Spiritual perspectives and practices at the end-of-life: A review of the major world religions and application to palliative care
Palliative care professionals promote well-being and ease suffering at the end-of-life through holistic care that addresses physical, emotional, social and spiritual needs. The ways that individuals cope with serious illness and prepare for death are often done so within a religious context. Therefore, it is essential that palliative care practitioners are sensitive to and have an appreciation of different religious perspectives and rituals to meet the unique needs of their patients and families. This paper provides a brief overview of the five major world religions - Buddhism, Christianity, Hinduism, Islam and Judaism - with particular emphasis of the respective perspectives on suffering, death and afterlife. Despite wide variation in these traditions, an understanding of common rituals surrounding death, funerals and bereavement can improve care for patients, families and communities facing the end-of-life.
Keywords: End-of-life, palliative care, religion, spirituality
Serious illness and imminent mortality often inspire people to pursue existential meanings and come to spiritual terms with their lives.  For such people, the end-of-life is a time of re-examining or re-affirming personal faith with the goal of achieving a peaceful death. For these reasons, participation in religious rituals can be an important priority for terminally ill patients and their families, and spiritual well-being may become the primary goal for the palliative care provider.
Spiritual well-being influences psychological functioning, such as anxiety and depression, in individuals with life-threatening diagnoses. , Specifically, patients with serious disease are more likely to experience significant psychological distress if they do not have a high sense of spiritual well-being. , While lack of belief in an afterlife has been associated with end-of-life despair (desire for death, hopelessness and suicidal ideation), spiritual well-being has been shown to have a more powerful effect on psychological functioning than beliefs about afterlife. 
Palliative care practitioners are obliged to promote a sense of well-being and to ease suffering in their patients in order to foster a 'good death'.  Optimal palliative care is holistic, encompassing physical, emotional, social and spiritual needs of dying patients and their families.  Palliative care professionals need to be sensitive to and have an appreciation of various religious traditions in order to meet the unique spiritual needs of patients and families having a variety of religious and cultural backgrounds. Having an appreciation of this diversity will help inform a more culturally sensitive palliative care practice such that providers will not impose their own convictions; rather, they will challenge their own assumptions and personal values of how to achieve a 'good death' as well as healthy grief for loved ones.
This paper provides a brief introduction to some of the ways that the five major religions face major end-of-life issues, with the understanding that these traditions are subject to a large degree of regional and individual variation. This latter point is critical; every major religion has denominations and there are subtle discrepancies in particular beliefs and practices. Additionally, there are many less common traditions that cannot be explored in this article, but this is not meant to de-value the significance of these other spiritual practices. Rather, we hope that this paper will serve as an initial introduction and an impetus for palliative care professionals to further examine the different spiritual perspectives and practices that influence the care they provide. We want to underscore that understanding different faiths and rituals will help the palliative care provider to be sensitive and proactive in addressing the spiritual needs of their patients and in guiding families to ensure a 'good death' and healthy bereavement to follow.
Fundamental principles of Buddhism align with issues addressed in palliative care. The notion of suffering is at the heart of the Four Noble Truths, and Buddha's teachings (sutras) encourage contemplation of suffering and death. For example, Upajjhatthana Sutra, also known as the 'Five Remembrances', underscores the impermanence of life: I am subject to aging, I am subject to illness, I am subject to death, I will separate from loved ones and I am the owner of my actions.  Buddhists believe in an afterlife whereby humans manifest numerous times and in various forms. The ultimate goal is to become fully enlightened and reach nirvana: freedom from the cycle of suffering and rebirth. Many Buddhists commonly practice death contemplations. 
While perimortem rituals can vary between countries and schools of Buddhism, widely held perspectives and practices prevail. A person's condition at the time of death is very important; essentially, if one experiences great angst while dying, an unpleasant rebirth could result.  Taking medications that may alter one's state of mind, such as narcotics, is generally discouraged as lucid awareness allows for virtuous thoughts, which impacts one's life transition and rebirth.  Death usually takes place at home where the dying person is surrounded by family, friends and monks who recite sutras and chant to facilitate a peaceful state of mind.
In Burmese practices, the body is taken by male family members and washed. It is then wrapped in clothes and the thumbs and toes are tied together by a family member's hair. A coin is place inside the mouth and at the head and a vase with a flower is placed beside the body.  Tibetan Buddhists believe that as soon as a person dies, he/she goes into a state of trance. In the days and weeks following, an intermediate state consisting of three phases (Bardos) is experienced, which is dream-like state between death and rebirth. 
