Validation of a Geriatric Trauma Prognosis Calculator: A P.A.L.Li.A.T.E. Consortium Study.

BACKGROUND/OBJECTIVES: The P.A.L.Li.A.T.E. (prognostic assessment of life and limitations after trauma in the elderly) consortium has previously created a prognosis calculator for mortality after geriatric injury based on age, injury severity, and transfusion requirement called the geriatric trauma outcome score (GTOS). Here, we sought to create and validate a prognosis calculator called the geriatric trauma outcome score ii (GTOS II) estimating probability of unfavorable discharge. DESIGN: Retrospective cohort. SETTING: Four geographically diverse Level 1 trauma centers. PARTICIPANTS: Trauma admissions aged 65 to 102 years surviving to discharge from 2000 to 2013. INTERVENTION: None. MEASUREMENTS: Age, injury severity score (ISS), transfusion at 24 hours post-admission, discharge dichotomized as favorable (home/rehabilitation) or unfavorable (skilled nursing/long term acute care/hospice). Training and testing samples were created using the holdout method. A multiple logistic mixed model (GTOS II) was created to estimate the odds of unfavorable disposition then re-specified using the GTOS II as the sole predictor in a logistic mixed model using the testing sample. RESULTS: The final dataset was 16,114 subjects (unfavorable discharge status = 15.4%). Training (n = 8,057) and testing (n = 8,057) samples had similar demographics. The formula based on the training sample was (GTOS II = Age + [0.71 × ISS] + 8.79 [if transfused by 24 hours]). Misclassification rate and AUC were 15.63% and 0.67 for the training sample, respectively, and 15.85% and 0.67 for the testing sample. CONCLUSION: GTOS II estimates the probability of unfavorable discharge in injured elders with moderate accuracy. With the GTOS mortality calculator, it can help in goal setting conversations after geriatric injury.

A comparison of prognosis calculators for geriatric trauma: A Prognostic Assessment of Life and Limitations After Trauma in the Elderly consortium study.

BACKGROUND: The nine-center Prognostic Assessment of Life and Limitations After Trauma in the Elderly consortium has validated the Geriatric Trauma Outcome Score (GTOS) as a prognosis calculator for injured elders. We compared GTOS' performance to that of the Trauma Injury Severity Score (TRISS) in a multicenter sample. METHODS: Three Prognostic Assessment of Life and Limitations After Trauma in the Elderly centers not submitting subjects to the GTOS validation study identified subjects aged 65 years to 102 years admitted from 2000 to 2013. GTOS was specified using the formula [GTOS = age + (Injury Severity Score [ISS] × 2.5) + 22 (if transfused packed red cells (PRC) at 24 hours)]. TRISS uses the Revised Trauma Score (RTS), dichotomizes age (<55 years = 0 and ≥55 years = 1), and was specified using the updated 1995 beta coefficients. TRISS Penetrating was specified as [TRISSP = -2.5355 + (0.9934 × RTS) + (-0.0651 × ISS) + (-1.1360 × Age)]. TRISS Blunt was specified as [TRISSB = -0.4499 + (0.8085 × RTS Total) + (-0.0835 × ISS) + (-1.7430 × Age)]. Each then became the sole predictor in a separate logistic regression model to estimate probability of mortality. Model performances were evaluated using misclassification rate, Brier score, and area under the curve. RESULTS: Demographics (mean + SD) of subjects with complete data (N = 10,894) were age, 78.3 years ± 8.1 years; ISS, 10.9 ± 8.4; RTS = 7.5 ± 1.1; mortality = 6.9%; blunt mechanism = 98.6%; 3.1 % of subjects received PRCs. The penetrating trauma subsample (n = 150) had a higher mortality rate of 20.0%. The misclassification rates for the models were GTOS, 0.065; TRISSB, 0.051; and TRISSP, 0.120. Brier scores were GTOS, 0.052; TRISSB, 0.041; and TRISSP, 0.084. The area under the curves were GTOS, 0.844; TRISSB, 0.889; and TRISSP, 0.897. CONCLUSION: GTOS and TRISS function similarly and accurately in predicting probability of death for injured elders. GTOS has the advantages of a single formula, fewer variables, and no reliance on data collected in the emergency room or by other observers. LEVEL OF EVIDENCE: Prognostic, level II.

