Spiritual Care At The End Of Life - Hong Kong Society of Palliative ...

HKSPM Newsletter
Spiritual Care At The End Of Life: A brief review of the
literature and cases sharing from a Christian's perspective
Marcella K.Y. LO, Assistant Director (Spiritual Care), Haven Of Hope Hospital
Dr. Antony C.T. LEUNG, Hospital Chief Executive, Haven Of Hope Hospital
Correspondence: kayeemlo@hotmail.com, aleung@ha.org.hk
Introduction
The definition of Spirituality is very broad.
‘Spirit’ indwells in the human being and was given
by God in the creation. The Bible says: “The Lord
God formed the man from the dust of the ground
and breathed into his nostrils the breath of life, and
the man became a living being” (Genesis 2:7). A
human being consisted of body, mind and spirit. A
human being is also created in God’s image.
Since God is spirit, all human beings have a
spiritual dimension.
Spirituality Vs. Religion
“Spirituality is the personal quest for
understanding answers to ultimate questions about
life, about meaning and about relationship to the
sacred or transcendent, which may (or may not)
lead to or arise from the development of religious
rituals and the formation of community. Religion is
an organized system of beliefs, practices, rituals
and symbols designed to facilitate closeness to the
sacred or transcendent (God, higher power, or
ultimate truth/ reality) and to foster an
understanding of one’s relationship and
responsibility to others in living together in a
community.” (Koenig, 2001) Therefore, spirituality
is broader than religious belief. A human being is
spiritual no matter he has a religion or not.
However, there is often confusion on spirituality
and religion in clinical practice. Many patients and
even some of the medical staff think that spiritual
issue is equivalent to religion. For example, a
patient says: “I am not religious, I don’t need a
chaplain.” Or a medical staff tells the patient “ Let
me refer you to see a chaplain whom will talk
about Jesus Christ with you ().” In fact,
spiritual care is much more than introducing a
religion. It involves the nurture of the spirit of the
human being in order to restore the peaceful state
that has lost due to sickness.
Spirituality and Religious tradition also have a
cultural influence. According to a study in Taiwan,
the thought (spiritual) need of a Chinese patient at
the end of life includes: “ getting through day by
day without thinking, meaningful life, expectation
that the suffering would be ending ” (Chao, 1993).
Another study opined that the spiritual needs of the
Chinese at the end of life includes: “meaning of
life, forgive and be forgiven, love and be loved,
hope and search for a religion.” (Yuan, 1998)
Different Models Of Care In Meeting The
Spiritual Needs And Promoting Holistic Care
More and more researchers have now
recognized the spiritual dimension in additional to
the traditional biopsychosocial aspects
of health and disease. Dr. Dana E. King
concluded that the biopsychosocial model did not
recognize explicitly the influence of religious
commitment and spirituality on health. She and
her colleagues integrated spirituality and
developed a biopsychosocial spiritual model in
order to make the health care more holistic. This
model was developed under the research of using
religion and spirituality as a coping mechanism in
medical illness. They found that “patients with
stronger religious beliefs and practices were
significantly less depressed at the time of hospital
discharge, even when controlling for severity of
the illness. In addition, patients with stronger selfreported
religious beliefs had better ambulation
states at discharge.” (King, 2000)
Sulmasy, in his study of this model, defined
spirituality as an individual on group relationship
with the transcendence which was about the
search for transcendent meaning through religion,
nature, music, arts, a set of philosophical belief or
relationship with friends and family. His research
was on the concept of human person as a being
in relationship. “Sickness, rightly understood is a
disruption of right relationship” (Sulmasy, 2002).
He also studied the relationship of human being in
terms of intrapersonal relationship, included
physical relationship of body parts, organs,
physiological and biochemical process and mindbody
relationship while extrapersonal relationship
included relationship with the physical
environment, interpersonal environment and the
transcendence. Therefore, Sulmasy defined
healing as “the restoration of right relationships”
(Sulmasy, 2002). Furthermore, based on this
concept, he found that at the end of life, although
the physical disturbance cannot be restored,
healing is still possible, since spiritual issues arise
in the dying process. Therefore, spiritual wellbeing
is a critical element in holistic health.
