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Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.

328

• How do we distinguish spiritual pain and distress from

emotional or psychological needs?

In fact, what is the evidence that spiritual care should

remain an embedded part of palliative care and how do the

research findings of academics translate into the daily real-

ities of diverse palliative care settings across the globe?

Assuming that we can find answers to those dilemmas,

•

Who is best placed to address those needs, especially if

the patient or family does not identify as religious?

Yet who except a dedicated religious or spiritual advisor has

the skills or capacity to offer spiritual care in the daily round

of palliative care? This chapter will seek to unpack these ques-

tions before returning to the holistic vision which remains at

the heart of modern palliative care across the globe.

Understanding Spirituality

Despite the fact that much spirituality research continues

to be concerned with definitions and concepts, finding one

definition of spirituality which is universally acceptable

has been “notoriously difficult” [13] and practitioners

commonly find the notion of spirituality too vague [14–

16]. However, there is consensus over elements within dif-

ferent definitions [17, 18] which provide clues to usefully

understand spirituality in the clinical or practice setting.

First, something as “basic” [14] as spirituality, which

relates to the essence of our being [19], which is experi-

enced in community and resonates with personal cultural

scripts [20, 21], cannot be reduced to a “one size fits all”

concept. Nevertheless, shared “psycho-spiritual” elements

[22] can be found within each of the world’s religions and

“humanistic spirituality” “allows for both secular and reli-

gious orientations to find common ground in the notion of

what it is to be human” [13, 23, 24]. Explorations of

Spirituality in Palliative Care

Margaret Holloway

Introduction

Spiritual care has been embedded in palliative care from the

outset. In Cicely Saunders’ vision for hospice she talked about

“total care for total pain,” delivered by a multidisciplinary

team which included a chaplain alongside clinicians and

others. Spiritual care is included in definitions of palliative

care [1–4], including for children, which the WHO defines as,

“active total care of the child’s body, mind and spirit” [1 p. 13].

A chaplain is identified as one of the core professions in

today’s multidisciplinary palliative care team [5] while at

the same time competency in spiritual care is included in

standards for other disciplines [6, 7]. Service delivery pro-

grammes specify its inclusion, including the recording of

spiritual needs and preferences [8, 9]. Indeed, it is argued

that suffering and distress at the end-of-life cannot be alle-

viated without a “deep knowledge of the nature of

suffering,” integrating spiritual perspectives alongside

psychological and socio-cultural [10 p. 799].

In its origins, Saunders’ vision was simple. Both nursing

and social work trace their beginnings in charitable reli-

gious foundations and ministering to the dying and

bereaved has always been a significant element in the reli-

gious pastoral role, across all religions. However, in con-

temporary palliative care, the progressive secularisation of

western societies alongside greater awareness within palli-

ative care of the complexities of working in contexts of

religious and cultural pluralism, combined with crossing

of boundaries between health and care professions, have

led to a more complex scenario [11, 12]. Questions are

raised for the clinical team which have very real import in

practice.

•

What do we actually mean by spiritual care?

• How do we recognise spiritual need?

https://t.me/med1917

Spirituality in Palliative Care 329

The European Association for Palliative Care takes a sim-

ilar approach, describing spiritual care as multi-factorial

and embracing [33]:

•

Existential challenges (e.g. questions concerning iden-

tity, meaning, suffering and death, guilt and shame, recon-

ciliation and forgiveness, freedom and responsibility, hope

and despair, love and joy).

• Value-based considerations and attitudes (what is most

important for each person, such as relationships with one-

self, family, friends, work, nature, art and culture, ethics

and morals, and life itself).

• Religious considerations and foundations (faith, beliefs,

and practices, the relationship with God or the ultimate).

We shall explore these dimensions further in this

chapter to seek out how, as health and care practitioners,

friends and family, we can offer spiritual care which may

transform the negativity of dying and bereavement by illu-

minating its darkness.

Assessment of Spiritual Need

A literature review of spiritual care at the end-of-life [14]

found that tools which help identify spiritual need are

popular with practitioners. Both language and emphasis

have shifted from Cicely Saunders’ identification of

spiritual pain to an approach which looks at spirituality as

both resource and potential root problem. (Table 1).