Multicenter external validation of the Geriatric Trauma Outcome Score: A study by the Prognostic Assessment of Life and Limitations After Trauma in the Elderly (PALLIATE) consortium.

BACKGROUND: A prognostic tool for geriatric mortality after injury called the Geriatric Trauma Outcome Score (GTOS), where GTOS = [age] + [ISS × 2.5] + [22 if transfused any PRBCs by 24 hours after admission], was previously developed based on 13 years of data from geriatric trauma patients admitted to Parkland Hospital. We sought to validate this model. METHODS: Four Level I centers identified subjects who are 65 years or older for the period of the original study. The GTOS model was first specified using the formula [GTOS = age + (ISS × 2.5) + 22 (if given PRBC by 24 hours)] developed from the Parkland sample and then used as the sole predictor in a logistic mixed model estimating probability of mortality in the validation sample, accounting for site as a random effect. We estimated the misclassification (error) rate, Brier score, Tjur R, and the area under the curve in evaluating the predictive performance of the GTOS model. RESULTS: The original Parkland sample (n = 3,841) had a mean (SD) age of 76.6 (8.1) years, mean (SD) ISS of 12.4 (9.9), mortality of 10.8%, and 11.9% receiving PRBCs at 24 hours. The validation sample (n = 18,282) had a mean (SD) age of 77.0 (8.1) years, mean (SD) ISS of 12.3 (10.6), mortality of 11.0%, and 14.1% receiving PRBCs at 24 hours. Fitting the GTOS model to the validation sample revealed that the parameter estimates from the validation sample were similar to those of fitting it to the Parkland sample with highly overlapping 95% confidence limits. The misclassification (error) rate for the GTOS logistic model applied to the validation sample was 9.97%, similar to that of the Parkland sample (9.79%). Brier score, Tjur R, and the area under the curve for the GTOS logistic model when applied to the validation sample were 0.07, 0.25, and 0.86, respectively, compared with 0.08, 0.20, and 0.82, respectively, for the Parkland sample. CONCLUSION: With the use of the data available at 24 hours after injury, the GTOS accurately predicts in-hospital mortality for the injured elderly. LEVEL OF EVIDENCE: Prognostic study, level III.

Chemotherapy Use, Performance Status, and Quality of Life at the End of Life.

IMPORTANCE: Although many patients with end-stage cancer are offered chemotherapy to improve quality of life (QOL), the association between chemotherapy and QOL amid progressive metastatic disease has not been well-studied. American Society for Clinical Oncology guidelines recommend palliative chemotherapy only for solid tumor patients with good performance status. OBJECTIVE: To evaluate the association between chemotherapy use and QOL near death (QOD) as a function of patients' performance status. DESIGN, SETTING, AND PARTICIPANTS: A multi-institutional, longitudinal cohort study of patients with end-stage cancer recruited between September 2002 and February 2008. Chemotherapy use (n = 158 [50.6%]) and Eastern Cooperative Oncology Group (ECOG) performance status were assessed at baseline (median = 3.8 months before death) and patients with progressive metastatic cancer (N = 312) following at least 1 chemotherapy regimen were followed prospectively until death at 6 outpatient oncology clinics in the United States. MAIN OUTCOMES AND MEASURES: Patient QOD was determined using validated caregiver ratings of patients' physical and mental distress in their final week. RESULTS: Chemotherapy use was not associated with patient survival controlling for clinical setting and patients' performance status. Among patients with good (ECOG score = 1) baseline performance status, chemotherapy use compared with nonuse was associated with worse QOD (odds ratio [OR], 0.35; 95% CI, 0.17-0.75; P = .01). Baseline chemotherapy use was not associated with QOD among patients with moderate (ECOG score = 2) baseline performance status (OR, 1.06; 95% CI, 0.51-2.21; P = .87) or poor (ECOG score = 3) baseline performance status (OR, 1.34; 95% CI, 0.46-3.89; P = .59). CONCLUSIONS AND RELEVANCE: Although palliative chemotherapy is used to improve QOL for patients with end-stage cancer, its use did not improve QOD for patients with moderate or poor performance status and worsened QOD for patients with good performance status. The QOD in patients with end-stage cancer is not improved, and can be harmed, by chemotherapy use near death, even in patients with good performance status.

