercomplexity to the picture. For example, Phelps and col-leagues [5] characterized the use of religious-basedcoping among a cohort of U.S. patients with advancedcancer and found that greater use of religious coping wassigniﬁcantly associated with increased use of ICU thera-pies prior to death [5]. This was not contingent on aspeciﬁc religion per se but upon the use of a faith-basedpsychological coping framework. Our group [6] foundthat more religious ICU patients and families reportedmore optimistic perceptions of outcomes of the criticalillness, including greater conﬁdence in treatment efﬁcacy.Such optimism regarding favorable ICU outcomes mayguide preferences for more aggressive ICU therapies.Finally, being active in a religious community is oftenassociated with social and emotional support during timesof illness [7], which may have inﬂuences beyond those ofindividual patients’ and families’ religious values. Thus,the mechanisms by which religion impacts preferences forand receipt of more aggressive ICU care is likely com-plicated and merits further investigation.The importance of religion to many patients and fam-ilies confronted with end-of-life decisions is irrefutable.Depending on the speciﬁc respondent population, any-where from 53 to 90 % of patients view religion asimportant in making serious health decisions [8, 9], andBu¨low et al. [2] found that 60 % of ICU patients andfamilies categorize themselves as religious rather thanreligion-afﬁliated. Other reports highlight the importance