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Patterns of Religious Practice and Belief in the Last Year of Life

^a Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey
^b Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
^c Department of Psychiatry, Duke University Medical Center, Durham, North Carolina

Ellen L. Idler, Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 30 College Ave., New Brunswick, NJ 08903 E-mail: idler{at}rci.rutgers.edu.

	Abstract

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Objectives. Although it is frequently assumed that issues of religious faith become more salient at the end of life, there is little or no population-based empirical evidence testing this assumption.

Methods. Using data from the New Haven site of the Established Populations for Epidemiologic Studies of the Elderly (N = 2,812), the authors examined self-reports of attendance at services, self-ratings of religiousness, and strength and comfort felt from religion for respondents who did and did not die within 12 months following an interview. Religiousness was assessed at baseline (1982) and in follow-up interviews in 1985, 1988, and 1994. Cross-sectional comparisons of levels of religiousness were made among persons in their last 6 months of life, persons in their last 12 months of life, and persons who survived 12 months, and longitudinal comparisons were made with religiousness at the previous wave.

Results. After adjusting for age, sex, education, marital status, religious affiliation, and a set of health status measures, the authors found that although attendance at religious services declined among the near-deceased, this group showed either stability or a small increase in feelings of religiousness and strength/comfort received from religion. Overall levels of attendance and religious feelings were high for this religiously diverse sample.

Discussion. Community studies of respondents in their last year of life are rare. In this sample, religious involvement appears to continue throughout the last months of life.

ACCORDING to conventional wisdom about philosophers' wagers and the absence of atheists in foxholes, religious faith is of critical importance at the end of life. But how salient are issues of faith and spirituality in the period immediately preceding death? Are there identifiable changes at the end of life, signifying a common experience of these issues in old age? Or do religious beliefs and practices remain stable throughout this stage of life? We know very little generally about the quality of life at the end of life and practically nothing about religious and spiritual identities in this critical period (Bradley, Fried, Kasl, and Idler 2000). A recent review of the literature on ethics and spirituality at the end of life concluded that although a great deal has been written about ethics, very little has been written about spirituality (Bevins and Cole 2000). Moreover, the small number of studies of religiousness at the end of life are primarily in the nursing literature and are often limited to populations of AIDS or cancer patients, many of them relatively young.

In this study we had a rare opportunity to examine the patterns of religious belief and practice in a large and representative sample of elderly people in their last year of life. The sample was composed of healthy elderly people living independently in a religiously pluralistic community, and observed over 14 years. With repeated observations of religious practice and belief available to us, we compared those in their last 6 and 12 months of life to respondents who survived 12 months or longer following an interview; we also compared last-year-of-life respondents' religious beliefs and practices with their own responses to these questions 3 years previously. The large size, religious diversity, and representativeness of the sample; the prospective design of the study; and the availability of both behavioral and subjective measures of religious involvement make this study unique in the literature on the end of life.

	Expectations of Decline

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Theory in social gerontology is equivocal with respect to religion and aging. On the one hand, the early and now disregarded disengagement theory suggests that individuals should, and do, withdraw from social roles, including religious roles, as they reach old age (Cumming and Henry 1961). Cumming and Henry argued that both religious piety and attendance at religious services should and did decline sharply among their respondents aged older than 75. Two decades later, the disengagement theory again became the basis for expectations about religious involvement in old age; Mindel and Vaughan 1978, in a small but influential study, argued that disengagement from religion appeared to take place with some forms of religious involvement but not others. In their sample of 106 elderly Missourians, they observed that levels of organizational religious activity were not strongly correlated with nonorganizational religious activity; nonattenders were just as likely as attenders to listen to religious services or music on radio or television or to believe that their religion helped them understand their lives. The health of the respondents was a strong influence on these differences; when compared with the unimpaired group, the impaired group had lower levels of organizational religious activities, but higher levels of nonorganizational activities. The shortcomings of the study, however, were its cross-sectional design and lack of multivariable methods. Subsequent studies have shown that although there is considerable empirical evidence that attendance at religious services does decline with age (Blazer and Palmore 1976; Ploch and Hastings 1994), such declines are primarily attributable to illness and disability (Idler and Kasl 1997b; Levin and Markides 1985).