Estimating Geriatric Mortality after Injury Using Age, Injury Severity, and Performance of a Transfusion: The Geriatric Trauma Outcome Score.

BACKGROUND: A tool to determine the probability of mortality for severely injured geriatric patients is needed. OBJECTIVE: We sought to create an easily calculated geriatric trauma prognostic score based on parameters available at the bedside to aid in mortality probability determination. METHODS: All patients ≥ 65 years of age were identified from our Level I trauma center's registry between January 1, 2000 and December 31, 2013. Measurements included age, Injury Severity score (ISS), units of packed red blood cells (PRBCs) transfused in the first 24 hours, and patients' mortality status at the end of their index hospitalization. As a first step, a logistic regression model with maximum likelihood estimation and robust standard errors was used to estimate the odds of mortality from age, ISS, and PRBCs after dichotomizing PRBCs as yes/no. We then constructed a Geriatric Trauma Outcome (GTO) score that became the sole predictor in the re-specified logistic regression model. RESULTS: The sample (n = 3841) mean age was 76.5 ± 8.1 years and the mean ISS was 12.4 ± 9.8. In-hospital mortality was 10.8%, and 11.9% received a transfusion by 24 hours. Based on the logistic regression model, the equation with the highest discriminatory ability to estimate probability of mortality was GTO Score = age + (2.5 × ISS) + 22 (if given PRBCs). The area under the receiver operating characteristic curve (AUC) for this model was 0.82. Selected GTO scores and their related probability of dying were: 205 = 75%, 233 = 90%, 252 = 95%, 310 = 99%. The range of GTO scores was 67.5 (survivor) to 275.1 (died). CONCLUSION: The GTO model accurately estimates the probability of dying, and can be calculated at bedside by those possessing a working knowledge of ISS calculation.

Injury severity and comorbidities alone do not predict futility of care after geriatric trauma.

BACKGROUND: When counseling surrogates of massively injured elderly trauma patients, the prognostic information they desire is rarely evidence based. OBJECTIVE: We sought to objectively predict futility of care in the massively injured elderly trauma patient using easily available parameters: age, Injury Severity Score (ISS), and preinjury comorbidities. METHODS: Two cohorts (70-79 years and ≥80 years) were constructed from The National Trauma Data Bank (NTDB) for years 2007-2011. Comorbidities were tabulated for each patient. Mortality rates at every ISS score were tabulated for subjects with 0, 1, or ≥2 comorbidities. Futility was defined a priori as an in-hospital mortality rate of ≥95% in a cell with ≥5 subjects. RESULTS: A total of 570,442 subjects were identified (age 70-79 years, n=217,384; age ≥80 years, n=352,608). Overall mortality was 5.3% for ages 70-79 and 6.6% for ≥80 years. No individual ISS score was found to have a mortality rate of ≥95% for any number of comorbidities in either age cohort. The highest mortality rate seen in any cell was for an ISS of 66 in the ≥80 year-old cohort with no listed comorbidities (93.3%). When upper extremes of ISS were aggregated into deciles, mortality for both cohorts across all number of comorbidities was 45.5%-60.9% for ISS 40-49, 56.6%-81.4% for ISS 50-59, and 73.9%-93.3% for ISS ≥60. CONCLUSIONS: ISS and preinjury comorbidities alone cannot be used to predict futility in massively injured elderly trauma patients. Future attempts to predict futility in these age groups may benefit from incorporating measures of physiologic distress.

