Religious beliefs at end-of-life: implications for palliative care providers—a narrative review

Introduction

Case

Mrs. H was an 85-year-old woman with end-stage heart failure hospitalized for dyspnea. Despite intensive heart failure management and continuous bilevel positive airway pressure (BiPAP) for dyspnea, her condition worsened and she grew increasingly unresponsive. The treatment team met with her family to discuss the goals of her care as Mrs. H could not participate in any medical decision making. After asking the family’s permission, the treatment team shared that Mrs. H’s prognosis was likely measured in days. They recommended shifting to a comfort care approach, which included changing Mrs. H’s code status to “comfort measures only,” enrolling in hospice care, and discontinuing BiPAP support. Mrs. H’s family agreed with the team’s recommendation not to escalate care, but they insisted on continuing the BiPAP, and explained that their Catholic beliefs prohibited them from removing the life support. They interpreted that it was reasonable not to escalate or start any new treatments given her poor prognosis but discontinuing ongoing treatments would “take her life out of God’s hands”. The family emphasized that discontinuing the BiPAP would interfere with the timing of Mrs. H’s death, which was a matter of God’s domain.

The treatment team and Mrs. H’s family continued to disagree concerning the cessation of ongoing treatments during continued conversations. An ethics consultation to mediate the matter was planned, however, Mrs. H died before the consult with the BiPAP providing breathing support. At her death, she appeared peaceful, and her family and the treatment team all believed that she was comfortable.

Mrs. H’s family is a typical family in the United States (U.S.) who uses their religious beliefs when interacting with medical teams, and this topic is worth evaluating in the context of the religious needs of patients at end-of-life (EOL).

Palliative care and religion

Palliative care is a field of medicine that focuses on providing exceptional symptom management for seriously ill patients, supporting medical decision-making and working to match patient and family values with their treatment plans. Palliative care aims to focus on and alleviate all aspects of an individual’s suffering, from physical to emotional to spiritual. Other fields of medicine may overlook the role of spirituality and religiosity in the decisions that patients make, but palliative care’s humanistic approach is well suited to highlight this focus. This humanistic approach can help all healthcare professionals to address the spiritual and religious needs of patients, especially at EOL, by fostering authentic conversations that help patients and their loved ones to incorporate their spiritual values and goals within their treatment planning and decisions.

Prevalence of religious beliefs and impact on health care outcomes

The religious landscape in the U.S. has changed drastically in the past 40 years. The number of Americans reporting no religious affiliation increased from 5% in 1972 to 30% in 2023 with noteworthy declines in affiliation with several Christian faith traditions (1,2). The 2023–2024 Religious Landscape Study (RLS) and other Pew Research polling shows the proportion of the populace that identifies as Christian has hovered between 60% and 64% over the past five years but has dramatically decreased from the 1970s (1,2). Meanwhile, the proportion of Americans who identify with a religion other than Christianity has trended upward. The 2023–2024 RLS shows that around 70% of U.S. adults are religious and 29% are religiously unaffiliated (2). Gallup data demonstrates similar numbers (3).

Key measures of religion have held steady in recent years. Since 2021, between 44% and 46% of U.S. adults report praying daily. Thirty-three percent say they minimally attend religious services in person monthly. The percentages have been in the low 30s since 2020 with the number increasing to 40% when virtual attendance is included (2).

Most Americans do hold religious and spiritual beliefs. Eighty-six percent of U.S. adults believe people have a soul or a spirit, 83% believe in God or a universal spirit, 79% believe there is something spiritual beyond the natural world, and 70% believe in either in heaven, hell or in both. Eighty percent think about God or religion “quite a bit” or “some” of the time (2). Many report thinking about the meaning of life (84%), feeling a deep sense of wonder about the universe (80%), experiencing spiritual peace and well-being (74%) or a connection with humanity (72%), and feeling the presence of something beyond this world (61%) (2). The data suggests religiosity in the U.S. has stabilized at a much lower rate than previously while spirituality has remained high.

