Commentary

Spirituality in palliative care:

what language do we need?
Learning from pastoral care
Marjory Byrne

ally dynamic’ (Kelly, 2002). This suggests

a natural progression from fragility and
Abstract
turmoil to the receiving of spiritual care,
This article is a sequel to Spirituality in palliative care: what language which is about preparing for an experience
do we need? (Byrne, 2002). It looks at the language of pastoral care,
we cannot evoke. Additionally, changes
its place in palliative settings and how it is regarded by patients and
carers. Spirituality and spiritual need is multifaceted, and the various
in a person may indicate that a spiritual
beliefs regarding the concept of spirituality and the spiritual needs experience and inner journey has taken
of terminally ill patients are appraised, and the methods of spiritual place, and that inner peace has been found
assessment reviewed. The role of the chaplain in spiritual care is (Saunders, 2003).
also assessed, and an ability to move beyond the boundaries of Spirituality is essentially all about the
their own denominational position addressed. Several components essence of a person, and the first task for a
of the language of pastoral care are identified. spiritual carer is to affirm the personhood
and identity of a patient (Wilcock, 1996).
This involves integrating the psychologi-
cal, emotional and spiritual dimensions

J
ean Vanier declared that to enter the of the person. The integration of care by
world of those who were broken it the interdisciplinary team continues to be
was important to learn their language. emphasised in palliative care. Chaplains
According to Stanworth (2004), man are encouraged to learn about spiritual care
searches on beyond the limits of medicine, from the nurse’s perspective. What then,
psychology or the humanities for a further can nurses learn from pastoral care and lit-
and all encompassing horizon that gives erature to support patients at a time when
meaning to human life and its finitude. Yet they are spiritually aware and dynamic?
in our culture and professional practice we
are often presented with tools for ‘doing’ Spirituality and palliative care
or ‘getting’ rather than those essential to There has been a lot of debate and writ-
spiritual care, of ‘being’ and ‘becoming’. ing to attempt to define spirituality. More
Pembroke (2002), writes that pastoral care recently, Swinton (2004) described spiritu-
calls for a move beyond the person-cen- ality as a dimension of humanness that is
tred counselling approach from, accept- unquantifiable, mysterious and individual.
ance, empathy and congruence, to giving, The depth and complexities of spirituality
availability and confirmation. Beuben clearly exist and have been described by
(2002) concludes that it is possible to move Kelly (2002) as multilayered and multi-
beyond art and science and find the person faceted. Spirituality consists of cognitive,
not to be studied or observed, but to be emotional and behavioural components
confirmed, affirming intrinsic worth and that contribute to defining a person and
Divine potential. Therefore, if ‘being’ with to the way life is experienced. Watson
someone is a gift of the self, as Pembroke et al (2005) consider that spirituality for
(2002) suggests then, perhaps the real chal- many has form as well as content, daily,
Marjory Byrne is lenge of spiritual care is that it affects not practical, social and material meaning.
Community Palliative
Care Nurse at The Prince only our practice but also our living. In palliative care, the concept of total
and Prince and Princess of Patients diagnosed with a life-threat- pain is said to include ‘spiritual pain’
Wales Hospice, Glasgow,
UK ening illness have been described as (Saunders, 1988). According to Peterson
Email: marjory.byrne@
‘physically haywire, mentally fragile, (1989), language gets its start under the
ppwh.org.uk emotionally unpredictable but spiritu- pressure of pain while Puchalski et al

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 Spirituality in palliative care: what language do we need? Learning from pastoral care

