Late this afternoon, I happened to be sitting in my office perusing the websites for the latest batch of surgical journals, trying desperately to catch up on my reading, something that I, like most academic surgeons, am chronically behind in, when I happened upon the website of the Archives of Surgery. There, the lead article caught my eye, and I downloaded it for later reading. Then, as I perused a few news sites (yes, I was procrastinating; but who doesn’t procrastinate from time to time?), and I came across a story about this very study:
CHICAGO - When it comes to saving lives, God trumps doctors for many Americans.
An eye-opening survey reveals widespread belief that divine intervention can revive dying patients. And, researchers said, doctors “need to be prepared to deal with families who are waiting for a miracle.”
More than half of randomly surveyed adults — 57 percent — said God’s intervention could save a family member even if physicians declared treatment would be futile. And nearly three-quarters said patients have a right to demand such treatment.
My first reaction was: Tell me something I didn’t know. Dealing with such situations, especially the ethics of dealing with situations in which science tells us that treatment is futile but the family demands futile care is among the most difficult task physicians will face. My second reaction was that it was rather jarring to see this so starkly placed in print. I also realized, upon going back to read the actual study, entitled Trauma Death: Views of the Public and Trauma Professionals on Death and Dying From Injuries and coming out of the University of Connecticut (I figure I owe the institution one, given how I trashed a study coming from there yesterday) that there was far more to the study than what was reported in the news report, which focused almost exclusively on the belief among the public that divine intervention could reverse a terminal injury and result in recovery. Although a major result, when taken as a whole, the study tells us a lot more than just that many Americans have religious beliefs that lead them to hope that God will produce miraculous recoveries for their family members from fatal injuries.
The first thing that has to be recognized is that this survey was primarily about trauma and end-of-life care in the post-injury situation. This is a bit of a different beast than end-of-life care in other fields. The reason, of course, is that trauma is sudden. Patients are injured suddenly, rushed to an emergency room, and then treated by strangers with whom neither the patients nor families have a preexisting relationship. Contrast this to, for example, my specialty of cancer care, where in most cases the realization that a patient’s tumor has progressed to the point where further attempts at curative therapy or even life-prolonging therapy are futile generally does not occur in such a rapid sequence. There is usually time for the patient and family to develop a rapport and some mutual trust with their doctors, nurses, and other health care professionals. True, there are occasional situations where a patient arrives at the emergency room in extremis from a previously undiagnosed advanced cancer and the patient and family have to be told that there is nothing that can be done to save the patient’s life, but such cases are pretty uncommon.
So what did the survey show? Several things, actually, and I’ll briefly discuss the major findings of the study. In some cases, the responses to the questions were recorded for both the general public and for health care professionals, and the differences in responses between the two groups are part of what’s revealing about this study. One thing that was interesting was that between 46-47% of both the public and health care professionals reported receiving emergency medical care in the last 10 years, a category into which I’ve fallen, actually–although just barely (it was over 9 years ago). In addition over 12% of both groups had had a close friend or family member die as a result of serious trauma, which just goes to show how ubiquitous traumatic injury is in our society, thanks mostly to the ever present automobile. In these aspects, there really was no difference between health care professionals and the general population.
