Papa Day: Shrine for Papa Day, 1995 (detail)

Those who face death reach for medical and spiritual resources, among others, to make sense of what is happening to them. Healthcare organizations and providers, therefore, attend to both medical and spiritual needs. This is nothing new. Spiritual and physical health have always been closely connected. In the past, responsibility for both spiritual and physical health rested in the same individual; clergy were often doctors, for example. Faith communities founded and sponsored medical endeavors, and nursing was perceived as a religious calling.

As health care developed, however, labor sharply divided, and by the beginning of the last century, medicine and religion had clear boundaries and different professional approaches. Physicians and nurses diagnosed and treated physical and mental disease. Clergy and pastoral caregivers attended to the soul. Yet, the often-overlooked religious aspect of medicine's history forms the background for contemporary concerns linking medicine, spirituality, and end-of-life care.

Chaplains insure that clinically oriented pastoral care is present in the medical center. Such pastoral care integrates particular theory and techniques regarding the place of religion in health care with a commitment to the spiritual well-being of patients, their families, and staff. The philosophy of holistic care allows clergy a place on the modern medical care team.

The rise of professional healthcare chaplains, however, reduced broader clergy involvement with the dying. Congregational clergy now concentrate on nurturing the healthy religious and spiritual lives of their communities. As a result, these clergy are not much better prepared than any other Americans to support the chronically or acutely ill through death and dying, according to a recent assessment by the American Medical Association's Institute for Ethics.

The gradual separation of medicine and religion reflects a shift in the way death is approached in our culture. Philippe Ariès, in his The Hour of Our Death, proposed that the effort to bring "wild" death into the controlled environment of the hospital is the effort to domesticate it. To some extent, medicine has succeeded: 80 percent die in a hospital or long-term care facility. Ariès argued, however, that our anxieties about death and dying will seep through any levees we build to contain them. For example, many people now fear losing control of their lives—and their deaths—to the medical machine and, thus, losing the chance to find meaning in death.

For the past twenty-five years, those striving to reform the way medicine cares for the dying have stressed legal and ethical issues, including questions of terminating treatment, euthanasia, and assisted suicide. Patient autonomy is the overriding concern as we try to manage death medically. Every state has now enacted legislation on advance directives, and a growing body of judicial opinion focuses on associated issues. Reformers have also focused on improving communication between patient and physician to combat seeming professional bias and insensitivity.

Unfortunately, there's no evidence that these efforts have succeeded. For example, patients, families, and physicians still seem terribly reluctant to raise the subject of death. Perhaps we have focused too much on healthcare institutions, patient-caregiver relationships, and legislative reform. We need to look anew at the spiritual resources the dying draw upon when facing the physical, emotional, and social pain and suffering that accompanies a life-threatening illness.

The 1997 Gallup survey Spiritual Beliefs and the Dying Process reinforced claims that American medicine often fails to provide what dying patients seem to want most—death at home among close family and friends, recognition of and support for the deeper spiritual dimensions of dying and death, and assurance that their families will not be overburdened with their care or neglected in their loss. Not many respondents—only 36 percent—saw the clergy providing broad spiritual support in their own dying days. Even less, 30 percent, would look to physicians for spiritual comfort; 21 percent to nurses. The findings suggest that people do not trust professional caregivers with spiritual care and support in their dying days.

Ironically, these findings come during a boom time for research on the potential effects of religion and spirituality in treatment interventions and outcomes, including the effects of spirituality on end-of-life care. Also fueling interest in spiritual care at the end of life have been the palliative care movement—with a stress on physical, emotional, social, and spiritual support during dying—and the Joint Commission on Accreditation of Healthcare Organizations' standard on a patient's right to spiritual care.

Still, recent attention to spiritual care for dying patients in acute care and hospice settings reveals a particular concept of secularized spirituality, according to A. Bradshaw, writing in Social Science and Medicine. The effort in health care to disassociate the spiritual dimension from religion produces a lowest common denominator that replaces the traditional notion of spirituality—the human being in relation to the transcendent—with a spirituality that is a personal and psychological search for meaning.

If spirituality is understood in this way—as a health benefit—there is the danger that spirituality will become a silver bullet; the more spirituality, the better the outcome, even when one is dying. The recent interest in spiritual care at the end of life may ironically represent the effort to domesticate spirit. Even if spiritual care is important for dying people, does not the spiritual life need to be pursued in terms of its own goals—a deeper relationship with the transcendent—and not in terms of any beneficial effects?

Finally, attention to spiritual care at the end of life raises ethical issues. Are there standards of practice or competence for spiritual care? How do we appropriately respect spiritual diversity? Is there an expectation of pastoral confidentiality? What are the ethics of a spiritual assessment? Do patients have a right to spiritual care on their terms? Is there an obligation to intervene in an unhealthy or harmful spirituality?

While there are many components to providing quality care to dying people, including physical, social, and emotional care, attention to spiritual concerns seems a poorly understood feature. To improve the spiritual component of care at the end of patients' lives, clinicians and clergy caregivers must understand persons' spiritual needs and the processes that support or the obstacles that impede high-quality spiritual care in the hospital, hospice, or congregation.

What spiritual care do people facing the end of their lives really want from their healthcare providers and from spiritual or religious leaders? How can caregivers better relate to people's spiritual needs over an extended time leading up to their deaths? How can we better coordinate spiritual care among medical personnel and the clergy? Spiritual care and support does not have to occur only in the last few days of a person's life; how can such care be offered over time to better prepare people for death?

Works Cited
American Medical Association, Institute for Ethics, "Education for Physicians on End-of-Life Care," in Module 3: Whole Patient Assessment. (Chicago: American Medical Association, 1998).