Communication About Advance Directives and End-of-Life Care Options Among Internal Medicine Residents.

BACKGROUND: Despite increasing awareness about the importance of discussing end-of-life (EOL) care options with terminally ill patients and families, many physicians remain uncomfortable with these discussions. OBJECTIVE: The objective of the study was to examine perceptions of and comfort with EOL care discussions among a group of internal medicine residents and the extent to which comfort with these discussions has improved over time. METHODS: In 2013, internal medicine residents at a large academic medical center were asked to participate in an on-line survey that assessed their attitudes and experiences with discussing EOL care with terminally-ill patients. These results were compared to data from a similar survey residents in the same program completed in 2006. RESULTS: Eighty-three (50%) residents completed the 2013 survey. About half (52%) felt strongly that they were able to have open, honest discussions with patients and families, while 71% felt conflicted about whether CPR was in the patient's best interest. About half (53%) felt strongly that it was okay for them to tell a patient/family member whether or not CPR was a good idea for them. Compared to 2006 respondents, the 2013 cohort felt they had more lectures about EOL communication, and had watched an attending have an EOL discussion more often. CONCLUSIONS: Modest improvements were made over time in trainees' exposure to EOL discussions; however, many residents remain uncomfortable and conflicted with having EOL care discussions with their patients. More effective training approaches in EOL communication are needed to train the next generation of internists.

An examination of end-of-life care in a safety net hospital system: a decade in review.

OBJECTIVES: To examine patterns of use of end-of-life care in patients receiving treatment at a large, urban safety-net hospital from 2000 to 2010. METHODS: Data from the Parkland Hospital palliative care database, which tracked all consults for this period, were analyzed. Logistic regression was used to identify predictors of hospice use, and Cox proportional hazards modeling to examine survival. RESULTS: There were 5,083 palliative care consults over the study period. More patients were Black (41%) or White (31%), and younger than 65 years old (75%). Cancer patients or those who received palliative care services longer were more likely to receive hospice; those who had no form of health care assistance were less likely. There were no racial/ethnic differences in hospice use. CONCLUSION: In this cohort, there were no racial/ethnic disparities in hospice use. Those who had no form of health care assistance were less likely to receive hospice.

Provision of spiritual support to patients with advanced cancer by religious communities and associations with medical care at the end of life.

IMPORTANCE: Previous studies report associations between medical utilization at the end-of-life (EoL) and religious coping and spiritual support from the medical team. However, the influence of clergy and religious communities on EoL outcomes is unclear. OBJECTIVE: To determine whether spiritual support from religious communities influences terminally ill patients' medical care and quality of life (QoL) near death. DESIGN, SETTING, AND PARTICIPANTS: A US-based, multisite cohort study of 343 patients with advanced cancer enrolled from September 2002 through August 2008 and followed up (median duration, 116 days) until death. Baseline interviews assessed support of patients' spiritual needs by religious communities. End-of-life medical care in the final week included the following: hospice, aggressive EoL measures (care in an intensive care unit [ICU], resuscitation, or ventilation), and ICU death. MAIN OUTCOMES AND MEASURES: End-of-life QoL was assessed by caregiver ratings of patient QoL in the last week of life. Multivariable regression analyses were performed on EoL care outcomes in relation to religious community spiritual support, controlling for confounding variables, and were repeated among high religious coping and racial/ethnic minority patients. RESULTS: Patients reporting high spiritual support from religious communities (43%) were less likely to receive hospice (adjusted odds ratio [AOR], 0.37; 95% CI, 0.20-0.70 [P = .002]), more likely to receive aggressive EoL measures (AOR, 2.62; 95% CI, 1.14-6.06 [P = .02]), and more likely to die in an ICU (AOR, 5.22; 95% CI, 1.71-15.60 [P = .004]). Risks of receiving aggressive EoL interventions and ICU deaths were greater among high religious coping (AOR, 11.02; 95% CI, 2.83-42.89 [P < .001]; and AOR, 22.02; 95% CI, 3.24-149.58 [P = .002]; respectively) and racial/ethnic minority patients (AOR, 8.03; 95% CI, 2.04-31.55 [P = .003]; and AOR, 11.21; 95% CI, 2.29-54.88 [P = .003]; respectively). Among patients well-supported by religious communities, receiving spiritual support from the medical team was associated with higher rates of hospice use (AOR, 2.37; 95% CI, 1.03-5.44 [P = .04]), fewer aggressive interventions (AOR, 0.23; 95% CI, 0.06-0.79 [P = .02]) and fewer ICU deaths (AOR, 0.19; 95% CI, 0.05-0.80 [P = .02]); and EoL discussions were associated with fewer aggressive interventions (AOR, 0.12; 95% CI, 0.02-0.63 [P = .01]). CONCLUSIONS AND RELEVANCE: Terminally ill patients who are well supported by religious communities access hospice care less and aggressive medical interventions more near death. Spiritual care and EoL discussions by the medical team may reduce aggressive treatment, highlighting spiritual care as a key component of EoL medical care guidelines.

