Association Between Self-reported Importance of Religious or Spiritual Beliefs and End-of-Life Care Preferences Among People Receiving Dialysis

Abstract

Importance: Although people receiving maintenance dialysis have limited life expectancy and a high burden of comorbidity, relatively few studies have examined spirituality and religious beliefs among members of this population.

Objective: To examine whether there is an association between the importance of religious or spiritual beliefs and care preferences and palliative care needs in people who receive dialysis.

Design, setting, and participants: A cross-sectional survey study was conducted among adults who were undergoing maintenance dialysis at 31 facilities in Seattle, Washington, and Nashville, Tennessee, between April 22, 2015, and October 2, 2018. The survey included a series of questions assessing patients' knowledge, preferences, values, and expectations related to end-of-life care. Data were analyzed from February 12, 2020, to April 21, 2021.

Exposures: The importance of religious or spiritual beliefs was ascertained by asking participants to respond to this statement: "My religious or spiritual beliefs are what really lie behind my whole approach to life." Response options were definitely true, tends to be true, tends not to be true, or definitely not true.

Main outcomes and measurements: Outcome measures were based on self-reported engagement in advance care planning, resuscitation preferences, values regarding life prolongation, preferred place of death, decision-making preference, thoughts or discussion about hospice or stopping dialysis, prognostic expectations, and palliative care needs.

Results: A total of 937 participants were included in the cohort, of whom the mean (SD) age was 62.8 (13.8) years and 524 (55.9%) were men. Overall, 435 (46.4%) participants rated the statement about religious or spiritual beliefs as definitely true, 230 (24.6%) rated it as tends to be true, 137 (14.6%) rated it as tends not to be true, and 135 (14.4%) rated it as definitely not true. Participants for whom these beliefs were more important were more likely to prefer cardiopulmonary resuscitation (estimated probability for definitely true: 69.8% [95% CI, 66.5%-73.2%]; tends to be true: 60.8% [95% CI, 53.4%-68.3%]; tends not to be true: 61.6% [95% CI, 53.6%-69.6%]; and definitely not true: 60.6% [95% CI, 52.5%-68.6%]; P for trend = .003) and mechanical ventilation (estimated probability for definitely true: 42.6% [95% CI, 38.1%-47.0%]; tends to be true: 33.5% [95% CI, 25.9%-41.2%]; tends not to be true: 35.1% [95% CI, 27.2%-42.9%]; and definitely not true: 27.9% [95% CI, 19.6%-36.1%]; P for trend = .002) and to prefer a shared role in decision-making (estimated probability for definitely true: 41.6% [95% CI, 37.7%-45.5%]; tends to be true: 35.4% [95% CI, 29.0%-41.8%]; tends not to be true: 36.0% [95% CI, 26.7%-45.2%]; and definitely not true: 23.8% [95% CI, 17.3%-30.3%]; P for trend = .001) and were less likely to have thought or spoken about stopping dialysis. These participants were no less likely to have engaged in advance care planning, to value relief of pain and discomfort, to prefer to die at home, to have ever thought or spoken about hospice, and to have unmet palliative care needs and had similar prognostic expectations.

Conclusions and relevance: The finding that religious or spiritual beliefs were important to most study participants suggests the value of an integrative approach that addresses these beliefs in caring for people who receive dialysis.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Scherer reported receiving honorarium from Cara Therapeutics outside the submitted work. Dr Engelberg reported receiving grants from National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH) during the conduct of the study. Dr Kurella Tamura reported receiving grants from the NIH during the conduct of the study, and personal fees from American Federation of Aging Research and Clinical Journal of the American Society of Nephrology outside the submitted work. Dr Roberts reported receiving grants from the University of Washington (UW) Kidney Precision Medicine Project, UW Kidney Research Institute, and UW Center for Dialysis Innovation; receiving personal fees from Wake Forest School of Medicine APOLLO and Northwest Renal Dietitians Conference outside the submitted work; serving as a patient advisor on the American Society of Nephrology (ASN) COVID-19 Response Team and Transplant Subcommittee and for the International Society of Nephrology, as an ambassador for the National Kidney Foundation (NKF) and American Association of Kidney Patients, as a member of the Reassessing Race in the Diagnosis of Kidney Disease Taskforce of ASN and NKF as well as the Kidney Health Initiative Patient and Family Partnership Council, and as a former KidneyX patient reviewer; and being a kidney transplant recipient with hemodialysis and peritoneal dialysis experience. Dr Curtis reported receiving grants from the NIH and Cambia Health Foundation outside the submitted work. Dr O'Hare reported receiving grants from the NIDDK during the conduct of the study and the VA Health Services Research & Development Centers as well as personal fees from the ASN, Devenir Foundation, Chugai Pharmaceutical Co Ltd, Japanese Society for Dialysis Therapy, Kaiser Permanente Southern California, New York Society of Nephrology, University of California San Francisco, Hammersmith Hospital, and UpToDate Inc outside the submitted work. No other disclosures were reported.