The first scenario was how to deal with a traumatic death at the scene in the prehospital environment. 50.1% of respondents prefer that a loved one fatally injured in an accident be taken to a hospital, with their reasons being evenly divided between hoping that further treatment can be done and feeling more comfortable at a hospital. This result does not surprise me in the least. In fact, during my days as a flight physician on a helicopter rescue service, there were at least a couple of times where we kept doing CPR and making efforts at resuscitation, even going so far as to fly the patient back to our home hospital or the nearest major medical center even though we knew the patient had been down too long to have any realistic chance of every being revived. One situation in particular I still recall involved a child who had drowned in Lake Erie near Put-in-Bay. To me it was immediately apparent that the unfortunate child had clearly been down far too long to have any hope of being resuscitated, but we continued CPR anyway. Those situations, when they happened, made me feel acutely uncomfortable, and after the Put-in-Bay incident I expressed that to the nurses and pilots (most of whom were far more experienced than I at this), asking why I as the physician in charge couldn’t have just called the code on the scene. (Indeed, to this day I sometimes think about that child. This incident happened around 16 or 17 years ago, and he would now be college age if he had survived.) The answer was that we were doing this as much for the families and referring paramedics, the feeling being that we should not overrule the original decision to begin CPR and should give the on-site rescue team the benefit of the doubt. Also, if we were to come flying onto the scene in our big fancy helicopter and then call the code over, it was thought, it might seriously demoralize the rescue workers, and it would certainly devastate families, friends, and random onlookers. At the time, I could sort of see the rationale, but I also thought it to be incredibly demoralizing to myself, the nurse, and the rest of the flight crew to have to go through the motions even in hopeless cases like that. On the other hand, I also understood in drowning cases the maxim that the patient isn’t dead until he’s “warm and dead,” realizing that hypothermia can be protective of the brain to a sufficient degree that on occasion revival is possible. What I didn’t understand was why we sometimes did the same thing in non-drowning injuries.
My point, I guess, is that in the field we frequently do things and take victims to the hospital as though there is hope even when we as trained health care professionals know there is almost certainly none, and we not infrequently do it more for emotional than rational, science-based reasons. There are also legal reasons, because sometimes autopsies will be required, but even in such cases there is no science-based reason why the victim couldn’t be taken straight to the morgue after having been declared dead in the field.
In contrast, health care professionals were much more willing to let a fatally injured loved one be taken somewhere other than a hospital, with only 13.6% being willing to allow the victim to be taken elsewhere as compared to only 1.7% of non-professionals. Moreover, only 13.4% of professionals would insist on having their loved one taken to a hospital because they thought something might be done, which most likely reflects a more realistic view of the situation. One interesting question asked was: “If there were an alternative facility with religious and counseling services, which would you prefer?” 63.4% of health care professionals would prefer that alternative service while only 29.4% of the general public would. Again, this likely reflects a more realistic understanding among health care professionals.
The second major finding was that 52% of the general public and 62.7% of professionals would prefer to be present in the emergency room during resuscitation. I must admit that this is a tough one for me. If the victim were a child, the numbers increase to 79% and 78.7%, respectively. I have to admit that this is a tough issue for me. Back when I used to cover trauma, I thought that the presence of family in the trauma room was very distracting to me in my desire to do my utmost to save the life of the patient, and I feared that the rather nasty sites, sounds, and, yes, smells of a resuscitation could traumatize the family member. On the other hand, in the case of a conscious patient I can well understand how the presence of a family member could be reassuring. It’s an issue I never resolved, and, given that I haven’t had to do a trauma resuscitation in nine years, it’s an issue I’m unlikely to have to face again.
Finally, let’s deal with the part of the study that everyone’s reporting. In essence, it is the finding that 57% of the general public believe that divine intervention could save a patient’s life when physicians have come to the conclusion that further attempts at life-saving treatment are futile, while only 19.5% of health care professionals expressed such a belief. As a corollary, it was also asked about patients in a persistent vegetative state (PVS), such as the one Terri Schiavo was in: “Do you believe that someone in a PVS could be saved by a miracle?” To this, the general public answered 61.3% yes and 32.5% no; health care professionals answered 20.2% yes, 57% no. These proportions were strikingly similar to the proportions of people who believe that divine intervention can save the life of a patient who is fatally injured. The results of this survey might also help explain why so many religious people took views so contrary to those of the medical mainstream regarding the Terri Schiavo case. On the other hand, what is lacking in a lot of the reporting about this survey is the additional finding that, on a scale of 1 to 10 where 1 indicates no trust at all and 10 indicates complete trust, the public scored their level of trust in a physician’s recommendation that further attempts at life-saving treatment would be futile at 7.0, which is pretty high in the case of a traumatic injury and in dealing with physicians who are not well known to them. In contrast, health care professionals scored their level of trust at 9.4.