Spiritual healing is also a significant healing that
will bring peace and hope to patient at the end of
life.
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One of the most significant spiritual sufferings
at the end of life is existential suffering. Chochinov
and his colleagues studied the notion of dying with
dignity. They developed a dignity-conserving
model of end of life care including the issues of
hope, meaning, purpose and dignity, which could
improve the quality of end of life care. They found
that, for many patients, maintained dignity was
highly dependent on how they perceived
themselves to be seen. Therefore, supporting the
perception that patients maintain their sense of
worth, as affirmed by those who care for them is a
powerful dignity-conserving strategy. (Chochinov,
2002) This is also a model in which the patient’s
life history is concerned. The life story of a person
is a good resource in initiating and providing
spiritual care. The process of being listened,
acknowledged, and remembered is a healing
process that will help the patient to find the
meaning of life, identity, and hope.
Dr. William Breitbart, based on Viktor
Frankl’s logotherapy developed a model of
‘meaning centered psychotherapy’. “According to
logotherapy, the striving to find a meaning in one’s
life is the primary motivational force in man.”
(Frankl, 1939) Breitbart started his study with a
psychotherapy group, which was “designed to help
patients with advanced cancer to sustain or
enhance a sense of meaning, peace and purpose
in their lives even as they approach the end of life.”
(Breitbart, 2002) After an eight-week course, the
participants who had completed this course found
that they had a more profound way of thinking
about their lives and their mortality. They also
found that the connectedness with others or
something greater than themselves was important.
Therefore, meaning of life as a spiritual issue is a
factor that gives strength in suffering. It is like a
mother who can bear the suffering in giving birth to
a baby because it is meaningful to her.
Kaye Herth in his study, defined Hope as “an
inner power directed towards a new awareness
and enrichment of ‘being’ rather than ‘rational
expectations" (Herth, 1990). In his study of
“fostering hope in terminally-ill people” Herth found
that the presence of active spiritual beliefs and
spiritual practices are important sources of hope.
“The patient noted that their spiritual faith provided
a sense of meaning for their suffering that
transcended human explanations and fostered
their hopes.” (Herth, 1990) Therefore, hope is an
important element at the end of life. Hope gives
strength for enduring suffering. For the suffering is
not everlasting and by expecting a positive future
ahead, people can stand better against the
suffering.
Spiritual Care And Hospital Chaplaincy Service
With Cases Sharing From Haven of Hope Hospital
In some countries with Christian inheritage,
healthcare organizations are requested to have
established guidelines in spiritual care tailored to
meet the needs of the community (Scottish
Executive 2002). The chaplaincy on clinical
pastoral care services in Hong Kong has also
developed very rapidly over the past decade.
Most of the palliative care units now have support
from in-house or visiting hospital chaplains who
are an integral member of the clinical team. Their
valuable contributions in holistic care towards the
end of life are being increasingly recognized.
According to Judith Allen Shelly, “Christian
spiritual care focuses on helping others to
establish and maintain a dynamic personal
relationship with God by grace through faith.”
(Shelly, 2000) Gorman opined that “ Spiritual care
in the critical environment is always patientcentered
and works towards integration and
peace making” (Gorman, 2002). Through their
compassionate presence, empathy, listening,
prayer, scripture, ritual, worship, hymns, and
pastoral counseling, the spirit of the patient is
nurtured. The presence of the chaplains or clinical
pastoral care team facilitates the discussion and
supportive intervention of spiritual issues such as
meaning of life, life after death, interpersonal
relationship, hope of the future, existential
suffering, forgiveness and letting go the burden,
religious rituals and burial ceremony etc which are
especially important at end of life care. In Haven
of Hope, we observed a “3Rs” phenomenon in our
patients, which could contribute to a peaceful
death. The “Rs” stand for (1) Reconciliation with
self, (2) Reconciliation with significant others and
(3) Reconciliation with Creator God” as illustrated
by Figure I and the following cases sharing.