Narrative and Biographical Approaches

In keeping with the hospice and palliative care philosophy of

helping a person to live until they die, of focusing on those

things which are important to this individual and their

family, tools which derive from narrative and biographical

spiritual practice in contemporary society suggest that

death is one of the key factors in understanding this

phenomenon [25]. Our task as practitioners, is, first, to

understand our own spirituality in the face of death, from

which foundation we can reach out to connect with the

spirituality of the other person [21].

Fundamentally, this is about finding meaning within what

may be chaotic, contradictory, or at first sight senseless. There

is plentiful evidence that the process of seeking and finding

meaning is a constant and enduring feature of human

existence [26] which, in contemporary secularised societies,

manifests as the creation of personalised meanings out of the

spiritual traditions and resources which are available [27].

Other approaches to conceptualising spirituality focus

on its attributes, for example, love, joy, peace, hope.

Discussions of spirituality and spiritual care at the end-of-

life emphasise meaning and connectedness but draw these

attributes into the process. For example, the US National

Consensus Project on Palliative Care defined spirituality as:

“…the aspect of humanity that refers to the way individuals

seek and express meaning and purpose and the way they

experience their connectedness to the moment, to self, to

others, to nature, and to the significant or sacred.” [28 p. 887]

Cicely Saunders has been credited with promoting this

concept of spirituality as meaning-making [29], represent-

ing the despair of the dying person as spiritual pain. This

brings us to another aspect of spirituality – that it is intrin-

sically bound up with the darkness of life, including the

suffering of those with terminal disease. Those definitions

of spirituality which emphasise its positive force may, at

first reading, jar with the realities of dying in circum-

stances (such as pandemic) when all that counts for best

practice appears to be undermined. Some writers deal with

this by “embracing the paradox” of death [30] and seeking

to understand the relationship between negative and

positive feelings and experienced spirituality [31].

From my own practice and research into spirituality in

death, dying, and bereavement, I have reached the

conclusion that it is useful to understand spirituality as a

coming-together of three dimensions [32]:

• Spirituality is concerned with meaning and purpose, in

particular, the search for meaning.

• Spirituality is experienced through relationships, and

those relationships may be with an external or “higher”

source, or sources of spiritual strength may be found in

families, friends, or communities.

• Spirituality promotes certain behaviours and practices,

within oneself and also towards the other person.

Table 1 Assessing spirituality as both resource and problem.

Purpose of assessment Outcome of assessment

Facilitate connection with

spiritual resources within

self, family, and

community

Strength and support

Identify unmet spiritual

needs and what might meet

those needs

Holistic care

Identifying where deep

spiritual distress is source

of agitation

Spiritual care the priority in

restoring well-being

https://t.me/med1917

330 Chapter 22

Both these tools take the same approach of seeking out

the spiritual resources which this person has to draw upon

and facilitating or strengthening their access to them, tak-

ing account of beliefs which the person holds which have

important implications for their treatment, especially end-

of-life care decisions.

Spiritual Pain or Distress

Narrative and biographical approaches are also useful in

illuminating the pain of deep spiritual distress. Spiritual

pain has been described as,

“pain operating at a deeper level of consciousness …

manifest in a wide variety of symptoms such as constant

and chronic pain; withdrawal or isolation from spiritual

support systems; conflict with family members and

friends; anxiety, fear or mistrust; anger; self-loathing;

hopelessness; feelings of failure … unforgiveness; despair;

and fear or dread” [36 p. 4].

The key to determining that what is being manifested is

spiritual distress, as well as the emotional and psychological

affects, is that gentle probing will uncover a religious or

spiritual issue at its root or core.

Certain factors commonly promote spiritual distress

and may, when combined, promote crisis:

• Loss of a faith which was once important in the person’s

life;

• A sense of alienation, dissonance, or deep conflict in the

inner self;

• A need to find answers leading to wrestling with unre-

solved questions, sometimes referred to as the “groanings”

of the soul;

•

A model of an external deity or force which is punishing,

unforgiving, disappointed, manipulative, and controlling [37].

