Caring at the end of life has been a central concern at the Park Ridge Center for several years. We have been deeply involved in furthering the cause of dying well with activities that run the gamut from intimate patient care to public policy initiatives. In 1996, we began to investigate ritual as a realm of human experience that responds to the most intensely felt needs of dying persons, their families, and caregivers. A year later, with a grant from the Robert Wood Johnson Foundation, we brought together a diverse group of practitioners and theorists to explore rituals at the end of life. Although our investigation sought to achieve a number of objectives, we concentrated on rituals surrounding the process of dying in institutional settings. Our modest goal was to map the key issues for future exploration rather than beat a fast track to resolving them superficially.

Earlier research, as well as the experience of our clinical consulting staff, supported our guiding assumption: Various forms of ritual activity come into play as the dying process unfolds. In our work, we had observed that as someone approaches death in the acute-care setting, a wide range of actors directs and participates in multiple rituals. We had already noted that the beginning and end of these rituals as well as the movement of different actors in and out of them were hard to mark. Further, it had become apparent to us that these actors did not usually have consistent intentions, uniform agendas, or a shared understanding of the rituals as they unfolded. For example, physicians tended to engage in rituals of medical practice to control the clinical environment, while families drew upon their own religious and/or cultural rituals to find meaning and practical guidance in the face of impending death. Although these rituals generally met authentic needs and sometimes supported one another, at other times they clashed and undercut all hope of achieving the best outcome, i.e., a better death for the patient.

To learn more about the in-depth character of these ritualization processes and what evoked them in the context of institutionalized dying, we asked a series of leading questions. For example, how can rituals that spring from different yet legitimate needs serve a single interest like dying well? How, for instance, might medical, cultural, and religious rituals explicitly complement one another? Can they be more clearly identified, carefully orchestrated, and strategically deployed to improve the care of the dying? What can assist participants in appreciating the need for and meaning of each other's ritual practices as part of dying? Might new rituals be elaborated to meet the various needs of patient, family, and practitioner in the institutional setting? Disclosing the potential contribution of ritual practice to end-of-life care, we concluded, will depend on answering these and many other questions.

Catherine Bell, a professor at Santa Clara University, served as an important resource in our discussions. In her insightful analysis of ritual activity, Ritual Theory, Ritual Practice (Oxford University Press, 1992), she manages to almost effortlessly guide the imagination of anyone interested in the place of ritual in end-of-life care. Her description of ritualization as "a way of acting that is designed and orchestrated to distinguish and privilege what is being done in comparison to other, usually more quotidian activities" is strikingly relevant, although dying, despite being part and parcel of the human condition, is hardly a quotidian pastime. No matter what the circumstances, a certain dignity should attach to the passing of a human being. Ritualization provides both the framework and the means for adding a note of dignity to the dying process. Ritualization is, according to Bell, "a strategic way of acting in specific social situations." The often emotionally charged and socially complex dying process invites and indeed seems to naturally evoke the human tendency to cope through ritualization.

Currently, major initiatives are under way to improve the care of the dying in America. Human and financial resources are being marshaled at an unprecedented pace to transform the culture of dying. Important institutions (e.g., the Robert Wood Johnson Foundation through its Last Acts Initiative) and influential individuals (e.g., Mr. George Soros through his Project on Death in America), as well as some insightful policy makers (e.g., Senators Rockefeller and Collins, sponsors of the Advance Planning and Compassionate Care Act), have decided we need "strategic ways of acting" and intervening as the process of dying unfolds. Ritual theory and ritual practice bear special relevance to these initiatives. Exploring and exploiting ritualization as an important source for the stratagems we need will enhance our chances of ameliorating the sting of death in America.

The Park Ridge Center is committed to the design and implementation of research projects and educational initiatives that highlight the importance of ritual in the provision of care at the end of life. We are developing practical tools that will illustrate the inherent power of ritual to contribute to a better, more humanly fulfilling death. We are convinced that a deeper appreciation of ritual practice will lead to important changes in end-of-life care. Ritual celebration can and will, if appropriately acknowledged and nurtured, transform the experience of death for patients and those who attend them.