Recently, Hays and colleagues 1998 examined one of the forms of nonorganizational religious activity, the "electronic church." They found in a longitudinal study of elderly North Carolinians, that declines in attendance were caused primarily by declines in functional ability. They also found that the use of religious media increased over time, although this increase was not limited to those with deteriorating health. Thus the modified view is that there may be disengagement from some forms of religious organization but not others, and in fact quite high levels of nonorganizational religious activity may be maintained among impaired respondents.

A second line of research that might lead one to expect declining religious involvement, and that bears more directly on the very end of life, is the work regarding terminal drop or terminal decline (Berg 1996; Kleemeier 1962; Siegler 1975). The terminal decline hypothesis states that changes in many functions, including but not limited to higher intellectual functioning, are not correlated primarily with chronological age (distance from birth), but rather are a function of the individual's distance from death. Recent work in this area has taken a broad view that decline is pervasive in many areas of life in the period before death, and this broad decline represents a diminishing of the vitality of the self in all areas of functioning, not just in the intellectual arena. Findings from the Berlin Aging Study (BASE) have shown that time to death was associated with lower life satisfaction, lower positive affect, and more social loneliness (Maier and Smith 1996). No work of which we are aware has examined religiousness or spirituality in connection with terminal decline, even though the abstract nature of religious symbols makes it an intriguing question. To the degree that spiritual capacities or religious beliefs are associated with higher intellectual functions and/or emotional equilibrium, in addition to physical functioning, then one might expect decline in them.

It is also possible that religious faith takes on a different and negative meaning at the end of life. The passage of time may eliminate the opportunity for an individual to make restitution or receive forgiveness from another, leading to guilt and despair. In a spiritual context, the end of life may trigger a faith crisis with respect to an unjust God who would permit death to occur or to ineffectual prayer for healing, leading to decreased trust or hope in God's help.

	Expectations of Increase

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On the other hand, from the psychological perspectives of Erikson 1968 and Jung 1933, one would make quite opposite inferences about religiousness at the end of life. Erikson's influential eight stages of human psychosocial development culminate in old age, when individuals are faced with the challenge of looking back over their lives and constructing an interpretation of them. Erikson called the psychosocial crisis of old age the crisis of ego integrity versus despair; the achievement of a sense of individual integrity he defined as "the ego's accrued assurance of its proclivity for order and meaning ... the acceptance of one's one and only life cycle and of the people who have become significant to it as something that had to be" (1968, p. 139). In his later writings, Erikson (Erikson, Erikson, and Kivnick 1986) speculated that it might be necessary to add a ninth stage to his scheme, consisting of "a sense or premonition of immortality ... as creatively given form in the world religions" (1986, p. 336–337). Similarly, there is Jung's blunt and frequently quoted statement that "among all my patients in the second half of life ... there has not been one whose problem in the last resort was not that of finding a religious outlook on life" (Jung 1933, p. 229). By and large, however, theories of psychological development in late life have had rather little to say about the role of religious beliefs. Interestingly, theories of faith development (Fowler 1981), which address issues of the development of religion and spirituality over the life course, posit at most a rather loose relationship between age and faith. These theories propose that development can become arrested at any stage or age, and that "mature" faith is achieved by a relative few. In our study we did not have any indicators of maturity of faith. However, one may expect that, as the individual's personal story takes shape and approaches completion, it can be increasingly articulated within the "master story" of the individual's faith tradition, allowing the dying person to find meaning in his or her life up until that point.