However, it is important to balance appropriate psychiatric

care for depression at end-of-life with separate recognition

of existential despair, in which complete desolation, pro-

found meaninglessness, hopelessness, helplessness, and

powerlessness may be experienced [38]. The following

story (Box 1) illustrates how a psychiatrist and art therapist

worked together to address the deep pain manifested in

depression and existential despair.

Holding to a model of a negative external deity or force

is commonly associated with a history of abuse or very

strict religious upbringing and has been described as “neg-

ative religious coping” [39]. Box 2 illustrates how the

spiritual care advisor was able to help the patient find

peace by connecting her with other elements of her faith.

approaches have been widely used. For example, broad, gen-

eral questions might be used to elicit sources of meaning or

comfort in the person’s life. The FICA [34] and HOPE [35]

tools both use a mnemonic as a shorthand device.

The FICA Assessment Tool

This suggests four sets of questions stemming from the

domains of:

Faith, belief, and meaning

ii)

Importance (of faith) and influence

iii)

Community

iv)

Addressing these issues/actioning a care plan.

In each area, the practitioner or clinician begins with try-

ing to ascertain the importance of faith or a faith

community in the person’s life. Where the person does not

identify any formal religious background, the questioning

moves to trying to establish what are alternative sources of

meaning or broader spiritual support in their life.

The HOPE Assessment Tool

By contrast, the HOPE tool starts from broader sources of

hope and meaning (under the heading “sources of hope,

meaning, comfort, strength, peace, love and connection”)

and in so doing establishes whether religious faith is one

of these and if so, how important it is. For example, the

practitioner/clinician may ask what helps to sustain the

person in difficult times and may specifically ask whether

organised religion is one of their sources of support. If the

answer is “yes,” under the heading “Organised religion,”

questions are used to delve into how it is that their faith

helps, whether they derive significant support from a

faith community, for example, or, indeed, whether some

aspects (such as attending religious services) are not

important. If, however, the person points to the prime

importance of friends and family, for example, the

assessment moves into looking at “Personal spirituality or

practices,” independent of organised religion. It is impor-

tant to remember (although the tool does not make this

clear) that these personal practices may co-exist with par-

ticipation in formal religion or they may serve as an

alternative spirituality. For this reason, the first section of

the assessment, which looks broadly at sources of

meaning and sustenance, is extremely important, and,

skilfully conducted, should lead gently into the deepest

hopes and fears of the person facing death. The fourth

section, “Effects on medical care and end-of-life issues,”

allows the clinician/practitioner to explore the implica-

tions of the spiritual or faith position which the person

has shared, for their treatment.

https://t.me/med1917

Spirituality in Palliative Care 331

working [40]) with differing levels of skill, as in the Marie

Curie Religious and Spiritual Competencies model [41].

This identifies four levels of interaction that take place in

the hospice and the different competencies which are

required at each level. This starts with a basic awareness of

spiritual need and the listening and communication skills

to engage with patients about these, which, it argues, are

required of all staff or volunteers in their casual contacts

with patients, their families, and carers; Box 3 provides an

example of this level of interaction. The complexity prog-

resses from there through the ability to recognise and refer

“difficult needs” and develop a spiritual care plan to

address those needs (see Box 1 for a case example) to the

fourth level, appropriate only for those staff or volunteers

whose primary responsibility is spiritual and religious care,

whether of patients, visitors, or other staff. At this level, the

worker may expect to be engaging with complex spiritual

and existential needs; Box 2 and the Fellow Traveller

Interpreting stage provide case examples of this level.

Popular among practitioners is the notion of spiritual

companioning. The fellow traveller model of spiritual

companioning (Figure 1) illustrates how different practi-

tioners with their varying skillsets may, together, carry out

spiritual care in practice.

By asking the question “What can I do for you?” and in

careful listening to the answer, all practitioners can iden-

tify if and when another person on the team might be

better able to meet this person’s needs [42]; however, as

emphasised in the Fellow Traveller model, this does not

have to mean that the original team member withdraws,

but that they work together with a colleague to best support

the different aspects of care.