For the purposes of this article, we define “spirituality” as “a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred” (4). Spirituality can be experienced through religion and through non-religious means, including through nature, the universe, vocation, family, community, pets, learning, and other connections or circumstances. We define “religion” as a set of beliefs, behaviors, practices, and rituals which seek to facilitate communication, closeness, or alignment with the transcendent, whether personal or impersonal, and originates from established traditions (5-9). “Religiosity” is the degree to which one follows a religion and can be measured by religious behavior (worship attendance, prayer frequency), religious belief (God, afterlife), and religious belonging (Buddhist, Catholic, etc.) (1,9). Being “religious” includes espousing any of the above behaviors, beliefs or belonging. Someone who rarely attends worship services may strongly hold religious beliefs, and another individual may participate regularly in a faith practice and not hold deep beliefs, and both would be classified as “religious”. Importantly, each factor within an individual may fluctuate over time and life circumstances (10,11). “Religious coping” is a concept seen in serious illness and is defined as the way people use their religious beliefs to make sense of and adjust to stressful life events, including dying. Religious coping may include any religious practice or beliefs (7,12,13).

Religion in health

The religiosity of patients and families plays an important role in health behavior and health outcomes. For instance, external health locus of control is the belief that one’s health depends on external factors such as God or chance (14), with the belief that God or a higher power has the ability to intervene in the world also a contributing factor (15). This type of religiosity was negatively associated with vaccination rates during the COVID-19 pandemic (16). Similarly, patients with advanced cancer who have high religious coping and self-report high spiritual support from their religious communities were at greater risk for aggressive EOL medical care and deaths in an intensive care unit (ICU) (17).

Multiple health care guidelines and organizations encourage health care professionals to recognize and seek to understand the religious dimensions of the lives of patients because of the noted impact of religiosity on medical outcomes (7,18-21). Palliative care is a field of medicine that provides holistic care by attending to all components of an individual and can be particularly attuned to the spiritual and religious needs of individuals. The existing religious framework of patients provides a web of meaning for patients when they approach EOL (11). This religious framework involves religious beliefs, behaviors, and belonging and can significantly impact medical decision-making (see Table 1). This article argues that the spiritual and religious beliefs and behaviors of patients and families should be attended to as closely as their physical and emotional concerns, especially at EOL.

We will review the content of some of the religious beliefs present during EOL and how they can influence medical care and decision-making. We will also discuss potential pathways for palliative care teams to address the religious beliefs of patients and their loved ones to promote culturally sensitive and patient-centered care. We present this article in accordance with the Narrative Review reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-25-89/rc).

Methods

Search strategy

The search strategies are summarized in Table 2. We carried out an electronic PubMed (pubmed.gov) search on April 21, 2025, for English-language articles published between January 1 of 2010 and January 1 of 2025. The following search terms were used: religious beliefs; end-of-life; palliative care; adult 19+ years.

We included published articles, regardless of study design, which reviewed the religiosity of patients as well as religious beliefs potentially present and their possible impact in EOL situations. We focused on adult patients. We excluded non-English articles. We also excluded articles discussing pediatric EOL. We did not include all literature on the topic of religious beliefs and EOL. All articles were selected from the PubMed database to limit the scope of the article to have a medical framework. While there are databases more comprehensively covering religion, our intention was to have articles that had a more narrow focus on religious impact on medical choices at EOL.

Articles were vetted by two reviewers, M.M. and N.I. If inclusion or exclusion was not clear through review of the title and abstract, the co-authors vetted and discussed the articles. Once selected, articles were included in the references and their impact and conclusions studied in detail.

The presence and impact of religious beliefs at EOL (see Table 3)

Impact for palliative care teams

How religious beliefs impact EOL medical decision making affects palliative care teams. One study looked at patients with advanced cancer and measured multiple religious beliefs and themes related to EOL medical care decision-making: God’s sovereignty, sanctity of life, miracles, and sanctification through suffering. Eighty-seven percent of patients endorsed at least one religious belief with 62% endorsing three or more (13). Greater endorsement of religious beliefs was significantly associated with less understanding of the terminal nature of illness (13). This indicates that when palliative care providers work to communicate the medical reality of an individual’s condition, they may stall efforts if they do not account for the religious beliefs of their patients.

A retrospective cohort study of ethics consultation cases pertaining to conflict regarding life-sustaining treatment decisions examined the presence and influence of religion in these situations. In 25% of the cases reviewed, religion played a key role particularly for individuals who were non-white, whose principal language was not English, were born outside the USA, and had limited income (27). Religion was present in these cases through a belief in miracles and God’s power, religious teachings on medical treatment, and religious and cultural beliefs that diverge from prevalent American medical viewpoints (27).