More recent studies of aging and faith have emphasized the importance of religious coping resources for meeting the particular challenges of old age such as bereavement, social isolation, cognitive impairment, pain, disability, and decisions about end-of-life care (Bevins and Cole 2000; Kimble, McFadden, Ellor, and Seeber 1995). Religious coping resources are seen as lowering depression and reducing anxiety, alcohol abuse, and even suicide, all of which are relatively common in elderly populations (Koenig 1995). Particularly notable is the work of Pargament 1997 and colleagues, who have argued that the most challenging moments of life occur in old age: "Painful as they are, these critical moments offer a remarkably open window into human character, faith, and the process of coping with the final transitions of life" (Pargament, Van Haitsma, and Ensing 1995, p. 47). In this view, religious coping resources offer the elderly individual the ability to maintain and integrate the self, to retain feelings of mastery over the environment, to continue their intimate relations with others, and to come to grips with mortality (Pargament et al. 1995). The success or failure of religious coping mechanisms is somewhat beyond the scope of this article, however. From the coping perspective we simply drew the premise that religious coping responses should be especially prominent in old age because this is the time when existential or health crises are likely to occur. Operationalizations of "religious coping" in the research literature have long included subjective states, cognitions, or emotions, as well as religious practices such as prayer (Ellison and Taylor 1996; Harrison, Koenig, Hays, Eme-Akwari, and Pargament 2001; Pargament et al. 1990). Hence this perspective led us to expect increases in both religious behavior and belief in those meeting the heightened adaptational challenges of old age.

Thus with conflicting theory failing to guide us adequately, we undertook an exploratory analysis of trends in religious behavior and belief in the period immediately preceding death. We examined cross-sectional differences between respondents who were and were not in their last 12 months of life for several indicators of religiousness. We also looked at change within respondents over time for three waves of data. Because the health status of respondents might have affected either their capacity to attend services or their religious feelings, we adjusted our analyses for several measures of health status. Analyses were also adjusted for age, sex, race, education, marital status, and religious preference.

	Methods

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Sample
Data for the study came from the New Haven site of the Established Populations for Epidemiologic Studies of the Elderly (EPESE). Data collection procedures have been described elsewhere (Cornoni-Huntley, Brock, Ostfeld, Taylor, and Wallace 1986). The stratified, weighted sample was representative of the elderly population of metropolitan New Haven, Connecticut (N = 2,812). Participants were interviewed annually in their homes or by telephone from 1982 to 1989 and once again in 1994. Mortality surveillance for the sample was continuous through 1996, and loss to follow-up was less than 1%. Virtually all deaths were confirmed by death certificate.

Response rates at baseline and at annual follow-up interviews were quite high for a community study. This is critical to the feasibility of this project, because selective initial response and attrition could be expected to have a disproportionate impact on respondents in their last year of life. At baseline, 82% of sampled respondents completed interviews, and response rates for annual reinterviews averaged 94–96% of the surviving sample. When a respondent was too ill to provide usable information, a close family member or care provider was asked to provide basic information. Proxies did not respond to items that called for the respondent's judgment or attitude. Deaths began occurring in the sample shortly after interviewing began. Fig. 1 shows the time period of the follow-up. Of the 2,812 respondents who began the study in 1982, just 939 survived for 12 months following their final interview in 1994.

View larger version (15K): [in this window] [in a new window]   Figure 1. New Haven sample, 1982–95, deaths occurring in the year following interviews that included religion items. Shaded areas of survival curve represent deaths in 12 months immediately following face-to-face interviews. n = 499. Data are from the Established Populations for Epidemiologic Studies of the Elderly.