‘To help in (2000) maintain that patients learn to felt apprehensive about giving spiritual
assessing and cope with and understand their suffering care; he recommended and carried out a
through their spiritual beliefs or the spir- programme of education and reflection
responding to a
itual dimension of their lives. For those for staff.
patient’s spiritual patients still struggling with issues of suf- Kearney, considers that spiritual needs
needs, most staff fering and whose pain appears to be unre- are expressed by the questions people
said that they solved it may be necessary to pose the ask. ‘Why’ questions indicate a search for
would like the question; what are these patients strug- meaning and are often accompanied by
opportunity to gling to find? Is it information about, or spiritual pain. Feelings such as hopeless-
an understanding of, their illness, a belief ness and despair are more indicative of
have reflective
system, or as Peterson suggested, are they spiritual pain and guilt feelings are more
sessions with searching for a relationship beyond life indicative of religious pain. Feelings of fear,
colleagues’ itself with the transcendent? Transcendence according to Kearney (1990), can be either.
goes beyond the ordinary range of human The spiritual for Kearney is the essence of
experience into the realm of the super- what it means to be human, issues of the
natural. It seems, however, that while it is soul that concern our deepest values and
possible to define physical, psychological meaning. However, according to Walter
and social pain, ‘a numinous fog seems to (1999), the challenge of spiritual care can
descend when the focus is on spiritual pain’ affect our living as well as our practice.
(Kearney, 1990). Galek et al (2005) completed an analysis
of the literature considering spiritual needs
Spiritual needs and spiritual care and concluded with seven main constructs:
Wilcock (1996) suggests that the beginning belonging, meaning, hope, the sacred,
of spiritual care of the dying and bereaved morality, beauty, and acceptance of dying.
is ‘seeing the person’. Our perception of Bash (2004) reports that spiritual experi-
each patient as a person is very important. ence is individual to each person and that
Flexibility is also required to accommodate the task of nurses is to identify and respect
the differing requirements of individual the person’s expression of their spiritual
personalities and circumstances. Wilcock experience and to offer their support.
(1996) describes this as like working in
the wilderness where pain, fear, disabling Spiritual assessment
or embarrassing symptoms, unfinished Bash (2004) explains that spiritual expe-
business in relationships and many more rience cannot be measured scientifically.
aspects of illness and suffering block the Assessment tools can only help profes-
road to peace and wholeness. sionals to describe and identify the out-
What constitutes spiritual care? Hospice ward expression of spiritual experience.
staff at The Prince and Princess of Wales According to Greenstreet (2006), there are
Hospice were given a questionnaire based three sources of assessment tools: those
on journal articles and books on spiritu- for research purposes, those in published
ality in a hospice situation. According to literature and those developed for clinical
the staff in the hospice, spiritual life is practice but unpublished. Paloutzian and
more than simply a person’s religion – they Ellison’s (1982) spiritual wellbeing scale
described it as the centre of a person’s life. has been one of the most frequently used
Information about treatment, diagno- research tools. Stoll’s 1979 questionnaires
sis and prognosis was regarded as a spir- for assessment of spiritual need focused
itual need by only half of the respondents. on religion, a comparable survey being
Requests for a favourite object, to be crea- the Spiritual Orientation Inventory (SOI),
tive, to pray, talk about faith, death and which was based on humanistic philoso-
dying, to have a religious ceremony, to phy and designed to measure the spirit-
talk about experiences, to deal with unfin- uality of the nonreligious. Catterall et al
ished business and to have company were (1998) audited the effectiveness of spiritual
all identified as spiritual needs by most of care and devised a spiritual care standard
the respondents. To help in assessing and that involved initial assessment and review.
responding to a patient’s spiritual needs, McSherry and Ross (2002) advise that a
most staff said that they would like the lack of common language or jargon may
opportunity to have reflective sessions affect the quality of data used in audit.
with colleagues. Brown (2001), a chap- Galek et al (2005), went on to develop a
lain at Highland Hospice, found that staff multidimensional instrument to assess a

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 Spirituality in palliative care: what language do we need? Learning from pastoral care

