References 1. Sightings T. How Baby Boomers Will Change the Economy. U.S. News & World Report. http://money.usnews.com/money/blogs/On-Retirement/2013/01/15/how-baby-boomerswill-change-the-economy.

Published January 15, 2013. Accessed November 21, 2013. 2. Blow HH, Sprung CL, Reinhart K, et al. The world's major religions' points of view on end-of-life decisions in the intensive care unit. Intensive Care Med. 2008;34(3):423-30. http://0-link.springer.com.library.meredith.edu/article/10.1007/s00134-007-09738/fulltext.html. Accessed November 21, 2013.

3. De pentheny o'kelly C, Urch C, Brown EA. The impact of culture and religion on truth telling at the end of life. Nephrol Dial Transplant. 2011;26(12):3838-42. http://0ndt.oxfordjournals.org.library.meredith.edu/content/26/12/3838.full. Accessed November 21, 2013. 4. Blandford J. An Examination of the Revisionist Challenge to the Catholic Tradition on Providing Artificial Nutrition and Hydration to Patients in a Persistent Vegetative State. Christian Bioethics. 17(2):153-164. http://0cb.oxfordjournals.org.library.meredith.edu/content/17/2/153.full.pdf+html. Accessed November 13, 2013. 5. Jotkowitz AB, Clarfield AM, Glick S. The care of patients with dementia: a modern Jewish ethical perspective. J Am Geriatr Soc. 2005;53(5):881-4. http://0onlinelibrary.wiley.com.library.meredith.edu/doi/10.1111/j.1532-5415.2005.53271.x/pdf. Accessed November 21, 2013.

6. Blow HH, Sprung CL, Baras M, et al. Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study. Intensive Care Med. 2012;38(7):1126-33. http://0link.springer.com.library.meredith.edu/article/10.1007/s00134-012-2554-8/fulltext.html. Accessed November 21, 2013. 7. Phelps AC, Maciejewski PK, Nilsson M, et al. Religious coping and use of intensive lifeprolonging care near death in patients with advanced cancer. JAMA. 2009;301(11):1140-7 http://jama.jamanetwork.com/article.aspx?articleid=183578. Accessed November 23, 2013.

8. Wolenberg KM, Yoon JD, Rasinski KA, Curlin FA. Religion and United States physicians' opinions and self-predicted practices concerning artificial nutrition and hydration. J Relig Health. 2013;52(4):1051-65. http://0link.springer.com.library.meredith.edu/article/10.1007/s10943-013-9740-z/fulltext.html. Accessed November 21, 2013.

Stacy Cliff Lifecycle II Artificial Nutrition and Religious Preference

Introduction The Baby Boomers are a generation of the United States population born between 1946 and 1964. According to U.S. News and World Report, by 2030, the number of Americans over the age of 65 will be 72 million. This is a drastic change from a reported 40 million in 2010.1 How our government will handle the financial burden of dramatically increasing Social Security payments and medical bills covered by Medicare for this population is actively debated. Not to be ignored, is the eventual increase in debilitating conditions such as Alzheimer disease and dementia, and the preparedness of our medical system and medical professionals to accommodate these individuals. The preparedness of Boomers and their families is also vital. This includes having honest conversations about end-of-life care including: artificial nutrition and hydration (ANH), life-support, and the preparation of an advance directive or a living will. Boomers may not wish to discuss end-of-life care, it is a conversation that seems foreboding and final, and they are just beginning their well-deserved golden years. Yet, it is extremely important to make wishes known, especially if incapacitated due to advanced dementia, Alzheimer disease, or other cognitive or physical conditions. If directives are not recorded, then a patients end-of-life care will be dictated by medical professionals. While this prospect may not seem grim, due to trust in medical teams and their oath to cause no harm, it may not be in accordance to the patients religious beliefs and attitudes. As Americas aged population increases so does the cultural diversity of the general population. In 50 years the majority of Americans are predicted to be of non-European descent.2

In this essay, I will present how different religions view end-of-life care. Specifically, how it may affect patients and physicians decisions to administer, withhold, or withdraw ANH. I will highlight how important it is for patients and physicians to consider the impact their religions have on the care they desire, the care they are willing to give, and the possible conflict of the physicians beliefs and patient autonomy. Religious Doctrine Christians, Jews, and Muslims vary in their views concerning end-of-life care. This variation is apparent in the practice of truth telling at the end of life. Telling the truth is acknowledged by Western medicine as imperative in preparing for the end-of-life. Yet, in some Eastern cultures and religions, Islam for example, the truth is routinely concealed from patients.3 I believe this cultural difference could cause conflict when physicians are considering ANH, and in respecting this cultural difference, patient autonomy is circumvented. If a patient is cognitively impaired and unable to make decisions concerning their care, family members should convey their wishes; yet if they have moments of coherence, and are uninformed of the severity of their illness, they may not prevent the administering of ANH. Mistakenly they could think it necessary to improve their health. However, if I remove my ethnocentric proclivity, I could reason that by informing a patient of their health status against their cultural norms it would also negate their autonomy. Regardless, this results in an occurrence where ANH may not be desired, health care costs have been inflated unnecessarily, and the patient is subjected to treatment that could be harmful and uncomfortable. The review article by Bulow et al2, discusses the worlds major religions standings on ANH. Christians are broken down further into several sub-groups, but for simplicity here, I will discuss the views of only Catholics and Protestants. Catholic Pope John Paul II declared, before his death in 2004, that ANH was not a medical act, it is a natural means of preserving life. Not providing ANH would cause death by starvation and dehydration and that is considered euthanasia.2,4 This directive refers to patients who are in, or who have progressed to a