Case 1: Letting go of the anger inside
Mr. C, around 70 years old, was an aggressive
and strong willed man. At the beginning of his
admission, he was very quiet but angry inside.
He did not show any interest in the chaplain’s
visit. He was frequently upset with his physical
state and medical treatment. He always
complained about the “wrong treatment” he
received in other hospitals. He had actually
written a lot of complaining letters during the few
past years before and was still emotionally
submerged in his anger upon admission to the
Hospice Care ward in Haven of Hope. During his
hospital stay, the chaplain’s patient attitude,
pleasant visit and persistent prayers gradually
made an impression on him. One day, he paged
the chaplain and wanted to know more about
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Christianity. After some serious thinking, he became
a Christian eventually. A few days before he passed
away, he asked to see the Chaplain again. In the
meeting he showed the copies of all his complaining
letters written previously to the chaplain and asked
the chaplain to continue fighting for his case after his
death. The chaplain encouraged him to let go his
anger and feeling of injustice to God whom is the
final and most fair judge. Finally, he understood and
accepted the suggestion. He died peacefully after
he had let go all his anger, which he had harboured
for a long time.
Reflection: In this case, I found that “let go” is an
important way to deal with anger. A patient cannot
die peacefully harboring unresolved anger. Anger
from perceived ill treatment by others or unfairness
can be resolved when we understand that God, the
fair, highest and final judge is on our side and He
cares us. When we lay our burden down before
God, we are free.
Case 2: Loneliness In The Face Of Death And
The Issue About Life After Death
Mr. G was about 60 years old. He was an
intellectual and educated man. His family loved him
very much. They spent time with him every day and
night. He felt their love and caring. However, Mr. G
found that he still did not have peace. He had great
fear of death. Despite the nearly constant presence
of his family around him, he still felt very lonely in
the face of imminent death. He was frustrated and
depressed. He described himself as “ a ship sailing
in the ocean without a direction”. He started
searching for the eternal meaning of life and
received pastoral counselling from the chaplain.
Finally, he found transcendence after he received
Jesus Christ as his saviour. He said that he now
had a direction in his life and he knew where he
would go when he passed away. He also had an
assurance that Jesus would be with him even in his
dying process and would accompany him through
the valley of death. He did not feel lonely anymore.
Mr. G died peacefully.
Reflection: People may feel very lonely at the dying
process. Loneliness is an inner feeling despite the
number of people around. It could be a spiritual
issue. Compassionate presence and skillful
listening are important aspects of spiritual care to
facilitate a more peaceful death. More importantly,
many people experienced transcendence in their
newly founded faith in GOD and the promise of
eternal life. With the belief that they will be going to
heaven after death, they will have more courage to
face death and dying. It is like when people know
that they are migrating to a lovely place, they will
long for it. Therefore, having the assurance of life
after death is a hope for the future that will facilitate
peaceful dying.
Case 3: Taking Care Of Unfinished Business
Mr. B was dying in the hospital. The relatives said
that he could no longer recognized people when
the chaplain arrived, she sat beside him;
encouraged him to rely on Jesus Christ; prayed for
him, read him a scripture and held his hand for a
while. The patient had no response. When Mr. B
was still a resident in an old aged home, he had
allowed the chaplain to write his life story for
publication in a book describing spiritual growth in
frail elders residing in old aged homes. Despite his
poor physical condition, Mr. B took the matter very
seriously and tried his best to help. Although at
that time the chaplain was not sure whether Mr. B
was conscious or not, she talked to him in his ears,
“ Mr. B, you don’t have to worry about your
biography and the publication of the book. I do
remember what you have told me before and have
recorded everything down, I will finish the job for
you.” After a while, Mr. B suddenly woke up and
said,“ Are you chaplain A Thank you very much.”
After a few days, Mr. B passed away in peace.
Reflection: Project undertaken by the patient at
his end of life could have much significance to him
and his family. It may also carry special meaning,
often spiritual ones to them. Spiritual care workers
and the clinical team involved in end of life care
should pay special attention to this and try to assist
the patients to complete their projects.