Measures
We analyzed three dependent variables measuring religiousness. Responses to the question about attendance at religious services ("About how often do you go to religious meetings or services?") were recoded from six ordinal categories to number of times per year they represented. Those who never attended were coded 0 (times per year); those who attended once or twice a year were coded 1; those who attended every few months were coded 4; those who attended once or twice a month were coded 18; those who attended once a week were coded 52; and those who attended more than once a week were coded 104. Regular twice-weekly attendance at services is common for some churches in New Haven (Griffith, English, and Mayfield 1980). A second measure emphasized the subjective religious identity of the respondent ("Aside from attendance at religious services, do you consider yourself to be deeply religious, fairly religious, only slightly religious, not at all religious, or against religion?"). This item was coded so that the last two categories were combined, and the high score was for deeply religious (4). Finally, we assessed feelings of benefit from religion ("How much is religion a source of strength and comfort to you?"). This item was coded 1 (none) to 3 (a great deal). All items were analyzed separately. Proxies were asked the item for attendance at services, but not the subjective religiousness items.

Our measures of health status included functional ability, prescription medications, hospitalizations, nursing home stay, and bed disability. All health status measures were asked identically at each of the four interviews, and for each model we used the concurrent health status variables. Functional ability was assessed with a 15-item scale with scores that ranged from 0 to 150 ( = .87 for the 1982 scale; for details, see Idler and Kasl 1997a). Prescription medications were observed in the home by the interviewer; we used the number of different medications the respondent had taken in the past 2 weeks. Respondents were asked if they had been hospitalized during the previous year, if they had ever been a patient in a nursing home, and if they had spent more than 1 week in bed during the previous 3 months; each item was coded 1 for yes and 0 for no. The respondent's sex and age in years were included in all analyses. Finally, we adjusted for religious preference and race jointly by creating dummy variables for White Protestants, Black Protestants, Jews, and others/none and comparing them with the reference category of Roman Catholics.

Analysis
We began by comparing the last-year-of-life sample with the total baseline sample with respect to missing data. For our cross-sectional analyses, we estimated analysis of covariance models with each of the three religious involvement items in 4 years of follow-up as the dependent variable and religious preference/race and sociodemographic factors as covariates; in a second step we adjusted for current health status. We treated time to death following each of the four interviews as a set of two dummy variables, one for 0–6 months and one for 6–12 months, with 12-month survival as the reference group. Thus the two end-of-life groups were completely different for each year of analysis, whereas the comparison group of survivors remained somewhat the same, losing only those who died 12 months or longer after the previous interview but before the next one. For our longitudinal analyses, we created difference scores for each religion item by subtracting the respondent's score in 1982, 1985, or 1988 from his or her score in the next round of interviews (1985, 1988, 1994) and treated the differences as dependent variables in covariance models adjusted for the same sociodemographic and health status measures as in the cross-sectional analyses.

	Results

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Our first concern was that, even if our near-death respondents had agreed to interviews with very high response rates, there could still be substantial amounts of missing data within the interviews that would affect the analysis. A second concern was that the last-year-of-life group would be very different demographically from the total sample. These issues are addressed in Table 1 .

We present the cross-sectional data on patterns of religiousness in Table 2 and Table 3 . Table 2 shows each of the three measures of religiousness regressed on time to death and a set of sociodemographic and then health status variables, for 1982 only. Table 3 displays the least squares means calculated for each religiousness measure for each survival group in all years, with post hoc tests of significance. This approach shows two different but equally important aspects of the analysis: the relative importance of the last year of life as a determinant of religiousness (in Table 2 ), and the absolute levels of religious involvement of respondents in the three time-to-death groups (in Table 3 ).

The second pair of columns has a much simpler story to tell. With respect to how religious they believed they were, it made no difference whether or not the respondents were in their last year of life or not. Many other factors did differentiate within the sample: Men believed they were less religious than women; older people believed they were more religious than younger elderly people; those with more education and those who were married reported they were less religious than those who were less educated and unmarried; and White Protestants, Jews, and those of other religions felt less religious than Roman Catholics, whereas Black Protestants reported feeling more religious. Interestingly, none of these coefficients changed in any meaningful way when the health status variables were introduced in Model 2. None of the health status measures were significantly correlated with feelings of religiousness, with the exception of the number of prescription medications—the more medications, the higher the feelings of religiousness.