‘Expressed patient’s spiritual needs. Having analysed encounters were considered to be more
spiritual needs the literature and established seven main diverse. Through listening, the chaplain
fell into four constructs, Galek et al placed these within then uses ‘expert and informed’ theologi-
a 29-item survey that was designed to be cal knowledge and expertise obtained from
categories:
inclusive of traditional religion as well as their training and experience as well as
religious and non institutional-based spiritual needs. personal life and spiritual experience. The
sacramental, Essentially, tools should be short and vulnerable position of the chaplain neces-
existential, simple for use in clinical practice. One sitates a provision for the chaplain’s own
teleological problem with an assessment tool is that spiritual needs. Many chaplains expressed
and practical’ spiritual needs are being determined by that these were met partly through patient
the staff, with the patient responding to encounters (Mowat and Swinton, 2005).
the questions and the categories in the Cobb (2001) makes an interesting point
assessment at the time of the assessment. about the difference between spiritual and
Patients, however, may still have needs not pastoral care. The spiritual, he consid-
covered by an assessment and therefore ers, points away from faith while pastoral
the tool may limit expression (Mitchell care moves towards it. This could result
and Sneddon, 1999). A tool constructed in a tension between vocation and what is
to allow self-assessment called FACIT-Sp- expected from the chaplain in healthcare.
Ex has a long and short version allowing Can chaplains provide or facilitate spir-
patients to circle one of four suggested itual care to people of all faiths and none?
categories from ‘not at all’ to ‘very much’. Mowat and Swinton (2005) conclude that
This tool includes questions about feel- the chaplain models a new way of spiritual
ing peaceful, forgiven, loved, thankful, being by moving beyond the boundaries of
and a sense of purpose. Patient narratives their own denominational position. They
or stories are believed to be efficient liv- also pose other important questions: are
ing assessment tools, bringing connection spiritual support and relationships com-
often spontaneously, in conversation or at mon and available to all to give, or are they
the time of assessments. The experienced peculiar to those who have had theologi-
professional will observe and actively listen cal training to give them? Is spiritual car-
to stories and dialogue, which can allow a ing a gift from the Holy Spirit or a skill
spontaneous assessment. Tools, however, that can be encapsulated in a competency?
are helpful to the less experienced. (Swinton and Mowat, 2005). If both, then
chaplains would become ideally placed to
The chaplain’s role give and train others in spiritual care. As
According to Cobb and Robshaw (1996), their role would include giving the sacra-
the healthcare understanding of spiritual- ments, it could be argued that this would
ity is a secularised version of the Christian essentially be the role of a specialist. The
understanding. In a study by Mowat and role as educator and teacher and the chap-
Swinton (2005), patients assumed that the lain’s personal qualities were considered
chaplain’s role was to offer comfort, and to be more significant than clarity of role
to talk and encourage people in times of (Woodward, 1998). A lot of what was done
distress and concern. Expressed spiritual simply depended upon the person and how
needs fell into four categories: religious and care was given.
sacramental, existential, teleological and
practical. Teleological refers to events hap- The chaplain’s report
pening because of the purpose that will be Being with others as the chaplain means
fulfilled by them. Sometimes, all four cat- listening attentively and helping patients
egories were expressed at once or one led clarify what is important in their life, thus
naturally into another. trying to make sense of the here and now
Chaplains employed a number of key and finding the ‘real you’ in the roller
skills based on their experience and knowl- coaster experience of illness. Being the hos-
edge: listening, use of theological knowl- pice chaplain means meeting and valuing
edge and expertise, helping and showing people as they are – the Bible calls such an
dependence and vulnerability. attitude grace – and that essentially means
Pastoral listening allowed patients and ‘gift’. The most precious gift we have is
staff to express spirituality in ways that are ourselves, which is more than knowledge,
unavailable in other professional contexts, skills or belongings – it is the essence of
the outcome and expectations of chaplaincy who we are and why we do what we do.

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 Spirituality in palliative care: what language do we need? Learning from pastoral care

‘Forgiveness and Spiritual care means helping people to of the patient to articulate thoughts and
reconciliation can find meaning, hope and wholeness in their feelings. This is also reflected in nursing
life and relationships. When faced with life- literature, where the environment, work-
be important steps threatening illness we often ask the deep load and lack of privacy are considered
allowing strength questions in life – who am I? What is life to be barriers to the nurse giving spiritual
and peace to cope about? What gives my life meaning? care. Role boundaries could also be a con-
with the serious Seeking answers to such questions can sideration. Nurses may consider that the
nature of terminal be frightening and bewildering. So having chaplain should take the lead and pursue
illness’ a companion and helper makes the journey spiritual need although happy to take part
of discovery less daunting. in delivery of care. Bradshaw (1997) writes
It may mean helping you to find that about relational and behavioural aspects of
sacred space where you are touched by spiritual care when concluding that spir-
God, and there find peace and healing. itual care for the nurse should be lived out
Equally it may mean just having someone rather than talked about.
to listen to you, your pain, your hopes,
your fears and to help you if you wish to Language of pastoral care
communicate this to others who are signifi- Stanworth (2004) writes that to hear the
cant to you. (Rev Alan Donald, 2006). spiritual needs of patients it is essential to
appreciate the poetic function of language.
Spirituality and pastoral care Patients use symbols and metaphors to
Walter (1999) suggests that the pastoral draw attention to aspects of their experi-
approach moves beyond psychotherapy ence that might be overlooked. Beuben
and attentive listening, to spirituality with (2002) proposes three modes of perception:
transcendence. Lartey (1997) also suggests the observer who analyses for information,
that we should be asking about the per- the onlooker who uses intuitive powers
son’s experience of, or beliefs about, the believing that they can find the person
transcendent realm and how those affect within and a third that looks beyond to the
what the person is experiencing. Those person to be confirmed. Such confirma-
working in pastoral counselling also con- tion goes beyond acceptance and affirms
clude that the spiritual should not be sepa- worth; intrinsic worth that speaks of
rated from its theistic origins. Pastoral care Divine potential. Walter (1999) encourages
engages with the questions concerning the a reaching beyond the psychotherapeutic
fear of death or the uncertainty of what lies approach with the language of ‘forgive-
beyond death and finds answers to ques- ness’, ‘hope’ and ‘love’.
tions about a view of God. Forgiveness and reconciliation can be
Writing from a pastoral perspective about important steps allowing strength and
the preparation required to provide spir- peace to cope with the serious nature of
itual care, Kelly (2002) describes spiritual terminal illness. Such practice brings a
need as being quite dynamic, something way through and beyond the problems
which changes from moment to moment that psychology uncovers. Hope has been
and is ongoing, particularly during or after found to be so essential to patients that it
a crisis. Consequently, spiritual care can- has been described as almost equal to life
not be compartmentalised or fitted into itself. Hope-fostering strategies have been
appointments because it may require an encouraged and practised in nursing par-
availability that goes beyond what we ticularly since the work of Herth (1990).
consider to be convenient and cuts across Cassidy (1988) explains that for some to
all our professional plans. Spiritual need receive love is all that remains for there is
is multifaceted, and involves an individ- no time to await the results of research nor
ual reflecting on any part of their personal the ability to interact with others in any
story. Spiritual need is also multilayered way. Cicely Saunders considered at such
and the depth of a patient’s need depends times that the way care is given touches the
on how they interpret their present circum- most hidden parts.
stances, the privacy of their surroundings
and how the patient relates to the health- Key components of the language
care professional present with them at that ‘Availability’, according to Pembroke
moment (Kelly, 2002). It also depends on (2002), means the reception of the other,
the patient’s physical and psychological their thoughts and feelings, their hopes and
state and on the personality and the ability dreams and their pains and fears into one’s

