Care of the spirit that transcends religious, ideological and philosophical boundaries
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.38898
Source of Support: None, Conflict of Interest: None
Spirit and spirituality are human universals, which are understood, expressed and lived out in different ways. Care of the spirit is an integral component of holistic palliative care, respecting the individual spirituality and experience of the person for whom we care. Whatever be the religious, ideological or philosophical background of the patient and the clinician/carer, certain skills, knowledge and attitudes are essential in providing effective care of the spirit. Rather than using a single perspective, such as either a secular or a religious approach, to meet the needs of all in a pluralistic setting, effective, patient-centered spiritual care draws on the (often shared) wisdoms of the great spiritual and philosophical traditions and of the evolving understandings of these, science and art. Carers need both an awareness of their own spirituality and spiritual practice and an ability to 'bracket' this in focusing on the needs and care of the patient's spirit.
Keywords: Care of the spirit, palliative care, religious, secular, transcending
When writing an article on this topic for a journal with a largely Indian and South East Asian readership, I am well aware of writing from a Western pluralistic context and therefore necessarily with a Western perspective. However, I offer these thoughts humbly and respectfully, trusting that what is useful will be taken and used, and from a recognition that both dying and spirituality are shared human experiences, with common dynamics, although lived out within one or more of a myriad of cultural, religious and secular expressions.
Researchers and writers from across a range of perspectives and cultural settings have acknowledged the universality of a spiritual dimension in human experience. ,, Research in recent decades suggests that a spiritual dimension in humans has biological and social evolutionary imperatives. , Some see this as purely an important social construction with survival value; for others, it is a human response to a reality beyond the solely material world. Whatever beliefs are held about the why, some research suggests that the human capacity and need for meaning and belief are hard-wired in human beings. ,,
Spirituality is one of many concepts with a variety of expressions, for which recognition of similarities or 'family resemblances' across these different expressions provides a more accurate understanding of the concept than could a simple definition.  Despite the plurality of beliefs and practices within spirituality, the palliative care literature reflects a wide agreement on spirituality's common concerns: (a) meaning and purpose, (b) connectedness, (c) values, (d) faith ('ultimate concerns'  ) and beliefs, (e) transcendence (that is, moving beyond oneself into a 'far larger landscape',  which may or may not relate to divinity) and (f) becoming or wholeness. ,, The spirit, an equally difficult-to-define concept, is commonly defined as 'animating and vital principle', life principle' and 'essential quality' (Concise Oxford Dictionary, Collins Standard Reference Dictionary). This spirit is named and experienced in various ways including: as the human spirit, the spark of the divine, ground of being, higher self and many names for aspects of the divine. Despite different names, it is a deep, inner resource on which people can draw. This is significant particularly at times of challenge, such as living with a life limiting illness and facing death. At a time characterized by the loss of so many personal, physical and psychological resources, the spirit remains a potential source of strength. It is this spirit that infuses the whole person and provides the impetus to living as fully as possible, including an engagement with life and the questions and challenges life presents. This engagement forms one's spirituality  and will be developed to a greater or lesser extent and in conscious and unconscious ways throughout life.
An individual's expression of his/her spirituality will depend on personality, culture (social, religious and family culture), the times in which (s)he lives and his/her life experiences. Throughout life people find ways to nurture their spirit to help give it expression and to meet its needs for connection, meaning, transcendence, values and wholeness. Common spiritual resources and practices have been found throughout history to be effective in this and are used, with variations, across all spiritual and cultural traditions. Relationships [with self, family, friends, community, one's environment and the transcendent (however the transcendent is experienced)] are powerful means of providing a sense of self, of connection, of meaning in one's life. Connection with or immersion in the beauty, power and gentleness of nature; metaphysical pursuits, such as meditation, prayer, ritual, silence and philosophy; and artistic or creative pursuits (art, poetry, music, creative work, etc.) can all be means, paradoxically, of both grounding a person in their own centre and taking them beyond themselves (transcendence). They also can provide and express values, connection and ways to wholeness.
Examples of the variety of different expressions of a similar spiritual practice include the similarities in the mystical/meditative traditions of all of the great spiritual traditions (including aboriginal traditions) and in secular life, using many forms of meditation and contemplation as ways into stillness, a grounding of oneself and a connection with the transcendent. These include Yogic breath-work, mantra-based prayers such as Buddhist and Catholic rosary prayers and the chants of all religions, contemplation of a word of wisdom or a work of art, the Australian Aboriginal experience of 'Dadirri' or inner stillness, a quiet walk along the beach and the centuries of traditions of other Eastern and Western meditation practices!