The final pair of models was rather similar to the second pair. Respondents who were in their last year of life did not differ in their feelings of strength and comfort from religion from those who survived. Other sociodemographic differences were also similar: Men; younger respondents; and White Protestants, Jews, and those of other religions felt less strength and comfort than women, more elderly respondents, Roman Catholics, and Black Protestants. The same indicator of poorer health status (number of prescription medications) was also associated with greater comfort from religion. Thus, of the numerous influences on feelings of religiousness in this cross-sectional sample of elderly people, whether or not one was in his or her last year of life appeared rather unimportant, and it mattered little whether or not health status was considered. These models explained 13–14% of the variance in religious feelings.

Table 3 examines these variables more closely, again cross-sectionally, in each of the 4 years. For each year, adjusted least squares means were calculated from the multivariate models presented in Table 2 (and replicated for the other years in analyses not presented). Post hoc tests of differences were run, comparing the means for each of the two last-year-of-life groups to the 12-month survivors. Briefly, there were only two significant post hoc differences among the 24 tests, a number only slightly above what one would expect by chance. Those who died in the next 6 months attended services significantly less often (in 1994) and were more deeply religious (in 1988) than who lived 12 months or more. Elsewhere, although there were no statistically significant differences, persons in their last 6 months, and last 6–12 months of life were sometimes more frequent attenders, sometimes less, when compared with those who survived 12 months or longer. The two measures of subjective religious feelings showed only very small differences, again in both directions. The most important feature of the table, however, is not the differences or lack of them, but the quite high average levels of involvement for all of the groups. Average attendance at religious services ranged from a low of 12 times per year, or once a month, for persons in their last 6 months of life in the last year of follow-up, to a high of 30, for persons in their last 6–12 months of life in 1988; where there was a significant difference, it was in the direction of lower attendance for the soonest to be deceased. Average levels of how deeply religious respondents felt were at or above the equivalent of "fairly" (3 on a 4-point scale); where there was a difference here, it was in the direction of deeper feelings of religiousness for the short-term survivors. Average levels of strength and comfort received from religion were also high, mostly 2.5 and higher on a 3-point scale, with no differences to speak of.

The next set of analyses moved from the cross-sectional to the longitudinal. We examined group differences in changes from the previous round of interviews, adjusted for age, sex, marital status, education, and the health status of the respondents at the later time. The bar graphs show an increase or decrease in religiousness as bars above or below the center line, which represents no change. Fig. 2 shows a slight increase in attendance from 1982 to 1985 for the 6–12-month and 12-month survivor groups, but it shows a significant drop of six times per year for the 0–6-month survivor group. In 1994 as well there was a significant drop in attendance from previous levels for the 0–6-month group, compared with the 12-month survivors. Recall from Table 3 that the absolute level of attendance in this population was very high.

View larger version (17K): [in this window] [in a new window]   Figure 2. Change in attendance from previous interview, 1985, 1988, and 1994. Means were calculated from models adjusted for all covariates as in Table 2 . N = 2,812. Data are from the New Haven site of the Established Populations for Epidemiologic Studies of the Elderly. *p < .05 for comparison of means with 12 or more months.

View larger version (12K): [in this window] [in a new window]   Figure 3. Change in religiousness from previous interview, 1985, 1988, and 1994. Means were calculated from models adjusted for all covariates as in Table 2 . N = 2,812. Data are from the New Haven site of the Established Populations for Epidemiologic Studies of the Elderly. *p < .05 for comparison of means with 12 or more months.

View larger version (10K): [in this window] [in a new window]   Figure 4. Change from previous interview in receiving strength and comfort from religion, 1985, 1988, and 1994. Means were calculated from models adjusted for all covariates as in Table 2 . N = 2,812. Data are from the New Haven site of the Established Populations for Epidemiologic Studies of the Elderly. *p < .05 for comparison of means with 12 or more months.