Case 4: Reconciliation and Forgiveness
Mr. X was a middle-aged man. He had inoperable
liver cancer and his previously robustly built body
was now much emaciated. His temper though,
remained hot even upon his admission to the
Hospice for terminal care. He frequently scolded
his poor wife with abusive words and all the
relatives visiting were afraid of his explosion of
tantrum. However, he was a changed man after he
found forgiveness, acceptance and eternal hope in
Christ. His physical condition was going downhill
and one day he told the caring staff that he would
die soon. He asked the nurses to gather his close
relatives around and let them into his room one by
one. Then individually from his wife, his brothers,
to his 12 years old son, he shook their hands,
apologized to them, sought their forgiveness and
said farewell. This was a very beautiful scene.
The whole ward was touched. And surely as he
predicted, he passed away a few days later with a
smile on his face, finding peace and reconciliation
with himself, his beloved ones and God.
Reflection: The need to love and loved, as well as
to forgive and be forgiven are inherent in our
human nature. Restoring the broken relationships
with significant others and our Creator God brings
peace to the terminally ill. A peace that has
transcendent effect and could not be brought by
any medications!
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Conclusion
Spiritual needs are present and significant for
may patients in their last stage of life but many
healthcare workers lack the necessary skill to
uncover and address these issues (Murray 2004).
In providing holistic care to our patients and their
families, the spiritual aspect of the human being
cannot be ignored. Spiritual care may be specially
critical in palliative care where patients often
experience existential suffering and ask spiritual
questions. When a patient is at the end of life, we
cannot expect any physical growth or physical
healing but there is still room for spiritual growth
and spiritual healing. Meeting their spiritual care
needs can help to provide a patient with a good
ending in his life despite his physical suffering.
However, Spirituality is probably one of the most
ignored areas in healthcare research including the
palliative care field and further investigation in this
area is cogently needed (McGrath 1999).
Reconciliation, letting go, finding inner peace and
hope facilitated by good spiritual care and support
had been observed happening in many of the dying
persons.
Reference:
1. Breitbart W (200l). Spirituality and meaning in support
care: Spirituality-and meaning-centered group
psychotherapy interventions in advanced cancer.
Supportive Care in Cancer, 10(4): 272-280.
2. Breitbart W, Heller KS (2002). Reframing hope: Meaningcentered
care for patients near the end of life. An
interview with William Breitbart. Innovations in End-of
–Life Care, 4(6): www.edu.org/lastacts.
3. Chochinov HM (2002). Thinking outside the box:
Depression, hope, and meaning at the end of life:
Innovations in End-of-Life Care, 4(6): www.edc.org/lastacts.
4. Chao CSC (1993). The meaning of good dying of Chinese
terminally ill cancer patients in Taiwan. Ann Arbor, Mich:
University Microfilms International.
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6. Herth K (1990). Fostering hope in terminally ill people.
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Religion and Health. New York: Oxford University Press.
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Care 1999: 7: 3-9
10. Murray SA, Kendall M, Boyd K, Worth A, Benton TF.
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11. O’Gorman ML (2002). Spiritual care at the end of life.
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12. Scottish Executive Health Department. Guidelines on
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13. Shelly, JA (2000). Spiritual Care: A guide for caregivers.
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14. Sulmasy DP (2002). A biopsychosocial-spiritual model for
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December 1,2004 from Cancer.org.tw website:
http://www.cancer.org.tw/Library/Content7_Detail.aspID=1252
(in Chinese).
Figure I: The “3Rs” Phenomenon
leading to a peaceful death
RECONCILIATION with self,
others and GOD
“For God was pleased to have all his fullness dwell in him, and through him to RECONCILE to himself all
things, whether things on earth or things in heaven, by making peace through his blood, shed on the cross.
Once you were alienated from God and were enemies in your minds because of your evil behavior. But
now he has reconciled you by Christ’s physical body through death to present you holy in his sight, without
blemish and free from accusation” (Colossians 1: 19-22)
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