The mystics of all religions and
spiritual traditions tell us again and again that death is only for the
physical body, not for the Soul.
“Truly, it is only
this (the body) that dies when the Soul departs from it. The Soul never
The saints speak of death as a wonderful transition from this limited
and finite existence to an eternal and infinite immortality.
appeared my death knowing whom I would kiss, I died a thousand times
before I died.”
Death is something perfectly normal, something that we all see every
day and something that will inevitably happen to every living being at
some time or another. The scriptures tell us it is something very
simple and natural.
“Just as a man
discards worn out clothes and takes other new clothes so does the
embodied Soul discard worn out bodies and takes other new bodies.”
Death pertains only to the body, which like a machine, is subject to
wear and tear, dysfunction and eventually complete breakdown. The Soul,
however, is unborn and undying, eternal and immortal. For those people
who learn to identify themselves with the Soul instead of the body or
for those who have taken refuge in a Higher Power death does not hold
so much fear.
“Where, O Death, is your victory? Where is your sting?”
Spirituality in Palliative Care
By Dr Dominique Cassidy MD, FMH
Dominique Cassidy is an FMH specialist in psychiatry and psychotherapy.
At present she works as a consulting doctor in psycho-oncology and
liaison psychiatry at Valais State Hospital in Switzerland. She
is also an intermediary teacher at the School of Medecin of Lausanne,
for the module: "Spirituality, Religion and Medecin",
|Dr Dominique Cassidy MD, FMH
instructor in "Therapeutic Meditation", mindfullness meditation
programmes for psychiatric patients and an instructor in "Conscious
Centering", burnout prevention program based on meditation, yoga,
aikido and spiritual inquiry for healthcare practitioners.
and medicine are two words that until recently were not thought of as
compatible; they belonged to two different worlds that would not meet.
Times have changed in recent years however and now western medicine has
started to study the impact of the spiritual dimension and include it
in the basic care of patients. This article provides an introductory
overview of this topic. It includes a historical perspective, and a
description of some of the ways spirituality is conceptualized and
practised in a therapeutic context.
There was a time in European culture when medicine was part of, and at
the service of, religion. Medicine was based on the truths recognized
by the church, and religion explained both the cause and the solution
to illnesses. The first hospitals were known as "hostels of God," and
monks and nuns were the primary caregivers in those institutions.
After the Renaissance however, around the 16th century, as science
started to prove the limitations of religious beliefs concerning the
laws of nature, medicine and spirituality began to face each other in
opposition: progressively God was left out of medical care, monks and
nuns were replaced by nurses, and the whole of the spiritual dimension
was increasingly denied or simply forgotten.
Times are now changing once again and science is becoming increasingly
interested in spirituality. In the last 40 years, a growing number of
studies, both in medicine and neuroscience, have demonstrated the
impact of the spiritual dimension on health and well-being. In
addition, scientists have become curious regarding spiritual practices
such as meditation, and the number of studies around this topic has
grown exponentially over the last decade. More and more doctors and
nurses are now prescribing meditation to complement the usual
In 2005, the World Health Organization replaced the old
‘bio-psycho-social model’ describing the different aspects of humans,
with the ‘bio-psycho-social and spiritual model’, incorporating the
anthropological view that the spiritual dimension is constitutive of
our humanity. Spirituality is now understood as one of the basic
components of our human experience, and therefore it is an aspect that
needs to be included both in scientific research and, more importantly,
in the care of patients.
Palliative care, with its predominant focus on the process of death and
dying, is relatively advanced in its emphasis on caring for the
spirituality of patients, and many tools have been developed to support
caregivers in addressing these topics with patients. This trend is now
extending to teaching hospitals and in general medicine, and medical
students are being introduced to spiritual care during their studies.
Spirituality, Religion and Religiosity
Spirituality, religion and religiosity are words quite often confused
as the being the same, therefore great effort has been made to clearly
define them in a way that allows healthcare professional to communicate
around this subject.
There have been many attempts to define spirituality, and each of them
address two different aspects: the question of life's purpose and the
connection to that which is transcendent. "Spirituality implies a
universal questioning about intent and the meaning of life, and belongs
to the essence of humanity's search for transcendent values.