The body is never left alone after death and generally remains for up to 4 days, after which it is cremated. From the time of death to cremation, family and friends pay respects and visit the body. During cremation and on subsequent days, monks continue to chant to promote good energies in the life transition. Family and friends then give food and candles to the monks to create goodwill, which helps the lingering spirit of the dead person. 
The teachings of Jesus Christ presented in the New Testament reflect that death is a consequence of sin and is a temporary separation of body and soul. Furthermore, death of sin is birth to eternal life and the dead will be raised and judged at the second coming of Christ.  The palliative care professional ought to be aware that Christian patients may view their illness and death as punishment and may experience associated feelings of guilt. 
Christians believe that the soul of the deceased goes on to the afterlife, ultimately to Heaven or Hell after being judged by Christ. The likelihood of going to Heaven is greater if one believes in Christ as Savior, lives a wholesome and unselfish life and gives penance and is renounced of sins. Death anxiety may be evident since no one knows, for sure, whether he/she will go to Heaven. A 'good' Christian death involves being spiritually prepared, having resolve in interpersonal relationships (forgiveness) and reconciling sins. 
It is important that the dying receive their last rite by a priest or a minister, which involves any or all of the following: (1) "Anointing of the sick" - The dying person is prayed over and the body is anointed with holy oils; (2) Reconciliation - The dying person confesses his/her sins and the priest absolves the person of any guilt; and (3) Holy Communion - The dying person receives a holy wafer representing the body and blood of Christ. The ritual concludes with a prayer. The last rite is intended to give the dying person spiritual aid and comfort and to fortify the soul, enabling one to bring Christ into the centre of the experience and to meet death with tranquility. 
A wake service takes place in the immediate days after death to allow loved ones to pay their last respects; the coffin is usually open, at least partially. A funeral service occurs in a church and is often followed by a graveside religious service. Most Christians are buried in a coffin, although cremation is acceptable as long as the ashes are interred. Mourning practices include prayer to God and to the loved one who has died (since some Christians believe that the dead person can hear and answer prayers). Lighting candles in memory of loved ones who have died is a common practice in many Christian traditions, which symbolises the ignition of eternal light and love of Christ.
Hinduism comprises a wide variety of religious traditions that have diffused throughout India and the world. Yet despite this variation, certain major themes are commonly shared by most Hindu religious traditions such as the primacy of the Vedas, notions of cause and effect (karma), a cyclical model of death and rebirth (samsara) and spiritual liberation (moksha). , Likewise, there are common themes surrounding the dying process that may be relevant for effective palliative care delivery.
For instance, Hindu patients and family members may be reticent to seek pain relief and other physical symptoms if they consider suffering as a form of austerity (tapasya), an opportunity to achieve spiritual liberation by burning away the karma accumulated over multiple lifetimes. ,, Under such conditions, the needs of the body and soul may be at odds with one another. However, people often recognise that they cannot remember the actions of previous lives and therefore cannot determine whether there is a karmic need for further suffering. Under these conditions, it may be the sacred duty (dharma) of the physician to heal the pain, just as it is the collective duty of the family to insure that their relative dies an auspicious death - which often precludes dying under traumatic circumstances. 
In addition to the absence of trauma, Hindu notions of an auspicious death often entail that the person leaves the world having lived a long and prosperous life with many children and a significant period of time near the end for spiritual development.  In many instances when these ideals cannot be achieved, adherence to rituals can play an even more important role. Patients may listen to prayers or recite their mantra up until the moment of death or travel to a place of religious pilgrimage. , Families may arrange for a particularly auspicious cremation rite (anteyeshti samskara), ensure that the celebratory feast (bhojan) is well-attended 12 days later or that the ashes are disposed of in a sacred geographic area.  Although these latter rites occur post-mortem, advanced awareness and preparation may reassure a spiritually oriented patient or help the family with anticipatory grieving.
The teachings of Islam represent a unitary monotheistic religious tradition that has been revealed by God through the prophet Muhammed. Yet on the surface of this underlying unity, there may be local differences in the ways that certain Muslim communities interpret these teachings. The term 'vernacular Islam' has been used to describe these local interpretations, which are often associated with complex ethical dilemmas.  Human suffering presents one such dilemma. On the one hand, the Quran states that suffering allows the believer to atone for previous sins, thus linking submission to suffering with submission to God.  On the other hand, it also considers the relief of another's suffering to be a highly virtuous act and states that God has not created any illness without creating a cure. 