A pattern of sociodemographic factors tended to be present when religion, including religious beliefs, was central to conflict over life-sustaining treatment, suggesting a cultural component to the conflict which could be mediated by distrust in the health system (27,31,32). These findings are supported by other studies which show that some minority populations exhibit higher levels of religious practices as well as religious and spiritual beliefs and coping along with higher preferences for more intense EOL care and lower advance care planning participation (11,24-26,32-41).

Locus of control

The study of ethics cases also highlighted locus of control. Patients with high religiosity may give a deferral of control to God. Surrogates with high religiosity may believe that care decisions belong to God and not themselves or the treatment team. But, there may also be a desire to regain control that is exemplified when families invoke religious beliefs to assert control in situations in which they felt powerless (27).

Other research literature shows a potential relationship between religious beliefs and health control. For instance, one study found that higher scores on a scale to measure “God Locus of Health Control” beliefs such as “God is in control of my health” and “Whatever happens to my health is God’s will” were associated with late-stage disease at presentation for patients with colon cancer (22). Beliefs that place God at the center of control for one’s health (a type of externalizing religious belief) often involves deferring responsibility for health outcomes from self to God (22,42). Believing in miracles has been associated with greater life satisfaction, but also with greater “divine health deferral” which is associated with poorer physical health (42,43). Attributing health concerns to external sources such as God may provide a coping mechanism for some patients. A mild reduction of stress caused by the existence of health problems may occur by placing the locus of control for health results outside of oneself and in the hands of God. However, this process may also reduce motivation to engage in positive health behaviors that range from employing preventative measures to adhering with recommended treatments to seeking to fully understand one’s terminal illness or delaying EOL discussions and decisions (13,22,23,42,43). In addition, deferral to God has been associated with lower levels of advance care planning engagement (24-26).

Divine deferral of health responsibility and belief in miraculous healing were reported to be higher among Evangelical Protestants and Black respondents in a study examining religious beliefs about health control. Socioeconomic status, health risk, and religious exposure all contribute in part to these findings. People with lower SES are especially vulnerable to inadequate access to health care along with restricted capability to take personal control of their health (43). These individuals may cope with the latter through a belief in miracles or deferring their health concerns to God.

Coping through a belief in miracles may be on the rise, especially among religious people (44,45). Religious communities may be buttressing this growing belief in the possibility of a miracle (17). Belief in miracles or God’s intervention appears to impact the medical decision-making of patients and their loved ones (29,46,47) with many religious people likely seeing medical treatments as a primary avenue through which divine intervention such as miracles can take place (17,48). Thus, many religious peoples and communities may see declining or withdrawing medical treatments as restricting a crucial means by which a miraculous healing from God can occur (17).

Community clergy

Half of terminally ill patients are visited by community religious leaders, so it is important to examine how clergy can influence the impact of religious beliefs on patients at EOL (23,28,30,49). A significant majority of clergy endorsed life-prolonging beliefs, such as God’s ability to perform a miracle leading to cure of a patient with a terminal diagnosis (86%). Fewer, but still a significant percentage, of clergy affirmed seeking treatment because of the sanctity of life (54%), postponing medical decisions because God is in control (28%), and redemptive suffering vindicating perseverance of painful medical procedures (27%). This messaging is more likely to come from Black ministers, clergy serving congregations of low income, Evangelical clergy, and Pentecostal clergy. Clergy who sanctioned life-lengthening religious beliefs and values were half as likely to have a discussion with their congregants about hospice care and limiting treatment. Without this discussion with their community clergy, patients were half as likely to receive hospice care and twice as likely to receive ICU care in the last week of life. Clergy affirmation of divine control leading to deferral of medical decisions predicted ICU utilization in the final week of life (23).

Some clergy hold religious beliefs and values that both support aggressive treatment for patients with incurable illness and acceptance of death (23). Those that prioritize intensive EOL treatment may not realize the impact of their spiritual support actions in terminal illness (17,23). Many clergy report being reluctant to challenge patients’ assumptions about religious beliefs which can drive the pursuit of life-prolonging measures (30).

Medical aid in dying (MAID)

One study of the views of clergy regarding ethical EOL controversies, including MAID, revealed several relevant beliefs; 80% of clergy think there are some circumstances in which a patient may be allowed to die with only 16% believing that everything possible should be done to save a patient’s life in all circumstances (28). This suggests that a majority of clergy make an ethical distinction between physicians allowing a terminally ill patient to die and physicians intending death via MAID (28). In addition, three specific religious beliefs of the clergy associated with negative views toward MAID are worth noting. First, 59% of clergy believed the worth of a person’s life is not measured by one’s quality of life and that suffering at EOL does not diminish the sacredness of life. Second, a majority of clergy believe that only God controls the timing of death. Any actions perceived as rejecting divine authority about the timing of death and giving that authority to any human are considered wrong. Finally, 27% of clergy see physical pain and suffering as serving a spiritual purpose and exhibiting virtue through patience in suffering. This holds the promise of transcendent meaning as well as exemplifying human dignity despite physical suffering. Although MAID may stop the temporary trial of pain, it may block the prospect of spiritual growth within said pain at EOL (28).