vegetative state only, not to those suffering from dementia or end stage disease. The Catholic Church allows the withholding and withdrawing of ANH if it is burdensome, dangerous, extraordinary or disproportionate to the expected outcome.2 Protestants are less strict in their

doctrine concerning life-sustaining therapies. If there is little hope of recovery it is understandable to most to withhold or withdraw ANH therapies. The Jewish religion has three broad denominations: reform, conservative, and orthodox. Halacha, or the Jewish legal system of all denominations, forbids the hastening of death, even if the person has no hope of recovery. It is not required to prolong suffering or to lengthen a terminally ill patients life, but it is forbidden to withdraw life-sustaining, continuous treatment. According to the Halacha, illness (including dementia), is evil. Refusing or removing ANH could be interpreted through its teachings as giving up, thus allowing evil to triumph.5 It is only permissible to withhold food and treatment if it will cause complications, therefore hastening death. Otherwise, food and fluids are considered basic needs, not treatment, and thus unrelated to the dying process. To withhold nutrition is considered euthanasia and prohibited. If a patient willingly refuses food and hydration, the physician or medical team is required to attempt, though not forcefully, to change their mind. Prohibiting the withholding of nutrition is presently debated within Judaism centers. Rabbis are focusing on how ANH should be classified, whether it sustains life or prolongs death, thus is an obligation or is obligatory.2 Their decision may result in the relaxing of ANH directives. Muslims believe that everything possible must be done to prevent premature death. Basic nutrition should never be withheld. To deny nutrition would starve the patient to death which is a crime according to the Islamic faith.2 Also, importantly, the decision to withdraw futile treatment should be collective, involving the patients informed consent, consultation with the family, and all those involved in providing health care, including the attending physician.2 Despite their opposition to withdrawing ANH, Muslim physicians were as likely as other physicians to withdraw ANH according to patient wishes. To explain this observation, researchers

hypothesize that 91% of Muslim respondents were born outside of the US, and prior research has suggested that immigrants are more likely to accommodate morally controversial patient requests than US born physicians.2

Religious impact: Patient and Physician Religious affiliations are major contributors to end-of-life decisions. Depending on the respondent population, the Ethicatt study6 reports that 53 to 90% of patients consider religion very important when faced with a health crisis. A prospective cohort study7 revealed terminally ill cancer patients who coped with their diagnosis through religion, received significantly more treatment near death. I believe this could be related to a religious patients optimism in the power of prayer, the belief in divine intervention, thus, increased confidence in treatment efficacy. If the perceived efficacy is higher, aggressive treatments will seem warranted. The religion of a patient is not the only religious variable concerning end-of-life care. The religion of the physician has been shown to be independently significant in decisions concerning ANH.6,8 Thus, it would seem the religious beliefs of patients and physicians may contradict each other. If you consider Americas heterogeneous population, odds of a patient and physician not sharing religious beliefs are good. In fact, 66% of Jewish, 53% of Catholic, and 35% of

Protestant professionals surveyed would act against a competent patients wish even if it might be lifesaving, and 88% of Protestant and 84% Catholic doctors are more likely than Jewish doctors (62%) to try to talk a patient out of futile treatment.6 In the study by Wolenberg et al8 a survey of US physicians found that most physicians support withholding ANH even in cases in which the patient is not dying, and withdrawing ANH even when the patient can assimilate the nutrition.8 Compared with Protestant physicians, Jews and Muslims were significantly more likely to object to not administering ANH, and Muslims significantly more likely to oppose withdrawing ANH.8 As a whole, considering inter-religion differences do exist, two out of three physicians from major religious affiliations would honor a request to discontinue tube feedings

from one suffering from advanced dementia.6,8 This data depicts the variation in the practices of professionals of different religions. It also suggests that patient autonomy could come second to the religious views of the attending physician. In my opinion, this emphasizes the importance of having an advance medical directive, and also discussing wishes with loved ones. It is unknown if a physician would even be aware if his religious beliefs were prejudicing his judgments. If the patient is cognitively incapacitated, the designated surrogate could hopefully recognize religious conflict and, ensure patient wishes are adhered to.

Conclusion Different religious beliefs can be the source of passionate arguments and discussions among patients, family members, and medical professionals. Medical professionals can alleviate this contention by becoming knowledgeable and respectful of others faiths and beliefs.2 While it may be challenging, adaption to the needs of patients of different religious backgrounds is necessary. This is especially true as our country becomes even more diverse, and our aged population increases dramatically. The occurrences of patients suffering from cognitive impairments and the chance they will be attended to by medical professionals with differing religious views will be increasing. In closing, I would like to acknowledge the role of dietitians on medical teams, specifically ones dealing with diseases of the elderly and end-of-life decisions. Dietitians can improve their status by becoming experts in understanding cultural and religious positions on artificial nutrition and hydration. This knowledge will be helpful in mediating communication between physicians,

patients and families. Improved communication will ensure that outcomes are in accordance with expectations, and the focus of treatment will be providing comfort to the patient, while adhering to their religious beliefs.