So how do these models help in the everyday realities of

practice? Commonly, practitioners report that they do not

feel equipped to address spiritual issues [43–45]. It is

important to find a model or approach which is both do-

able and inclusive. That means, one with which the

individual worker feels comfortable and which can be

delivered within their particular work environment [46,

47] and, most importantly, can be adapted so as to be

appropriate for the individual person in their family,

community, and cultural context. The “models” presented

in this chapter in fact do just that, and their different

approaches can be combined.

What they do not offer is step-by-step guidance as to

what the worker might do or say at any given moment or in

any particular circumstance. However, the following three

principles, all of which are embedded within the tools and

models presented in this chapter, offer a framework:

Models of Spiritual Care

In addition to models for assessing spiritual need, there are

numerous models designed to guide practitioners in

addressing those needs and providing spiritual support.

Sometimes this will be as part of a comprehensive

Box 2: Finding forgiveness and peace

Sandra was a woman in her 50s suffering from an inoperable

brain tumour. She had already lost her sight when admitted to

the hospice. Maureen, the spiritual care advisor, was called in

by the nurses because of Sandra’s extreme agitation, screaming

pronouncements of a religious nature – “I’m going to burn in

hell.” Sandra and her husband, David, belonged to a Christian

evangelical church. She appeared to be in spiritual anguish.

Maureen did not attempt to engage in spiritual ministry

through conversation but by gently holding and stroking

Sandra’s face, repeatedly assuring her that she was “safe and

secure.” This was the only thing which calmed Sandra, and the

nurses, who had felt there was little they could do for Sandra,

began to do the same. When Sandra died, a fortnight after

her admission, she was peaceful. The funeral reflected her

spiritual life as a singer and song-writer and Maureen found

it uplifting.

Box 1: A journey out of despair

Tim developed a brain tumour at the age of 30. He became

withdrawn when diagnosed, including with his wife. Following

psychiatric in-patient treatment for severe depression, Tim was

referred to Ella, an art therapist working in palliative care. The

psychiatric episode appeared to have been triggered by existential

despair – Tim had been brought up to believe that if he worked

hard, the rewards would follow, and now he felt both cheated

and a failure. When he started to draw after about a month, he

became very anxious and at times angry and frustrated. Ella

sees her role as being available to the patient, as a resource or

companion on their therapeutic journey. With Tim, she tried to

create a calm accepting environment in which his drawings could

be lodged, although he then discarded them. Two days before he

died, Tim did one final drawing which he presented to Ella for

her to keep. Ella believes that Tim had finally found a new way of

valuing his life. He appeared to be reconciled with himself as well

as with his wife.

assessment and holistic model of care and sometimes the

spiritual needs may be the starting point. People have a

diversity of spiritual need and thus require support from a

range of practitioners (see a model for interdisciplinary

https://t.me/med1917

332 Chapter 22

• “Being there”

• Helping to find sources of meaning

• Supportive care – “holding a safe nurturing space”

• Empathy and compassion – entering into “weak places”

• Attentive listening

• Sharing the journey

• Sustaining

From this we might conclude that spiritual care is as

much about being as doing. The notion, familiar to pallia-

tive care workers, of “sharing the pain” is one such example.

1. Our starting point must be the needs of the person and

those around them, to be open to the clues they give about

their sources of meaning and spiritual support.

2. We must understand enough about our own spiritu-

ality and journey, to be comfortable with that of the other

person [47–50].

3. We should neither under-estimate nor over-estimate what

we can offer, at any point and for however fleeting a moment.

Research has identified what it is that those healthcare

workers who are comfortable engaging in spiritual care say

that they do in practice [14, 51]:

JOINING

Spiritual awareness. Start where

the person is.

Appropriate for every worker

Robert is a palliative care consultant physician. He is treating Luke, a young man with an aggressive

osteo-sarcoma. Robert feels helpless in the face of Luke’s pain, which seems to consume his whole being.