Religion is the structured belief that addresses spiritual questions
through ethical and philosophical view points, including the notion of
a faith in God.
Religiosity is the practice a person is involved in as a way to
explore and express their religion or spirituality.
What are the
- Studies have shown that a great
majority of patients want to speak of
their spirituality/religion with their doctor. However, a minority of
doctors feel comfortable doing so. Doctors feel unprepared to have such
talks with their patients. They don’t have time to do so, and lack
sufficient understanding to actually recognize which patients have such
- Some studies with geriatric
patients show that those patients whose
spiritual needs had been addressed during their hospitalization needed
less time to recover and presented a reduced risk of relapse in general.
- Studies have demonstrated the
positive impact of a balanced spiritual
life on health and well-being, as well as the negative impact of
spiritual distress, the name given to a state of suffering regarding
one's spiritual life.
Specific questionnaires have been developed for doctors and nurses to
enquire about the spiritual lives of their patients and to determine if
specific attention is required. Questionnaires can give the caregiver a
general outline to follow, but of course a more experienced
professional will progressively approach those topics spontaneously
during the meeting with the patient.
The first questions are introductory and can be part of a general
- Are you a spiritual and/or
- What is the importance of that
dimension in your life in general?
- Do you have religious or
spiritual practice(s)? Do you belong to a spiritual or religious
- Has your religion or
spirituality been a source of support during your illness? Would you
like or need to speak to me about it?
Those next questions lead to a deeper evaluation, through four specific
The meaning of one's life
- What is/has been giving meaning
to your life?
The core values of the
- What is truly important to you?
What have you learned from challenging
situations? What values gives you strength?
The connection with what is
essential or transcendent
- What do you believe in? At what
moment do you feel at peace or
fulfilled? What supports you in moments of despair?
The coherence of one's
- Do you feel valued, loved and
supported? Are you at peace with
yourself? Is there anything unfinished in your life?
2. Spiritual distress
The concept of spiritual distress has been long confused with symptoms
of depression, and although it is true that some symptoms overlap,
there is a tonality about spiritual distress that needs to be
understood and addressed specifically.
We speak of spiritual distress when the patient is expressing
struggling or suffering with one or more of these issues:
- Loss of meaning in Life: "Why
me? My life is a failure. Nothing
- Loss of value: "I do not know
what is good or bad. I feel betrayed,
by others, by life, by God."
- A loss of connection with
transcendence: "I do not believe in God
anymore. I have no contact with what used to be essential to me.
Nothing inspires me anymore."
- Loss of spiritual identity: "I
am no one anymore, I've no more goals
nor role in life. I feel abandoned and alone. I cannot forgive myself.
I'm not at peace with myself."
In many hospitals, doctors and nurses can refer a patient to a
specialist in spiritual care. Often these are from a religious or
theological background, and are trained to meet people with their
religious or spiritual needs. If they are not available, much can still
be done by the primary caregiver, to the degree that they feel
comfortable to go in this direction with their patients.
Unlike a lot of western medicine, spiritual care is not defined by any
specific intervention, nor by any strict guidelines. The primary
qualification for spiritual care is to be grounded in one's own
spiritual life, and to express a quality of being that allows for an
authentic and deep encounter with patients.
3. Qualities or
practices of ‘being’ necessary for spiritual care
- To provide an attentive
presence and a loving curiosity with the
- To inquire gently with a
quality of listening that allows the patient
to express him/herself freely without adding personal beliefs,
judgments or opinions.
- To provide accompaniment
without directing or trying to influence the
patient in his/her quest.
- To inquire about the patient's
life, what has helped in the past, what
is a source of strength, what has been the most valuable in his/her
- To inquire about remorse,
unresolved issues, and the theme of
- To ask what the patient would
still like to accomplish or leave for
his/her loved ones.
