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Spiritual care at the end of life.

Dying patients have more than medical needs. In fact, what they feel most sharply, whether or not they are religious, are spiritual concerns. The Christian theological virtues of faith, hope, and charity, properly interpreted and translated to reflect the universal concerns with which they are connected, provide a starting point. Those who care for the nonmedical needs of the dying must attend to their patients on at least four different levels at once--emotional, ethical, religious, and spiritual. For years, the spiritual level had been considered part of the other three. Many caregivers simply identified the spiritual with the religious or tacitly assumed that the ethical or emotional issues covered the other-than-bodily concerns of the dying. But recently we find religious people protesting that their spiritual needs are not met by their religion, nor by anything in ethics or psychology, and nonreligious people raising questions about issues they call "spiritual." Not long ago in these pages, in fact, John Hardwig challenged bioethicists to look more closely at spiritual care.[1] At life's end, he observed, the dying usually return to long-neglected questions about what really counts in life. Many see little meaning in their narrowed and shortened future as they are forced to deal with friends and family in new and embarrassing ways. Where formerly they helped to lift burdens from the shoulders of others, they have now become a burden. They feel betrayed by their own bodies. They picture themselves as cast out from the society of the healthy. They can be overwhelmed by their feelings of isolation and abandonment, even self-hatred, fear, and anger. True, most caregivers recognize these needs as "spiritual," but few know how to respond to them effectively, whether they are the family members of a dying parent or professional pastoral care workers. Caregivers need words and ideas to guide the attention they pay. Field instructors in training programs need to clarify how the spiritual needs of the dying relate to their emotional, ethical, and religious needs. Hospice administrators need criteria for hiring effective caregivers. For all these domains of care, we need a more precise articulation of the spiritual. What is "The Spiritual"? To move the discussion a step toward that precision, I suggest we think of the spiritual as involving the ways we transcend ourselves that are not based on reason alone. Or to chisel more precision out of that amorphous term reason, we can think of the spiritual as that realm of our living that goes beyond the insights and values that we can easily explain. I don't mean to suggest that reason has no place in spirituality. We strategize, we plan, we analyze, we weigh pros and cons, we test our ideas on experience, we use logic to make sure we're being consistent and clear. But people facing death are concerned less with what they can account for and more with their hopes, their companionships, and all the happy, baffling decisions they made that opened up to them a richer and deeper life. It seems to me that this is what we mean when we refer to "the spiritual." We are speaking of "ultimate meaning." We are speaking of all the ways we are drawn toward a "beyond" throughout our lives despite the fact that we never fully understand it. I'm thinking of transcendent events: How art and music symbolize the harmonies that we seek. How falling in love means taking risks that a rational assessment would not warrant. How I might realize that the expression "There's more to this than meets the eye" is actually true about everything. How the questions about God and eternity occur even to militant atheists. Poetry can convey it: Like pond-bound fish under global vaults of air, Speckled by beams from up beyond our sight, Whence luster menaces yet entices, What shall we make of the light? Several sages, widely separated in history, identified three remarkably similar ways we approach these transcendent meanings. …