	Discussion

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In summary, our findings provide mixed support for the theoretical schema we presented at the beginning of the article. The findings do show evidence of declining attendance in the period immediately before death; this decline is evident for the last half year of life but not for the 6–12 months preceding it. This pattern would be consistent with the interpretation that the respondents in their last 6 months of life are experiencing rapid declines in health and functioning. To show that this decline is limited to those in their last 6 months of life we did some additional analyses (not shown), testing differences between the whole group in the last 12 months of life and those who survived 12 months or longer. We found that there were no differences at all between these two groups, in attendance or religious feelings. For this reason, we retain the focus on the last 6 months of life.

Also, the apparently lower levels of attendance in the 6–12-month group, when compared with the 12-month survivors, are almost entirely attributable to the poorer health of these respondents, because the significantly lower levels of attendance in the last-year-of-life group disappear when the analysis is adjusted for health status. The pattern of lower attendance is consistent with the multidimensional disengagement theory, in the sense that attendance would be the marker of religiousness as a social role. However, this decline in social engagement comes extremely late in the life course, and is clearly incomplete, if average levels of attendance remain as high as they do in the period immediately before death.

The stability/slight increase in the subjective measures of religiousness also supports the multidimensional disengagement perspective, because there is no decline here at all. Given the usual high levels of stability in attitudinal measures such as these, any change at all, and particularly an increase when the base levels are already so high, is worth noting. It is also noteworthy that health status has no impact on subjective feelings of religiousness. The possibility that terminal decline might affect religious and spiritual beliefs also has no support, because our more abstract, cognitive indicators of religiousness as identity or source of solace show no decline at all.

It appears that the multidimensional disengagement theory accounts for the patterns we see in our sample in that the behavioral and subjective measures of religious involvement behave differently. We also argue that the religious coping perspective contributes additional insight, in that the findings in Table 2 link poor health to higher levels of subjective religious feelings. The items themselves suggest that they are coping responses; respondents with higher numbers of prescription medications believe that they get more strength and comfort from religion and rate themselves as more religious than those taking fewer medications.

However, the approximate fit of our data with these theoretical schemes is not the most important finding of the study. We would rather emphasize the descriptive nature of the study, as a first look at the natural history of several forms of religious involvement in a large sample of elderly people approaching the end of life. It is far more important that we underscore that the lowest average attendance for any group studied is still quite high. For those with less than 6 months to live at the time of the final follow-up, the average attendance is still 12 times per year, or once a month. Thus we argue that it is the absolute, and not the relative, levels of religious observance and belief that are notable findings in this study.

These findings cannot be considered definitive; both the data and the analyses conducted here have limitations. This is a regional sample, and its particular ethnic and religious makeup may make the findings not generalizable to other elderly populations. The elderly population of New Haven is quite diverse in that it contains solid proportions of Christians, both Protestants and Roman Catholics, and Jews, and about half of the Protestants are African American. However, the sample overrepresents Roman Catholics and Jews and underrepresents Protestants, when compared with national figures. Moreover, it has only a tiny Hispanic (mostly Roman Catholic) representation and very few Muslims (included in "other religion"). As in many old northeastern cities, traditional neighborhoods divided by race, religion, and ethnicity have remained stable over generations. Churches and temples persist as the cultural centers of these geographical territories, providing services, support, and a sense of identity to congregation members who also know each other as family members and neighbors.

Perhaps a second limitation of this study is the uncertainty of the meaning of being in the last year of life. "Awareness of dying" has long been a topic of interest for social scientists studying populations of the terminally ill (Glaser and Strauss 1965; Seale 1991). These studies have concluded that there is a considerable range of awareness of how close to death one is, even among hospitalized, terminally ill patients with untreatable cancers. In a community sample such as ours, we must assume that there would be considerably less awareness on average than in a clinical sample. If many or even most study participants are unaware of how much time they have left, should we expect to see any differences in behavior or feelings at all?