People may use different resources and practices at different times of their lives. An important aspect of care of the spirit in palliative care is facilitating people's recognition of and reconnection with those spiritual resources that are meaningful and effective for them.  Many people do not consciously recognize their use of these sources of strength, re-connection, identity, hope and peace. Asking, "What gives you strength and nourishes your spirit?" allows all people, whatever be their philosophical, ideological or spiritual stance, to identify those resources, both inner and outer, which they have already found helpful and may be able to access again. Alternatively, it may lead to suggestions of other ways of finding the supports to meet their spiritual needs, given their changed circumstances. For example, a person has found in his life a sense of peace and connectedness in difficult times by going fishing quietly alone, but is now bed-bound and unable to do this. Care of this man's spirit might entail finding a picture of a boat or the sea to hang in his room, or teaching him visualization techniques to enable an entry into the experience and the benefits previously found in fishing in his small boat. Alternatively, he could be introduced to a new way of finding the quiet and peace he sought.
Asking questions such as those in [Table - 1] goes beyond asking about coping skills. These questions recognize human spiritual needs and identify the resources or practices most helpful for this particular person in this particular situation, to achieve what (s)he wants to achieve. As palliative care workers we can then work with the person towards this.
The aims of care of the spirit are to create and hold a safe, nurturing space in which the person with a life-limiting illness can "taste the waters of their own existence,"  listen to what life is asking of him or her in this situation and can respond to these questions in whatever ways they need to. "Life questions us and we must give answer."  Such questions in this situation may include, "What has your life meant? How will you spend the rest of your life? How will you die? What do you need to do to live and die as you wish? What gives you hope in this situation?" In answering these questions, the meaning and values for this person in this situation are found. The process of answering is rarely simple.
Spiritual care requires an approach and skills that create and maintain this safe, nurturing space. The role of the carer here is a facilitator or a midwife; the 'spiritual work' is the patient's own and is led by the patient, not the carer's agenda. The relationship between patient and carer is reciprocal, one which respects the spirituality, wisdom and experience of the person being cared for. This model of care demands of the carer a recognition of one's own vulnerability as a fellow human, "the vulnerability of listening and having no answers."  It requires an ability to 'live the questions'  alongside the patient, to stay present when there are no easy answers or simple solutions, often a challenging task.  For clinicians, used to finding solutions in a problem-based model of care, a mind-shift is required. There is a danger in the 'helping professions' - that we respond to spiritual and existential suffering as we do to physical pain or other symptoms; that we try to control or fix it.  Care of the spirit is not a problem-solving model of care, but one which entails being truly present and open to possibilities, respects a range of ways of knowing and involves deep listening.
Care of the spirit involves listening closely with the patient to what is happening for him or her and to support the person's discerning and working with this. This requires an ability to be truly present with the person and an understanding of what it is to listen attentively and to be open to what life/the divine/wisdom is saying. It is easy to see how the practice and incorporation into one's own life of the regular practice of an attentive, reflective approach (of whatever kind) develops abilities and skills in this area. Some thinking and reading about the spiritual issues facing dying people will also help develop insightful practice.
Working with the patient's spirit needs to be done in ways that are appropriate and healthy for each individual and which recognize the language and expressions of the spirit - symbol, metaphor, silence, dreams, paradox, ritual, music, dance and other expressions of beauty and creativity.  Simple attentive presence, touch, massage and 'depth-work',  such as working with images, dreams, art and music or meditation and other forms of prayer, are ways of connection and opening to wisdom. Psychology may play a role where there are psycho-spiritual issues to be worked through. Insightful symptom management is also a part of care of the spirit. Spiritual distress is often expressed in the body as pain or restlessness, just as physical symptoms, such as shortness of breath impact on spiritual and emotional states. We need to be attentive to the symbolic as well as the literal meaning of symptoms, using what Louis Heyse-Moore, a palliative care physician, has referred to as 'bifocal vision' to interpret the 'signs, symptoms and symbols' of spiritual pain. 
For many people, in dying, an active letting go of life, rather than a passive resignation, is a creative act of the spirit.
"Whatever beliefs are held about the meaning of death, conscious dying ultimately involves self-abandonment. In this act both body and consciousness are surrendered in an ultimate act of acceptance of what is and trust in whatever will be. Working with people who are dying involves facilitating their expression of this significant act of self-giving at the end of life, in ways which honour their deepest beliefs and their life." 