- To listen, touch, laugh,
provide communal prayer, presence, and
- To stimulate religious or
spiritual expressions (spiritual or
religious practices, reading, meeting with one's religious or spiritual
guide, being in nature, listening to music, writing...)
tips for healthcare professionals
Most patients, when addressing spiritual issues, do not ask for our
opinion, but want to be heard, understood, and loved. Ideally, in the
meeting with a caregiver, they can meet themselves, clarify what has
been obscured, and evolve on their own path. To allow that, the
caregiver must recognize, and stay away from his/her own beliefs, needs
and doubts, so that they do not interfere with the patient’s personal
process. If one is not clear about one's own challenges, the tendency
in the encounter with the patients will be either to deny their
suffering as a way to avoid one's own, or to quickly come up with some
solution, as a way to relieve oneself from our own unresolved doubts.
In both situations, the space needed by the patient is filled by the
anxiety of the caregiver.
To meet someone at this level requires that the caregiver get in touch
with and cultivate his/her own spiritual ground. The qualities listed
bellow can support such a process:
the ability to remain still, available; lovingly listening.
to recognize and accept and embrace that often: "I do not
know" or "I cannot understand" and "I am not able".
recognizing the ‘judging mind’
that prevents true
listening, and choosing to go beyond it to meet the other.
own relationship with death: How would I respond to the
of my own death? How would I spend my last months? What are my own
beliefs around death?
meaning of one’s work: What inspires me? What do I love about my
of our own spiritual life: meditation, prayer, reading...
Spirituality is now being is being slowly recognised and
reintegrated as one of the basic aspects of human existence.
Incorporating spirituality into medical care requires that it become
liberated from a long history of mistrust, and that healthcare
providers express greater willingness to address spiritual questions
for themselves and with their patients.
This movement is opening a new chapter in western medicine:
spirituality speaks of the aspect of our experience that cannot be
grasped by the mind, that cannot be measured by instruments and for
which nothing tangible can be prescribed. Medicine that includes such
an element will necessarily have to open itself to the ‘Mystery of
Life’, and will hopefully be enriched by a sense of awe and humility.
Each step, therefore, taken in the direction of including the spiritual
dimension in hospital or hospice care, and each step taken in the
direction of teaching and encouraging healthcare professionals to
explore in this direction, is a step towards a fuller, deeper and more
Seeing Them Off
By Dr Ramesh Bijlani
Ramesh Bijlani retired as a Professor from the All India Institute of
Medical Sciences where he established a patient care facility for
conducting yoga-based lifestyle modification courses for prevention and
management of chronic disease. He uses yoga as a tool in mind-body
Bijlani at the GPH World Hospice Conference 2008
surprising thing in the world is that everybody knows that death is
inevitable and yet behaves as if he were immortal", says Yudhishter in
To this one might
add that we also behave, and misbehave, with our near and dear ones as
if they were immortal. The result is that if they leave us suddenly
without warning, leaving no possibility of even saying "sorry", we are
left with life-long regret. The situation is not much better if they
give us a few months or years of notice by developing an incurable
disease such as cancer. The caregivers of such patients face several
Whether to tell the
patient the truth?
How much of the truth to tell and how to tell it?
To do all that is possible for prolonging the life of the patient or to
withhold those heroic measures which are likely to only prolong misery?
How much of a choice to give the patient in choosing the treatment?
What the approach should be to alternative systems of medicine?
Whether to add modalities such as distance healing, faith healing and
The list is
endless and the answers debatable.
There is not much
debate anymore on whether to tell the patient the truth. Even if
efforts are made to hide the truth from the patient, the patient knows
it anyway. In any case, the truth must be told; the only question is
how. A few important principles are that the news should be broken only
when there is ample time available to talk to the patient. All hope
should not be taken away from the patient, and the patient should feel
fully supported. It is cruel to break bad news to the patient in a
hurry and leave the patient all alone to digest its implications.
Regarding not taking away hope, it might be asked how hope can be given
when there is no hope while still sticking to the truth. The fact is
that there is no situation in which there is no hope. Remissions may be
rare in some cancers, but are known in virtually all cancers.