As for the questions about whether God could miraculously heal a fatally injured victim, it turns out that that question was just part of a series of several questions about how important sensitivity to culture and religion by medical staffs is to most people. Indeed, here is the table which summarizes the results and shows them to go far beyond what most reports have discussed:
Consistent with the religiosity of the U.S., large pluralities of both the public and health care professionals characterize their religious beliefs as either “very” or “somewhat” important in guiding their decisions about medical care in the event of critical injury. This survey suggests that, although health care professionals and the general public may differ in how they apply religion to their health care decisions, very similar numbers of the general public and health care professionals view religion as important in their lives and in their health care decisions during critical illnesses. I’ve pointed out before that, unlike the case with many scientists, physicians tend to have a level of religiosity that is at least as great, if not even greater, than that of the general public, and this study confirms it. It also suggests why physicians tend to fall for “intelligent design” creationism. While they have a more pragmatic approach to their religion when it comes to their area of expertise, accepting far more than the general public that if the medical evidence shows no hope of survival that there is no hope of survival; when they wander outside their area of expertise they are more prone to let their religion color their thinking. One surprise to me was how many people characterized their religious beliefs as being “not at all important” in guiding them in making health care decisions. It was 18.4% of the general public and 17.1% of health care physicians, with no statistically significant difference between the two. Based how religious the American public is by and large, I would have expected lower numbers. I also would have expected that it might be lower among health care professionals, given the previous responses that suggest that, when it comes to the expectation of miracles at least, health care professionals don’t let their religious views color their hopes for recovery to nearly the extent that the general public does.
Putting this study together, I see some rather muddled views of Americans when it comes to a large number of issues related to end of life care after an unrecoverable traumatic injury. Most people in the U.S. are religious, and most people still consider religion to be paramount in how they approach end-of-life decisions. This study also clearly points out that to the vast majority of people, including health care professionals, religion matters a lot, although health care professionals appear to be more able to keep their religious beliefs from affecting their expectations for recovery nearly as much as the general public does. The finding that so many people hold out hope for miraculous healing by God is simply a consequence of the religiosity of most Americans and in that context is not particularly surprising. It also points out the importance for health care workers of being sensitive to people’s religious beliefs, whether we as health care workers share them or not. Failure to be respectful can lead to nasty conflict and the patient’s family losing faith in the physician’s recommendations, with potentially disastrous consequences for good patient care. The study’s lead author put it well:
Jacobs said he frequently meets people who think God will save their dying loved one and who want medical procedures to continue.
“You can’t say, ‘That’s nonsense.’ You have to respect that” and try to show them X-rays, CAT scans and other medical evidence indicating death is imminent, he said.
Relatives need to know that “it’s not that you don’t want a miracle to happen, it’s just that is not going to happen today with this patient,” he said.
In the discussion, Dr. Jacobs also writes:
The large percentage of people who indicated that religious beliefs are important, including the potential for miracles to change futile outcomes, should be appreciated by health care professionals. Sensitivity to this belief will promote development of a trusting relationship that is critical to convey the scientific basis for the conclusion that there is objective, overwhelming evidence that continued medical interventions will not lead to a successful outcome.
Similarly, Dr. Michael Sise, trauma medical director at Scripps Mercy Hospital in San Diego observes:
Sise, a Catholic doctor working in a Catholic hospital, said miracles don’t happen when medical evidence shows death is near.
“That’s just not a realistic situation,” he said.
Indeed, it is not, but I do have to wonder why, if God is omnipotent, miracles don’t happen when the evidence is so unequivocal that death is near.