He asks Luke if there is anything else he can do for him. Luke asks to see the chaplain, although he had

not indicated any religion on admission.

LISTENING

Spiritual sensitivity. Assessment

of significance of spiritual issues.

Every worker up to a point

Elsie and her family are referred to Mike, the hospital social worker, because of family conflict. Elsie

has been a spasmodic church-goer throughout her life but she used to attend the Communion service

when she was a day hospice patient and she has expressed regret that she doesn’t feel “up to”

participating now. Her daughter, Susan, has told nursing staff that her mother’s “return to religion” was

purely to do with loneliness after her husband’s death and they are all better off without a God who

allows such suffering. Susan’s daughters, Louise and Samantha, are both very close to their grandma

and cannot bear the thought that she might die soon. Both girls attend Church parade as Girl Guides

and have asked for prayers to be said for their gran. Susan is angry and dismissive of this. Mike begins

to see Susan separately, gently untangling with her, feelings of anger and loss. Simultaneously, he

arranges for the chaplain to offer communion to Elsie at her bedside and for the church youth worker

to talk to Louise and Nicky.

UNDERSTANDING

Spiritual empathy.Only workers

with understanding of own

spirituality

Cathy is a palliative care nurse who works with a young couple, Nicky (who has breast cancer) and

Sean and their three-year old son, Liam. Cathy feels that by shouldering some of the practical and

physical burden and struggle for the family, the palliative care team gave Sean and Nicky the space to

complete emotional and psychological tasks. She describes Nicky as having embarked on her last

journey when she entered the hospice, investing ordinary events with new meaning which seemed

“almost spiritual,” although Cathy says she herself is not religious.

INTERPRETING

Spiritual exploration

Only workers with specialist

training or in conjunction with

religious professional/spiritual

care advisor

Laura is a social worker in a children’s hospital who had supported Vicky, a lone mother whose child

(Maddie) had a life-limiting condition. After Maddie dies, Laura feels at a loss to deal with Vicky’s

questions, such as where Maddie is now, and suggests she speak to the chaplain, Phil. When Vicky

angrily dismisses this idea, Laura talks to him herself. Phil suggests that she focus with Vicky on those

things which help her feel connected to Maddie. This helps to some extent but Vicky returns to

questions about the After Life which leave Laura out of her depth. She tells Vicky that that she had

found the chaplain friendly and open when she had shared with him her own struggles over Maddy’s

death. Vicky is struck by this and says she would like to talk to Phil.

The fellow traveller model. (adapted from [20]).Figure 1

https://t.me/med1917

Spirituality in Palliative Care 333

Suppose, however, that the source of the spiritual pain this

person is experiencing lies in a relationship which has

broken down, and it may not be possible to repair that rela-

tionship – perhaps because the person has died, perhaps

because they are not able or willing to forgive. Or it might

be a traumatic event of long-lasting impact, which cannot

itself be changed. This is where the twin concepts of whole-

ness and hope come into play.

•

A helpful short-hand definition of hope comes from a

group of mental health service users in an Australian study

[54] that no matter how bad things seem, it is possible to

hold on to the essential goodness of life.

•

That means being able to experience wholeness: within

myself and in relating to my immediate and wider environ-

ment. As one of my research respondents put it, “I’ve just

had to make a whole of all the bits and pieces” [55 p. 304].

When the care-giver is able to facilitate the employment

of hope, engender a sense of wholeness and transformational

change which allows the dying person to transcend the

darkness of their death, they are engaged in “co-creation of

a new narrative” [56].

Spirituality and Spiritual Care in

Multicultural Context

One of the criticisms of contemporary spiritual care is that it relies

on definitions of spirituality derived from research in western,

secularised societies; indeed, some have argued that “spiritual but

not religious” has no meaning in other world views [58].

Spiritual Needs of Specific Cultural Groups

In addressing this deficit, one approach is to focus on the impli-

cations for palliative care of the beliefs and practices of particular

groups. The Cicely Saunders Foundation has produced a set of

recommendations for spiritual care with Black and Minority

Ethnic Groups receiving palliative care [59]. Pointing out that

for many of these patients their faith is strengthened during

serious illness and that they wish to discuss the implications of

their beliefs and spiritual needs with physicians, the report rec-

ommends that palliative care services should work in close

partnership with local faith communities. There is a need to

counter ignorance and discomfort on both sides.