Furthermore, the remissions are not arbitrary: they are more likely
among those who expect them and psychoneuroimmunology offers a
plausible explanation for the phenomenon. That is why Bernie Siegel,
the famous cancer surgeon, says that one should beware of giving false
presents difficult dilemmas regarding the extent to which every new
advance in treatment should be used, and the types of treatment that
may be combined. Broadly speaking, there are three modalities of
treatment: surgery, radiotherapy and chemotherapy.
possible, is a good option because it reduces the tumour load and gives
the body’s immune mechanisms a chance to overpower the cancer cells
that may still be lurking here and there in the body.
chemotherapy, however, are double-edged weapons. They destroy tumour
cells, but they also damage the rapidly dividing normal cells; hence
their side effects. Among the rapidly dividing cells are also the cells
of the immune system. It is not always easy to determine whether the
benefit expected from radiotherapy or chemotherapy exceeds the harm
they might do by weakening the immune system. Further, a social and
moral dimension is added to the issue because chemotherapy is often
very expensive. If the family refuses chemotherapy, they may feel
guilty that they are not doing everything possible to prolong the life
of the patient. On the other hand, if they somehow manage the
chemotherapy, they might face bankruptcy for the sake of giving the
patient doubtful prolongation of poor quality life. If these decisions
are taken without any discussion with the patient, an important aspect
of the truth regarding his illness is being hidden from him. On the
other hand, if the patient is consulted on these points, it may be
difficult to avoid in the patient the perception that the family is not
doing enough for him in order to economize on the expenses.
disease, relatives, friends and other well wishers have a tendency to
suggest unconventional remedies such as alternative systems of
medicine, diet therapies, touch therapy, spiritual healing and so on.
Sometimes they even suggest specific practitioners or spiritual masters
and support their advice with anecdotal evidence. This happens all the
more in diseases such as cancer. It is difficult for any family to act
on all such advice. Which path to follow would, and should, depend on
what they, particularly the patient, have faith in. Even if the
treatment has no specific beneficial biological effect attributable to
its chemistry, it would at least act as a placebo if the patient has
faith in it. Placebos are currently looked upon with a great deal of
respect because first, they can work wonders; and secondly, if the
placebo is an inert substance, it will have no side effects. However,
it is not prudent to depend only on an alternative therapy unless
practitioners of scientific medicine have washed their hands of the
patient, or at least the patient and the relatives have taken a
conscious decision not to avail of scientific medicine anymore.
While all the
above questions and several other mundane considerations inevitably
enter the picture in a disease such as cancer, the most comforting and
creative approach comes from the spiritual worldview.
worldview not only helps us accept the disease as an expression of the
Divine Will, but also enables us to look at the disease positively. The
usual way to look at the disease is as a problem to be solved, a battle
to be fought, and an enemy to be conquered. From the spiritual point of
view, however, the disease is a powerful teacher. It is an opportunity
with an extremely high potential to stimulate the spiritual growth of
the patient and his caregivers. Since spiritual growth is the true
purpose of life, the disease helps them fulfill the purpose of life.
All events and circumstances can serve as opportunities for spiritual
growth. While ordinary everyday life gives opportunities for taking
only one small step at a time towards the fulfillment of the purpose of
life, traumatic events such as cancer are opportunities for taking
several big and rapid strides. A person going through the experience of
cancer for a couple of years, and his caregivers, can grow spiritually
more in those few years than in several decades of ordinary life. The
transforming effect of this growth outweighs the physical and emotional
hardship faced by the family. The effect of the transformation is to
bring the family closer, and to make them much more capable of loving,
caring and sharing. The transformation also equips them to face any
future vicissitudes of life with equanimity. They discover peace and
joy within themselves, and learn how to access these inner resources.
They get liberated from their dependence on external circumstances for
their happiness. Hence their happiness becomes event-proof and
shock-proof. Their overwhelming concern for recovery from the disease
is replaced by the need to redirect life in order to make life more
meaningful and fulfilling. Thus, the disease that seems to be a curse
becomes a blessing in disguise. Interestingly, with this attitude, not
only does the remainder of life become more meaningful, the remainder
also seems to get longer. There can be no better way of seeing off our
loved ones than to thank them for the opportunity they bring us even
while preparing to leave, and to make good use of the opportunity.