Spiritual resolution, acceptance, and peace

The role of religion and spirituality in providing meaning, comfort, strength, acceptance, and emotional stability at EOL is an important consideration for palliative care providers. Many providers often recognize how spirituality and religion helps patients positively cope when facing their mortality. One study showed that the illness event can catalyze spiritual change and transformation which can be a pathway to spiritual resolution, acceptance, and peace (11). This highlights the importance of the treatment team providing spiritual support to patients with terminal illness.

Interprofessional spiritual care

Knowing that religion and spirituality are important to most Americans and spiritual needs are common, it is essential to provide comprehensive spiritual care at EOL. Provision of spiritual care by the healthcare team is associated with better patient EOL outcomes, including higher rates of hospice enrollment, less aggressive interventions at EOL, and fewer ICU deaths (17,50). In fact, high religious coping patients with advanced cancer who received full spiritual support from the treatment team for their spiritual needs had near five-fold greater odds of receiving hospice care and more than five-fold decreased odds of receiving aggressive care at EOL as compared to those not receiving such support (51). Comprehensive, patient-centered spiritual support from the treatment team at EOL has been shown to increase patient quality of life at EOL (51) as well as decrease medical care costs at EOL (52).

Despite clear benefits, patients infrequently receive spiritual care from treatment teams (50,53). Inadequate resources, lack of training, lack of time, provider discomfort, and provider desire to avoid offending patients or projecting personal beliefs all contribute to insufficient provision of spiritual care (17,21,53,54). However, the data shows clear benefits, so efforts by palliative care teams to provide spiritual support for terminally ill patients are warranted. A collaborative approach to spiritual care involving the multiple members of the treatment team is the criterion standard at EOL (4,54-58). All members of the patient care team can act as spiritual care generalists by performing spiritual screenings and spiritual histories (54,59). In addition to initial assessments, spiritual care generalists can provide spiritual care with a simple strategy of compassionate connection with patients and by bearing witness to suffering (60,61). When front line screenings find spiritual distress or need, the generalist can refer to spiritual care specialists, board-certified chaplains (BCCs) (21,54,55,62,63).

BCCs are essential when patients give signs of more complex spiritual needs or distress. BCCs use detailed spiritual assessments to tailor in-depth spiritual support (64). There are several spiritual assessment models used within palliative care settings (59,63,65), including the Palliative Care-7 Assessment (PC-7) which provides a measurable assessment of spiritual and religious concerns for palliative care patients near EOL (63,66).

For these reasons, it is important to assess the religious beliefs of patients as these beliefs can contribute to healthy coping and a sense of wellbeing at EOL, and if not supported they can contribute to spiritual distress. A multilevel approach to spiritual support for patients includes general assessment and support from the full treatment team and secondary support when needed by spiritual care specialists to explore deeply into how patients’ religious beliefs may be impacting their well-being at EOL (54,67-69).

Spiritual care that is provided through an interdisciplinary treatment team approach is more medically literate than support from community clergy and is thus positioned to integrate the religious beliefs and values of patients with the medical realities of a patient’s illness. A respectful engagement by the treatment team with the religious beliefs of patients which sways their EOL medical decisions has the capacity to help patients find spiritual peace as they face their mortality. The treatment team that tries to support patients in finding a way to affirm their beliefs as they transition from a curative treatment focus to EOL care such as hospice helps patients and caregivers to feel heard and respected (51,61).

Religious beliefs and values in EOL medical care are informed by an individual’s cultural background and experiences, and BCCs have significant expertise in providing culturally literate care to minimize distrust in the medical system. The framework of cultural and religious humility and curiosity that BCCs employ has the potential to help provide effective and compassionate EOL care to religious and ethnic minorities (70-73).

Miracle talk

Given the high proportion of Americans who believe in the possibility of miraculous healing, the use of miracle talk by patients and families occurs frequently at EOL. This topic bears special consideration.

