The spiritual needs of the dying patient.

“. . . The American people want to reclaim and reassert the spiritual dimension in dying.” This was the major conclusion of a recent survey of 1,200 adults, 18 years or older, conducted in the United States during May 1997 (and completed before the June 1997 Supreme Court decision on physician-assisted suicide). Spirituality has been defined as “. . . that which allows a person to experience transcendent meaning in life. This is often expressed as a relationship with God, but it can also be about nature, art, music, family, or community—whatever beliefs and values give a person a sense of meaning and purpose in life.” So, every person, regardless of any commitment to a particular religious faith, has a real spirituality inasmuch as one experiences meaning and purpose in life. It is the real and immediate threat to this sense of meaning in the face of terminal illness that creates the spiritual distress of the dying. This article will expand on previous material presented in this series. It will explore the nature of suffering and its relationship to spiritual distress, identify ways that caregivers can address the spiritual distress of their patients, and examine the potential for healing in the terminally ill. The intent of this article is to help establish common ground in the midst of great diversity of faith and culture to facilitate dialogue and understanding between patient and caregiver as spiritual issues are addressed at the end of life. An inherent conflict exists between the technique (including technology) of medicine, which is problemfocused and reductionist by nature, and the spiritual needs of the dying, which are rooted in mystery. “Death is the edge of a mystery, and turning our faces toward the problematic, through the persistent use of technology, at the hour of death keeps us from having to face mystery. Death is no problem to be solved; it resists any such formulation . . . By keeping our attention on end-of-life problems, we ignore the mystery of the end of life.” Addressing the problems of the dying without caring for the person who is dying can cause suffering. At the heart of the spiritual distress of the dying is suffering. Eric Cassel has defined suffering as “. . . the state of severe distress associated with events that threaten the intactness of the person.” By its very nature, “suffering is experienced by persons. Suffering occurs when an impending destruction of the person is perceived; it continues until the threat of disintegration has passed or until the integrity of the person can be restored in some other manner.” Indeed, the challenge at the end of life is to restore and maintain the integrity of the dying person in the face of a clear and ever present threat of disintegration. Suffering affects persons in all their complexity. “. . . Suffering can occur in relation to any aspect of the person, whether it is in the realm of social roles, group identification, the relation with self, body, or family, or the relation with a transpersonal, transcendent source of meaning.” Another way to express the all encompassing nature of suffering is the concept of “total pain” articulated by Dame Cicely Saunders, the founder of the modern hospice movement. The four domains of pain that in their totality constitute “total pain” or suffering are: physical pain (and other distressing physical symptoms); psychologic or emotional pain (eg, symptoms of anxiety and depression); social pain (eg, fear of separation from loved ones, broken relationships); and spiritual pain. Many of the major spiritual concerns that Americans have about death were identified in the May 1997 Gallup survey. These include: fears of not being forgiven by God (56%), not being reconciled with others (56%), dying while being cut off or removed from God or a higher power (51%), not being forgiven by someone for a past offense (49%), not having a blessing from a family member or clergy member (39%), and concerns about the nature of the experience after death (39%). Dr Cassel has also observed that if the caregiver doesn’t recognize or diagnose suffering, he cannot relieve it. Because suffering affects persons, the standard objective measures used to diagnose diseases will not be helpful. Typically, suffering involves symptoms that threaten the integrity of the patient as a person. The meaning that Received June 4, 2002; Accepted June 4, 2002. From the Department of Surgery and Palliative Care Program, VA Ann Arbor Healthcare System, and University of Michigan, Ann Arbor, MI. Correspondence address: Daniel B Hinshaw, MD, FACS, VAMC (112), 2215 Fuller Rd, Ann Arbor, MI 48105.