In the medical literature, Muslim physicians have advocated the use of narcotic analgesics for the management of severe pain in terminally ill patients. , But this prescription comes with two important caveats. First, Islamic law (Sharia) does not allow the physician to use narcotics for the purpose of hastening death; deliberate euthanasia is strictly forbidden. Second, pain and symptom management may have to be balanced against the patient's ability to participate in prayers and other religious rituals in the final moments of life. These latter activities are believed as an important means to ensure the soul's passage to a better afterlife until the time of the resurrection. ,
The palliative care provider should recognise that the dying process is often a communal affair in Muslim communities. It is considered a spiritual duty for family members to care for their sick and dying relatives and such care is often seen as a blessed opportunity for close friends as well.  When the patient is conscious, imminent dying provides final moments for reflection and forgiveness. Family and friends may also assist the patient in religious observances or pray for the soul of the patient when he/she is unconscious. It is also important to note that the family may continue to provide these kinds of spiritual care for the patient just after physical death, for it is believed that the soul does not depart the body until burial.  For all these reasons, the proximity of loved ones is very important for the dying process.
When caring for a dying Jewish person and their family, an appreciation of biblical history and a summary of the rich tradition of Judaism provide valuable direction. The Book of Job focuses on questions related to human suffering  and the concept of afterlife is fundamental to Judaism and includes the coming of the Messiah.  During this time, the world will be brought to perfection and universal peace. Tranquility, lawfulness and goodness will prevail. However, specific details on the afterlife are not emphasised in Jewish teaching.
Traditional Judaism delineates a highly ritualised procedure for the time following death, although liberal Jews have modified these customs considerably. , When death is imminent, Jews recite specific prayers. During the last minutes of life, no one should leave the area unless they are overcome by emotion or become ill. It is a matter of respect to watch over a person as he passes from this world to the next. After death, Jewish law and custom specify a series of acts that have two aims: showing honor to the dead and helping the living. After death is ascertained, the eyes and mouth should be closed and a sheet placed over the face. Customs include: placing the body face up with its feet towards the door, placing lit candles at the head of the body, pouring out all standing water and covering up all mirrors in the home. Soon after the death, the rabbi is called and he notifies the Chevra Kaddish (Holy Society). The Chevra Kaddish refers to a group of individuals within the community who prepare the body for burial in strict accordance of Jewish law by reciting prayers, washing and dressing the body. Also, from the moment of death until burial, the deceased may not be left alone. Therefore, the family must arrange for a person called a shomer (watcher) to be at his side at all times. ,
Jewish funerals should take place as soon as possible, ideally within 24 hours after death. The service is either at a funeral home or at the graveside. Open casket practices as well as flowers and music are not permitted and cremation is frowned upon.
The first 7 days after the burial involves Shivah, an important period of mourning for Jews. Shivah takes place in the home of the deceased and is a gathering of family and friends, where memories of the deceased are shared and a prayer service is conducted. , Jews are instructed to grieve for a limited time and not excessively. Jewish teachings set limits for every stage of grief: 3 days for crying; 7 days for lamenting; and 30 days for not cutting hair or wearing laundered clothes. Specific instructions are given until the 1-year anniversary of the death. ,
Important to all of the major religions are beliefs and customs related to human suffering, the death experience and an afterlife. Besides the social aspects that religious affiliations provide, many people follow faith traditions for the purpose of making sense of life, death and life after death. All of the major religions strive for a peaceful experience at the end-of-life. Furthermore, these traditions tend to discourage deliberate attempts to hasten the death process. For this reason, the sacred texts of Buddhism, Hinduism, Islam and Christianity all clearly reject euthanasia although each allows efforts to relieve suffering at the end-of-life. ,, Along these lines, praying for and being with the dying person at the time of death is highly valued across these major religious traditions as a means to relieve suffering and facilitate the transition into the afterlife. While the family rituals during and after dying are often well-defined by textual traditions, they vary according to particular circumstances. Finally, it is important to note that death is a social experience and involvement of loved ones in the dying process is common across cultural traditions. For this reason, the palliative care professional should plan for the care of family and community along with that of the patient.
All persons, regardless of faith, want to have a peaceful experience when they die. Palliative care professionals are obligated to promote a 'good death', dignity and with minimal suffering.  [Table - 1] includes a list of questions to prompt palliative care providers in the care of dying persons, especially those from different faith traditions. Being sensitive to differences will allow for more thorough assessments and proactive planning that will ensure peaceful death, congruent with patient, family and community beliefs.
[Table - 1]