Four patterns of miracle talk can materialize during EOL scenarios, according to a review by Shinall et al. (74), and includes the innocuous, shaken, integrated, and strategic hopes for a miracle. “Innocuous” is language used to express a hoped-for medical outcome, but one that the patient does not truly anticipate happening. The “shaken” talk refers to when patients recognize that a miracle is not forthcoming and includes a sense of disappointment and grief. The patient’s trust in God may be shaken in this situation. The “integrated” hope for a miracle fits within the patient’s religious worldview, and the “strategic” miracle talk seeks to establish some sense of control in an otherwise powerless situation (74).

Whenever a patient or family expresses hope for a miracle of any kind, the treatment team should acknowledge and address this language, and several strategies have been proposed (74,75). Initially, a simple statement, such as “that would be wonderful” or “that would be fantastic” serves to affirm and align with the patient. This works particularly well for the “innocuous” hope for a miracle. For the “shaken” talk, providers should create a sense of safety and security to allow the patient to express and explore their distress. The “integrated” hope for a miracle responds well to a confirmation from the treatment team that everyone is both rooting for a miracle and providing appropriate medical care. Lastly, a “strategic” hope for a miracle can potentially lead to conflict with the treatment team, so it is important for the team to identify the causes of mistrust and providing support for a patient’s emotions (74,75). The AMEN protocol stands for “Affirm, Meet, Educate, No matter what” and also provides framework for responding to the patient’s belief in miracles at EOL (75).

Importantly, not all hope for a miracle occurs in the setting of mistrust in the healthcare system, and may simply be an expression of integrated religious hope. Treatment teams need to build trust in these moments through genuine care and presence to help patient’s maintain hope and hold space for their belief in miracles (32).

Training for community clergy

Medical professionals and healthcare institutions can provide education and training to religious communities and clergy regarding EOL. As Balboni and co-authors share, training for clergy to increase their EOL knowledge as well as in how to apply their religious beliefs and values within their practice of spiritual care with dying congregants may help clergy and their congregants to balance a belief in miracles or the sanctity of life with acceptance of and preparation for death as they consider EOL decisions together (23,30). Palliative care providers may be especially equipped to train clergy in balanced communication at EOL that legitimizes a hope for a miracle while also providing a theological framework which accounts for a poor prognosis and acceptance of death (30,76). Spiritual care specialists such as BCCs can train palliative care teams as well as clergy concerning such theological frameworks as part of nuanced spiritual care at EOL.

Conclusions

As this narrative review shows, religious beliefs have an enormous impact on choices patients and families make at EOL, and how treatment teams interact with these patients to provide the best possible EOL care when the medical realities of a situation mean that a person will die. Religious beliefs such as releasing control to God and the possibility of miracles are held by many patients during serious illness, and become even more pressing at EOL. These beliefs, often facilitated and reinforced by religious communities and clergy, can impact EOL medical care and decision-making in many ways. Concerningly, they may lead to results such as lower levels of advanced care planning and more intense care at EOL, which ultimately increases healthcare spending and does not align with the type of care most people favor at EOL.

As discussed in this article, spiritual care provided by treatment teams leads to more hospice usage and less aggressive care at EOL. While the highly skilled BCC is an essential member of the interprofessional treatment teams when offering spiritual care, all members of the treatment team can use specific spiritual screening tools and approach patient and family’s religious and spiritual concerns and beliefs with curiosity and humility.

There are many limitations to this study. This was a review of a single database and did not include databases that have a more religious perspective. Most of the studies were focused on Christianity within the U.S., with an underrepresentation of non-Christian religious and contemplative faith traditions in the review, which may affect generalizability to a non-Christian population. There is also inconsistency in how spiritual care is defined and provided in these articles and lack of randomized, controlled trials. There is also still limited literature on quantifying the impact of spiritual care providers on EOL outcomes.

While this article begins to explore the role of spiritual care in supporting EOL decision making, much more research is needed. Areas to consider include ways in which palliative care teams can work with BCCs when possible, and independent of them when none are available, is warranted to enhance care and support patients with all religious and spiritual needs at EOL. Additionally, expanding research into populations with non-Christian religious backgrounds both in and out of the U.S. will be important. Finally, opportunities to demonstrate through randomized, controlled trials will further quantify if there are causal relationships between provision of spiritual care and improved EOL outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-25-89/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-89/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-89/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This case is hypothetical and does not involve any real patient data. Therefore, ethical approval and informed consent are not applicable.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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