In developing care of the spirit that transcends religious, ideological and philosophical boundaries, what is needed is an approach that recognizes the universality of human experiences of dying and spirituality, of spiritual needs and spiritual resources and the richness in diversity of expression of these. It must also acknowledge wisdom across spiritual, religious and philosophical traditions, both the shared wisdom and the particular insights of different philosophies and belief systems, "to share one another's spiritual riches"  and come to understand something of different patients' resources and perspectives.
The modern palliative care movement arose from within the Western Christian tradition and has been heavily influenced by this. Models of care of the spirit have varied, according to local custom and the individual capabilities and inclinations of those delivering the care. In response to poor spiritual care given by some religious representatives, some authors have suggested replacing the religious model of care of the spirit with one based on a 'secular spirituality'.  While agreeing with their critique of 'empty religion' and 'empty ritual', I see in this suggestion the same potential dangers as for a solely religious model of care. Secularism is one set of philosophies and belief systems, among many, as is religion. The limitation of using only one perspective, either solely secular or solely religious, is the loss of the richness, which other perspectives bring. The reality which is the concern of the human spirit, especially when facing dying, is such that one perspective cannot provide all possible understandings, nor meet the diverse needs of all patients and families in our care.
From a simple, ethical position of justice and patient rights in a model of patient-centred care, excluding valuable spiritual perspectives and resources limits the range of appropriate care available for patients and families.
There are two other dangers of a model with only one or one set of, perspectives. The first is the possibility of the imposition (consciously or unconsciously) of expectations onto the patient. This may take the form of a presumption of the importance or lack of importance of spirituality to the patient or presumptions about preferred types of spiritual expression. Equally damaging is the second, a neglect of the patient's spiritual needs, due to carer ignorance and inability to recognize non-explicit or symbolic requests for spiritual help.
I therefore suggest a model of care of the spirit that is open to secular and religious expressions, using appropriately and in practical ways the gifts brought by many different forms of each of these. This does not mean that we need to agree with every perspective, but that in our clinical practice, we are open and respectful to whatever possibilities are meaningful for the people for whom we care, in meeting the needs of their own spirits and experiences.
For transcendence of boundaries happens not at the level of intellectual discussion, nor in theory, but at the level of the heart of human experience, experiences of the spirit, in listening to an individual suffering person and helping them find what their spirit needs.
"If one starts with doctrines, the arguments are endless…But when one comes to the level of interior experience, that is where the meeting takes place…It is in this cave of the heart that the meeting has to take place." 
Care transcending boundaries cannot happen where there is fear or defensiveness about beliefs or any religious or secular position. Care of the spirit requires openness and trust in the wisdom of the spirit.
Research has demonstrated that an awareness of their own spirituality makes palliative care clinicians more effective providers of care of the spirit. , One reason for this may be that in order to reach the stage of appreciating the value in others' belief systems and traditions, one must understand and appreciate the depth or spirituality of one's own. 
"Through the practice of deep looking and deep listening, we become free, able to see the beauty and values in our own and others' traditions." 
Groundedness in one's own spirituality and the wisdom learnt from this thus teaches important skills in care of the spirit. Equally important is that one's spiritual perspective is 'bracketed', that is put to the side, in working with the patient. It is the patient's spirituality that is important in this encounter, not the spirituality or agenda of the carer. Again, bracketing requires a sense of one's own faith that is mature and open to the value of other faiths, secular and religious, as valid spiritual paths. As a carer, being comfortable with a clear awareness of the limits of my own perspective is also important. Asking the patient, "What can I do for you?," rather than presuming to know, will allow me to judge whether referral is needed to someone better suited to meeting the person's needs than I.
Care of the spirit that transcends boundaries is possible not by ignoring the philosophical, religious and ideological bases of spirituality (as these are integral to the expression and living out of one's spirituality) but by acknowledging the shared experiences of spirit and its engagement with life, which is at the heart of all spiritualities. As Ramsden  notes in relation to culturally safe practice, care needs to be given, not regardless of the unique culture and spirituality of each individual, but ' regardful ' of this and responsive to it. Doing this requires openness, humility, acceptance of one's limits and setting aside any defensiveness. Awareness of one's own spirituality and practice of a reflective approach to life, which involves some thinking, reading and pondering on the concepts, issues and dynamics affecting people at the end of life, bring insight to the practice of care of the spirit.
Greater understanding and training in knowledge, wisdom and the development of skills in care of the spirit need to be part of palliative care education and incorporated into clinical practice.
[Table - 1]