In reality, if anything this study actually is fairly reassuring in that it shows that most of the general public have a high degree of confidence in the ability of physicians and health care teams to make a medical and scientific judgment about when there is so little hope of recovery that continued aggressive care is futile. True, it does point out that a large number of patients’ families have unrealistic expectations based on their religious beliefs and that these unrealistic beliefs can sometimes pose problems, but it is hardly good evidence of a major conflict between God and medicine or evidence that God somehow trumps medicine. It does, however, pose a problem in that large numbers of people (nearly 72.4%) believe that families have a right to demand futile treatment that doctors consider futile. This does not surprise me too much. What did surprise me is that 44% of health care professionals also answered the same way. This is a potentially problem, both from an ethical standpoint and from the standpoint of allocation of scarce medical resources.
On the other hand, when the questions are phrased in terms that highlight a some of the tradeoffs involved in the decisions, people are actually more reasonable than the reporting of the survey makes it seem. For example, consider the responses to these questions:
- “If doctors believe there is no hope of recovery, which would you prefer?” In answer to this question, 72.8% of the general public said that all life-sustaining treatments should stop and that the focus should turn to comfort care only; only 20.6% said all efforts should continue indefinitely regardless. In contrast, for health care professionals, the numbers were 92.6% and 2.5%, respectively.
- “Should efforts continue if they take medical resources and personnel away from other patients more likely to survive?” To this question, only 28.8% of the general public answered yes; 56.1% answered no. Health care professionals answered the question similarly: 23.3% yes and 62.8% no.
One suggested conclusion of this study is that, with sensitivity, this problem of unrealistic expectations based on religion can be overcome and that it is quite rare indeed that physicians can’t overcome such beliefs to the point where they have to try to overrule a family that wants everything to continue to be done past the point of futility. Sometimes, however, it takes time and patience. Insisting on “pulling the plug” immediately is almost always a recipe for disastrous conflict.
Another way of looking at the results of this study is not just to focus on religion, even though so many of the news stories reporting on it played the “God versus doctors” angle, sometimes to a ridiculous degree, and some antireligious bloggers have predictably taken these simplistic news reports of a more complex study to make snarky comments about doctors having to pander to “stupid” or “religiously deluded” Americans that make me glad indeed that none of them are physicianss. They have zero clue how necessary it is to deal nonjudgmentally with all sorts of unscientific beliefs, be they religious or not, and mockery is not a fruitful approach; moreover they miss the other aspects of the study that show that, despite these beliefs in potential miracles, people actually are more reasonable than the news stories make it appear.
In any case, the focus on religion takes away the focus from the real issue: improving public understanding of scientific medicine and what it can and cannot accomplish. Lots of patients have unrealistic beliefs about health care based on all sorts of things, be they religion, faith in pseudoscientific quackery, or just fears based on misinformation that is rife in the media (i.e., the claim by antivaccinationists that vaccines cause autism). Although I may rail about such irrationality on this blog when it gets out of hand, it’s important to remember that a blog is not real life. It’s a different venue, one designed to educate and entertain a general audience, not to mention to indulge my personal beliefs about the importance of science in medicine and my fears of the problems irrationality and anti-science cause in medicine and society at large. Persuading families and patients that what and evidence-based medicine recommends is the best for their injured or ill loved ones requires a far gentler touch.
ADDENDUM: Steve Novella comments. He discusses primarily the part of the study that notes that 72.4% of the public thinks that family members should be able to demand care that physicians deem futile for their loved ones. I didn’t dwell on that part of the study, but it is a result that is quite important in and of itself, especially the second part, which is the question of who should pay for such futile care insisted upon by the family against medical recommendations. The answers broke down thusly for the public: The insurance company 48.5%; the government 6.1%; the patient 37.0%. For health care professionals the numbers were 30.5%, 1.4%, and 54.8%, respectively.
Jacobs, L.M., Burns, K., Jacobs, B.B. (2008). Trauma Death: Views of the Public and Trauma Professionals on Death and Dying From Injuries. Archives of Surgery, 143(8), 730-735.