The authors recommend a shared model of spiritual

care between palliative care services and local faith

groups, which addresses education and training, referral

mechanisms, documentation of spiritual well-being in

assessments, and provision of a range of spiritual resources

With those principles in mind, there are certain “hooks”

or anchors in spiritual care practice.

Transcendence, Transformation, Wholeness,

and Hope

Listening to the other person’s story of their life, including

their spiritual journey (although they may not couch it in

traditional religious terms), allows us to reach behind the

patient receiving palliative care to the person facing their

own death. They may find fresh understanding of who they

really are and what is important to them [52]. In recognis-

ing this, the carer, “knows that the person lying apparently

helpless in the bed, whose medical progress is now termed

deterioration, has important inner steps still to take, steps

which may sometimes become strides” [30 p. 28].

For me, four concepts underpin the task of supporting

the person in their spiritual journey at the end-of-life

(Figure 2) (see [20] for a fuller exploration of these).

The notion of transcendence carries with it a whiff of

“other worldliness,” which has led some to bring it down to

the mundane and everyday by suggesting that it is about

“making the best of things” [53]. Yet spiritual care must be

about supporting the person in more than that.

• It may not be possible to change a situation or circum-

stance, but the problem is transcended when it no longer

has the painful, negative, or oppressive impact which it did.

• In this process, change or growth takes place within,

which is in itself transformational.

Box 3: Sharing the pain

Neil has motor neurone disease and attends the day-care unit

in his local hospice. His daughter also has motor neurone

disease and is currently an in-patient in the hospice. Gillian is

a healthcare assistant on the day-care unit. She and Neil form

a special connection built partly around shared memories of

having grown up in the same area at the same time, but, most

especially, Gillian’s daughter, who was the same age as Neil’s

daughter, had died about a year ago. Neil talks about his fear

of dying and shares his deep sorrow, grief, and guilt about his

daughter’s impending death and frustration that he cannot

even hug his wife when she needs comfort, nor articulate his

love for his family. Sometimes Gillian just sits with him while

he cries, where other people seem to avoid his pain. Just before

he dies, he is able to tell his wife that he loves her; she tells Gil-

lian that this was healing for them both.

https://t.me/med1917

334 Chapter 22

A Transcultural Approach

A broader approach seeks to find points of connection bet-

ween different faith and belief approaches, variously suggest-

ing that there are universal elements in all religions [22] as

well as common themes in how spirituality is understood

and experienced [21, 65]. Using listening and empathic skills,

the practitioner can thus engage with the unique experience

of the other person at the end-of-life, “maintaining the spirit”

by relating to the meanings sought and ascribed by them,

where one’s own traditions and practices may differ [21].

Reminding us that death is difficult across all cultures, an

Australian study concluded that an important first step is to

establish the “rules of engagement” around discussion of

diagnosis and treatment [66]. This may be particularly

important for chaplains, who come from a specific religious

and choice of spiritual care provider. These should be

underpinned by culturally specific knowledge and aware-

ness within the palliative care team, including the ability

to recognise and explore spiritual beliefs and narratives

which are potentially harmful, both to the patient’s sense

of wellbeing, but also to their ability to make informed

choices about treatment.

The relevance of these recommendations can be seen

when looking at these examples of research into the needs

of specific health groups.

Figure 2 Conceptual building blocks of spiritual care [57].

• US Latinos living with cancer were found to have

resorted to folk healing traditions for psycho-social-

spiritual support because they experienced a lack of

cultural fit with formal healthcare, preferring a holistic

model which merges religious and health practices [62].

• In a longitudinal study of over 2000 HIV-infected

Americans, women, non-whites and older people

reported higher levels of religiosity and spirituality;

importantly, 72% overall reported that their religious and

spiritual identities informed their decision-making [63].