United states acculturation and cancer patients' end-of-life care.

BACKGROUND: Culture shapes how people understand illness and death, but few studies examine whether acculturation influences patients' end-of-life treatment preferences and medical care. METHODS AND FINDINGS: In this multi-site, prospective, longitudinal cohort study of terminally-ill cancer patients and their caregivers (n = 171 dyads), trained interviewers administered the United States Acculturation Scale (USAS). The USAS is a 19-item scale developed to assess the degree of "Americanization" in first generation or non-US born caregivers of terminally-ill cancer patients. We evaluated the internal consistency, concurrent, criterion, and content validity of the USAS. We also examined whether caregivers' USAS scores predicted patients' communication, treatment preferences, and end-of-life medical care in multivariable models that corrected for significant confounding influences (e.g. education, country of origin, English proficiency). The USAS measure was internally consistent (Cronbach α = 0.98); and significantly associated with US birthplace (r = 0.66, P<0.0001). USAS scores were predictive of patients' preferences for prognostic information (AOR = 1.31, 95% CI:1.00-1.72), but not comfort asking physicians' questions about care (AOR 1.23, 95% CI:0.87-1.73). They predicted patients' preferences for feeding tubes (AOR = 0.68, 95% CI:0.49-0.99) and wish to avoid dying in an intensive care unit (AOR = 1.36, 95% CI:1.05-1.76). Scores indicating greater acculturation were also associated with increased odds of patient participation in clinical trials (AOR = 2.20, 95% CI:1.28-3.78), compared with lower USAS scores, and greater odds of patients receiving chemotherapy (AOR = 1.59, 95% CI:1.20-2.12). CONCLUSION: The USAS is a reliable and valid measure of "Americanization" associated with advanced cancer patients' end-of-life preferences and care. USAS scores indicating greater caregiver acculturation were associated with increased odds of patient participation in cancer treatment (chemotherapy, clinical trials) compared with lower scores. Future studies should examine the effects of acculturation on end-of-life care to identify patient and provider factors that explain these effects and targets for future interventions to improve care (e.g., by designing more culturally-competent health education materials).

Clinical trial participation among ethnic/racial minority and majority patients with advanced cancer: what factors most influence enrollment?