At the same time, this uncertainty may be seen as a strength of the study. The potential for learning about the last year of life in a wide range of people is in itself an exciting development. As Lentzner, Pamuk, Rhodenhiser, Rothenberg, and Powell-Griner 1992 and Lawton, Moss, and Glicksman 1990 pointed out, most of the data on the quality of life in the last year of life comes from studies of individuals who have been identified as terminally ill, such as respondents to the National Hospice Study (Morris, Suissa, Sherwood, Wright, and Greer 1986) or the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT; Knaus and SUPPORT Investigators 1995), or from hospital or nursing home patients; the emphasis has been on the quality of life as a function of care for the dying. Seale and Cartwright 1994, Lentzner and colleagues 1992, Lawton and colleagues 1990, and more recently Liao, McGee, Cao, and Cooper 2000 have attempted to move beyond studies of patients, to study the last year of life of respondents living in the community. However, these investigators identified individuals for their studies by sampling death certificates and have thus been limited by biases inherent in retrospective methods of data collection and the use of proxy respondents. Authors of these studies were aware of and directly addressed the problems of bias in proxy response, but they noted that it is extremely difficult to identify elderly people who are in their last year of life prospectively. The only feasible way of doing that is by having a large sample recruited with a high response rate, followed for a long period with little attrition other than mortality, and interviewed annually, so that an interview takes place in virtually every last year of life.

This makes the design and execution of the EPESE studies ideal for studies of the quality of the last year of life of elderly people living in the community. Such studies should become even more important in the future, if the compression of morbidity and disability into the very last period of life continues (Fries 1980; Manton, Corder, and Stallard 1997) and successful aging increasingly means dying of old age rather than disease (Nuland 1993; Rowe and Kahn 1998). A recent Institute of Medicine 1997 report made the point that clinical care of the dying has proceeded without population data on norms or outcomes. Our study exemplifies the promise of population data for study of the entire population of elderly people, not just the minority who are being treated in hospitals, nursing homes, or hospices. We see this study as an effort to describe the social life conditions of a representative sample of the entire population of elderly persons in this community; it is a public health perspective rather than a clinical one.

The significance of religion at the end of life is often accepted as a matter of faith. The institution of the modern hospice, providing specialized care for the dying, has traditionally emphasized spiritual aspects of care. The founder of the hospice movement, Dame Ciceley Saunders, explicitly conceived of the hospice as a quasi-religious institution, regarding the spiritual care of the dying as central to the mission of the institution (du Boulay 1984). The current version of the primary text in palliative care, the Oxford Manual of Palliative Care, continued this emphasis (Doyle, Hanks, and MacDonald 1998). The often contentious debates about the place of religion and spirituality in modern medical care (Sloan, Bagiella, and Powell 1999) are subdued when the subject becomes end-of-life care. The influence of traditional religious beliefs on the decisions of patients and families about subjects such as advance directives or the importance of last rites is usually acknowledged and respected, even in secular hospitals (Grodin 1993). Our findings support the wisdom of such respect. Despite a perhaps predictable occasional decline in attendance at public worship services during the last few months of their lives, our respondents demonstrate no decline, and even some increase in subjective feelings and beliefs about their faith. Evidence from this community study underscores the need to keep these resources available for those who may no longer be able to seek them out for themselves.

	Acknowledgments

 
The first author was supported by Grant R01 AG16750 from the National Institute on Aging. The third author was supported by funding from the Fetzer Foundation, Kalamazoo, MI, and from the National Institutes of Health, National Institute on Aging, Grants K01AG00856-02 and N01-AG-1-2102 in support of the Established Populations for Epidemiologic Studies of the Elderly (Duke).

We thank the staff of the Yale Health and Aging Project, the New Haven site of the Established Populations for Epidemiologic Studies of the Elderly, Diane Davis, Julie McLaughlin, Allen Buurma, and DuWayne Battle.

Received for publication July 5, 2000. Accepted for publication April 18, 2001.

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