Box 4: Research into spiritual needs of

specific groups

• Among rural older Americans with serious diabetes and

declining health, ethnicity was associated with private

religious practice, with African Americans having higher

levels of private practice than Native Americans, who in

turn showed higher levels than white Americans. Public

religious participation for all groups declined as their

health declined, suggesting that this may result in unmet

religious and spiritual needs at the end-of-life [59].

• Lack of understanding among healthcare professionals

of the SE Asian practice of burning clothes to provide for

the deceased can result in a psychiatric diagnosis [61].

• For devout Muslims, increased spiritual practice is a

necessary part of their preparation for death and not

simply for comfort [60].

https://t.me/med1917

Spirituality in Palliative Care 335

• It follows, therefore, that all members of the palliative or

healthcare team must be able to first, recognise spiritual

need and spiritual distress or pain, and second, engage

with this aspect of care as far as they are able; in some

cases, this will mean referral at a particular point to a more

appropriate person to meet these needs;

•

Not everyone (patients or staff) comes from a con-

firmed belief position or adheres to a particular religious

faith so we need to understand a broader spirituality and

make connections between this within ourselves and

within the other person.

There are multiple tools available to assess spiritual need

and offer spiritual care and this chapter has presented a

range. Despite this, we know that health and social care

practitioners can feel confused, inhibited or simply over-

whelmed by the challenges of supporting people and their

families at the end-of-life, such that spiritual care can seem

one thing too much and best left to the spiritual or reli-

gious professional. They, in turn, can feel that their own

identity may be off-putting for the person from a totally

different background and perhaps that their training has

not equipped them to bridge this divide. Yet we have

looked at how much unites us in our common humanity as

we face death. What is most important is that you, the

reader, can find in these resources those which resonate

with your own understandings and experiences of spiritu-

ality and with which you can engage as you travel with the

dying person and those close to them. Holistic care is

essentially about engaging our whole selves with the whole

person in need. It is this, however it is achieved, which lies

at the heart of palliative care.

References

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tradition, but may, in the “caring moment,” find themselves

ministering to people from a wide range of religious back-

grounds and faith, or non-faith positions. For example,

healthcare decisions are profoundly influenced by beliefs

and values about death and what happens after death, and

it is argued that chaplains should use their own experience

of weighing the issues to offer comfort, support, and

guidance, within the other person’s framework of belief –

religious or humanistic [30, 65–67]. Assumptions should

not be made based on cultural identity alone; a study of

Asian medical students from different cultural back-

grounds found varying personal narratives despite strong

identification with traditional beliefs and rituals [68].

Different emphases may emerge, such as a holistic

appreciation of life and death embracing body-mind-

spirit [65, 69] and death as transition from the material to

the spiritual world [68] in Eastern spiritual approaches,

where western perspectives tend towards a more

dichotomous approach to life and death, particularly in

highly secularised societies [67]. However, the question of

“what makes us essentially human” [70] unites and con-

nects across such divides. Perhaps challenging for modern

palliative care, is the approach to suffering, which may be

viewed as the gateway to a better life or ultimate fulfilment

[71] and within which belief framework, it may be impor-

tant for the person to pass from life to death in a calm and

“mindful” state [72]. However, whilst arguing that tradi-

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who are dying – for example, evidence is put forward for

the healing power of sutra chanting [73] – Japanese

scholars continue to work on “closing the gap” between

traditional Buddhist and modern healthcare as desired by

many Buddhist followers today. In so doing they have

identified significant accord with elements of the “good

death” in western culture, such as achieving reconciliation

in relationships, saying goodbye and relinquishing of

unnecessary concerns [72]. Likewise, the Federation of

Islamic Medical Associations has benchmarked their pal-

liative care services against the mapping undertaken by

the World Health Organisation, including of good

spiritual care [74].

Conclusion

This chapter has discussed spiritual care at the end-of-life

in its multi-faceted complexity and rich diversity. At the

same time, the message is simple:

• Spiritual care is not an add-on but an essential part of

providing holistic care for the person and their family at

the end-of-life;

https://t.me/med1917

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