BACKGROUND: Studies using administrative data report that racial/ethnic minority patients enroll in clinical trials less frequently than white patients. We studied a cohort of terminally ill cancer patients to determine a) if racial/ethnic minority patients have lower rates of drug trial enrollment than white patients once socioeconomic characteristics are accounted for and b) what factors most influence drug trial enrollment among patients with advanced canceroverall. METHODS: Coping with Cancer (CwC) is a National Cancer Institute/National Institute of Mental Health (NCI/NIMH)-funded multisite, prospective, longitudinal study of patients with advanced cancer. Baseline interviews assessed drug trial enrollment as well as socioeconomic characteristics. Logistic regression models estimated associations between drug trial enrollment and baseline characteristics. Stepwise, backward, and subset model selection was applied to select the final model where characteristics significant at α=0.05 remained in the model. RESULTS: At a median of 4.4 months prior to death, 35 of 358 patients (9.8%) were enrolled in a drug trial. In unadjusted analyses, race/ethnicity, health insurance, performance status, recruitment site, cancer type, preference for life-extending care, and lack of end-of-life care planning were associated (p<0.05) with enrollment. In multivariable analysis, patient race/ethnicity was not significantly associated with enrollment. Patients who reported not having an end-of-life discussion (adjusted odds ratio [AOR], 0.18; 95% confidence interval [CI] 0.04-0.83) and those not wanting to discuss life expectancy (AOR, 0.31; 95%CI 0.12-0.79) were more likely to be trial enrollees. CONCLUSION: Patient race/ethnicity was not associated with clinical trial enrollment after adjustment for socioeconomic covariates. Patients with advanced cancer endorsing less engagement in end-of-life planning were more likely to be enrolled in a clinical trial.

Support of cancer patients' spiritual needs and associations with medical care costs at the end of life.

BACKGROUND: Although spiritual care is associated with less aggressive medical care at the end of life (EOL), it remains infrequent. It is unclear if the omission of spiritual care impacts EOL costs. METHODS: A prospective, multisite study of 339 advanced cancer patients accrued subjects from September 2002 to August 2007 from an outpatient setting and followed them until death. Spiritual care was measured by patients' reports that the health care team supported their religious/spiritual needs. EOL costs in the last week were compared among patients reporting that their spiritual needs were inadequately supported versus those who reported that their needs were well supported. Analyses were adjusted for confounders (eg, EOL discussions). RESULTS: Patients reporting that their religious/spiritual needs were inadequately supported by clinic staff were less likely to receive a week or more of hospice (54% vs 72.8%; P = .01) and more likely to die in an intensive care unit (ICU) (5.1% vs 1.0%, P = .03). Among minorities and high religious coping patients, those reporting poorly supported religious/spiritual needs received more ICU care (11.3% vs 1.2%, P = .03 and 13.1% vs 1.6%, P = .02, respectively), received less hospice (43.% vs 75.3% ≥1 week of hospice, P = .01 and 45.3% vs 73.1%, P = .007, respectively), and had increased ICU deaths (11.2% vs 1.2%, P = .03 and 7.7% vs 0.6%, P = .009, respectively). EOL costs were higher when patients reported that their spiritual needs were inadequately supported ($4947 vs $2833, P = .03), particularly among minorities ($6533 vs $2276, P = .02) and high religious copers ($6344 vs $2431, P = .005). CONCLUSIONS: Cancer patients reporting that their spiritual needs are not well supported by the health care team have higher EOL costs, particularly among minorities and high religious coping patients.

Racial disparities in the outcomes of communication on medical care received near death.

BACKGROUND: Black patients tend to receive more life-prolonging care at the end of life (EOL) than white patients. This study aimed to evaluate whether differences in patient-physician communication contribute to disparities in EOL care between black patients and white patients. METHODS: Multi-institutional prospective longitudinal cohort study of 71 black patients and 261 white patients with advanced cancer. The main outcome measures were differences between black patients and white patients in relationships among EOL discussions and communication goals (terminal illness awareness, treatment preferences, and do-not-resuscitate [DNR] orders) and EOL care outcomes (life-prolonging care, hospice care, and receipt of EOL care consistent with preferences). RESULTS: End-of-life discussions between physicians and their white patients were associated with less life-prolonging EOL care compared with their black patients (adjusted odds ratio [aOR], 0.11; P = .04). Despite similar rates of EOL discussions (black vs white patients 35.3% vs 38.4%, P = .65), more black patients than white patients received life-prolonging EOL care (19.7% vs 6.9%, P = .001). End-of-life discussions were associated with attainment of some communication goals among black patients, including placement of DNR orders (aOR, 4.25; P = .04), but these communication goals were not consistently associated with EOL care received by black patients. For example, black patients with DNR orders were no less likely than black patients without DNR orders to receive life-prolonging EOL care (aOR, 1.57; P = .58). CONCLUSIONS: End-of-life discussions and communication goals seem to assist white patients in receiving less life-prolonging EOL care, but black patients do not experience the same benefits of EOL discussions. Instead, black patients tend to receive life-prolonging measures at the EOL even when they have DNR orders or state a preference for symptom-directed care.

Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer.

CONTEXT: Patients frequently rely on religious faith to cope with cancer, but little is known about the associations between religious coping and the use of intensive life-prolonging care at the end of life. OBJECTIVE: To determine the way religious coping relates to the use of intensive life-prolonging end-of-life care among patients with advanced cancer. DESIGN, SETTING, AND PARTICIPANTS: A US multisite, prospective, longitudinal cohort of 345 patients with advanced cancer, who were enrolled between January 1, 2003, and August 31, 2007. The Brief RCOPE assessed positive religious coping. Baseline interviews assessed psychosocial and religious/spiritual measures, advance care planning, and end-of-life treatment preferences. Patients were followed up until death, a median of 122 days after baseline assessment. MAIN OUTCOME MEASURES: Intensive life-prolonging care, defined as receipt of mechanical ventilation or resuscitation in the last week of life. Analyses were adjusted for demographic factors significantly associated with positive religious coping and any end-of-life outcome at P < .05 (ie, age and race/ethnicity). The main outcome was further adjusted for potential psychosocial confounders (eg, other coping styles, terminal illness acknowledgment, spiritual support, preference for heroics, and advance care planning). RESULTS: A high level of positive religious coping at baseline was significantly associated with receipt of mechanical ventilation compared with patients with a low level (11.3% vs 3.6%; adjusted odds ratio [AOR], 2.81 [95% confidence interval {CI}, 1.03-7.69]; P = .04) and intensive life-prolonging care during the last week of life (13.6% vs 4.2%; AOR, 2.90 [95% CI, 1.14-7.35]; P = .03) after adjusting for age and race. In the model that further adjusted for other coping styles, terminal illness acknowledgment, support of spiritual needs, preference for heroics, and advance care planning (do-not-resuscitate order, living will, and health care proxy/durable power of attorney), positive religious coping remained a significant predictor of receiving intensive life-prolonging care near death (AOR, 2.90 [95% CI, 1.07-7.89]; P = .04). CONCLUSIONS: Positive religious coping in patients with advanced cancer is associated with receipt of intensive life-prolonging medical care near death. Further research is needed to determine the mechanisms for this association.

Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life.

PURPOSE: Religion and spirituality play a role in coping with illness for many cancer patients. This study examined religiousness and spiritual support in advanced cancer patients of diverse racial/ethnic backgrounds and associations with quality of life (QOL), treatment preferences, and advance care planning. METHODS: The Coping With Cancer study is a federally funded, multi-institutional investigation examining factors associated with advanced cancer patient and caregiver well-being. Patients with an advanced cancer diagnosis and failure of first-line chemotherapy were interviewed at baseline regarding religiousness, spiritual support, QOL, treatment preferences, and advance care planning. RESULTS: Most (88%) of the study population (N = 230) considered religion to be at least somewhat important. Nearly half (47%) reported that their spiritual needs were minimally or not at all supported by a religious community, and 72% reported that their spiritual needs were supported minimally or not at all by the medical system. Spiritual support by religious communities or the medical system was significantly associated with patient QOL (P = .0003). Religiousness was significantly associated with wanting all measures to extend life (odds ratio, 1.96; 95% CI, 1.08 to 3.57). CONCLUSION: Many advanced cancer patients' spiritual needs are not supported by religious communities or the medical system, and spiritual support is associated with better QOL. Religious individuals more frequently want aggressive measures to extend life.