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

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HKSPM Newsletter 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 HKSPM Newsletter Mar 2004 Issue 1 : p 8
HKSPM Newsletter 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! HKSPM Newsletter Mar 2004 Issue 1 : p 9
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