HKSPM Newsletter Mar 2004 Issue 1 : p 7

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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 (同你講耶穌).” 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 CareMore 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 self-reported 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 mind-body 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 well-being 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.

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 patient-centered 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 insideMr. 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

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 DeathMr. 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 trans-cendence 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 BusinessMr. 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 ForgivenessMr. 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 forgive-ness 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!

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: Meaning-centered 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.

Spiritual Care At The End Of Life: A brief review of the literature and cases sharing from a Christian's perspectiveMarcella K.Y. LO, Assistant Director (Spiritual Care), Haven Of Hope HospitalDr. Antony C.T. LEUNG, Hospital Chief Executive, Haven Of Hope HospitalCorrespondence: kayeemlo@hotmail.com, aleung@ha.org.hk

Figure I: The “3Rs” Phenomenon leading to a peaceful deathRECONCILIATION 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)

HKSPM Newsletter Mar 2004 Issue 1 : p 8

HKSPM NewsletterHKSPM NewsletterHKSPM Newsletter HKSPM Newsletter HKSPM Newsletter HKSPM NewsletterHKSPM Newsletter HKSPM NewsletterHKSPM Newsletter HKSPM NewsletterHKSPM Newsletter HKSPM NewsletterHKSPM Newsletter

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 (同你講耶穌).” 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 CareMore 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 self-reported 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 mind-body 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 well-being 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.

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 patient-centered 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 insideMr. 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

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 DeathMr. 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 trans-cendence 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 BusinessMr. 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 ForgivenessMr. 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 forgive-ness 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!

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: Meaning-centered 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.

Spiritual Care At The End Of Life: A brief review of the literature and cases sharing from a Christian's perspectiveMarcella K.Y. LO, Assistant Director (Spiritual Care), Haven Of Hope HospitalDr. Antony C.T. LEUNG, Hospital Chief Executive, Haven Of Hope HospitalCorrespondence: kayeemlo@hotmail.com, aleung@ha.org.hk

Figure I: The “3Rs” Phenomenon leading to a peaceful deathRECONCILIATION 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)

HKSPM Newsletter Mar 2004 Issue 1 : p 9

HKSPM NewsletterHKSPM NewsletterHKSPM Newsletter HKSPM Newsletter HKSPM Newsletter HKSPM NewsletterHKSPM Newsletter HKSPM NewsletterHKSPM Newsletter HKSPM NewsletterHKSPM Newsletter HKSPM NewsletterHKSPM Newsletter

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 (同你講耶穌).” 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 CareMore 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 self-reported 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 mind-body 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 well-being 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.

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 patient-centered 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 insideMr. 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

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 DeathMr. 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 BusinessMr. 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 ForgivenessMr. 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!

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: Meaning-centered 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.

Spiritual Care At The End Of Life: A brief review of the literature and cases sharing from a Christian's perspectiveMarcella K.Y. LO, Assistant Director (Spiritual Care), Haven Of Hope HospitalDr. Antony C.T. LEUNG, Hospital Chief Executive, Haven Of Hope HospitalCorrespondence: kayeemlo@hotmail.com, aleung@ha.org.hk

Figure I: The “3Rs” Phenomenon leading to a peaceful deathRECONCILIATION 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)

HKSPM Newsletter Mar 2004 Issue 1 : p 10

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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 (同你講耶穌).” 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 CareMore 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 self-reported 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 mind-body 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 well-being 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.

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 patient-centered 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 insideMr. 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

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 DeathMr. 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 BusinessMr. 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 ForgivenessMr. 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!

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: Meaning-centered 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.

Spiritual Care At The End Of Life: A brief review of the literature and cases sharing from a Christian's perspectiveMarcella K.Y. LO, Assistant Director (Spiritual Care), Haven Of Hope HospitalDr. Antony C.T. LEUNG, Hospital Chief Executive, Haven Of Hope HospitalCorrespondence: kayeemlo@hotmail.com, aleung@ha.org.hk

Figure I: The “3Rs” Phenomenon leading to a peaceful deathRECONCILIATION 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)

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.

5.Frankl V (1939). Man’s searching for meaning. New York: Pocket Books.

6.Herth K (1990). Fostering hope in terminally ill people. Journal of Advanced Nursing, 15, 1250-1259.

7.King DE (2000). Faith, Spirituality, and Medicine. New York: The Haworth Pastoral Press.

8.Keonig H,.McCullough ME, Larson DB (2001). Handbook of Religion and Health. New York: Oxford University Press.9.McGrath P. Review: exploring spirituality through research: an important but challenging task. Prog Palliat Care 1999: 7: 3-9

10.Murray SA, Kendall M, Boyd K, Worth A, Benton TF. Exploring the spiritual needs of people dying of lung cancer or heart failure: a prospective qualitative interview study of patients and their carers. Palliative Medicine t 2004; 18: 39-45.

11.O’Gorman ML (2002). Spiritual care at the end of life. Critical Care nursing Clinics of North America 14 (2): 171-176,viii.

12.Scottish Executive Health Department. Guidelines on chaplaincy and spiritual care in the NHS in Scotland. Edinburgh: Scottish Executive, 2002.

13.Shelly, JA (2000). Spiritual Care: A guide for caregivers. Illinois: Inter Varsity Press.

14.Sulmasy DP (2002). A biopsychosocial-spiritual model for the care of patients at the end of life. The Gerontologist, .42, (Special Issue III): 24-33.

15.Yuan, HS (1998). The needs and care of terminally ill patient (臨終病人需求與關懷). Retrieved

December 1,2004 from Cancer.org.tw website: http://www.cancer.org.tw/Library/Content7_Detail.asp?ID=1252 (in Chinese).