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 Spirituality in palliative care: what language do we need? Learning from pastoral care

personal centre. ‘Confirmation’ is the proc- language of grace. Grace comes when we
‘Suffering involves
ess in which one struggles with the other, walk through a dark valley that is trans-
some symptom and aims at assisting the other in growing formed for the better, bringing growth to
or process that into their potential. Pembroke (2002) con- the person. Grace far exceeds the duty of
threatens the siders that in making oneself available or the law and theologically in grace covenant
patient because of disposable to another, we enter into their replaces contract (Pembroke, 2002).
fear, the meaning suffering. When we acknowledge their suf- It is often by listening to the patient
fering we unite with them and invite them story that we find graced moments. The
of the symptom, or
into our own prepared place of reception. story of the patient’s journey or narra-
concerns about tive has been instrumental in challenging
the future’ Suffering, anguish and affliction and changing practice and is increasingly
recognised as a method of research today
‘After meeting an individual in spiritual
(Stanworth, 2004). Cassidy (1988) con-
pain, I find that terms like “suffering”,
cludes that: ‘Right at the heart of the mys-
“anguish”, or “deep restlessness”
tery of suffering is the grace that sustains
most aptly describe the experience.’
us all carers and cared for alike…’
(Kearney, 1990)

Suffering involves some symptom or proc- Listening

ess that threatens the patient because of When we listen, we can be a bridge, a
fear, the meaning of the symptom, or con- touching place and a way back to spiritual
cerns about the future. It is an affliction of connectedness for one who is torn apart by
the person rather than the body. However, grief or fear. Often, listening is all that is
suffering can also have a positive influence required to allow the patient to re-establish
in theology where the patience and wait- their own spirituality, to find a small spring
ing it requires result in moving beyond the of grace, or a hope of meaning among the
person to God, and eternity becomes an fragments of life (Wilcock, 1996). Pain, CS
experience. Beuben (2002) maintains that Lewis, would argue, from a pastoral point
the crux of the sacrament of the anoint- of view, is God’s megaphone that tends to
ing and pastoral care of the sick is that we make us listen to Him.
suffer with, mourn with and ease the pain
of others. He goes on to say that suffer- Silence and touch
ing can ‘embitter us, save us or gentle us’. Silence is a language as full of commu-
Therefore, the endurance of the fire expe- nication and information as words are.
rienced by suffering can result in a refin- A silence is to be read, heard and beheld
ing process that demonstrates a different and is deeper and more transforming than
perspective. words (Wilcock, 1996). Silence arrives
through words and words find their value
Compassion and wholeness in silence.
Touch is raw language and can be brutal,
‘For a compassionate man, nothing
gentle, healing or coercive. It is immediate
human is alien, no joy and no sorrow,
communication and can bypass the muddle
no way of living and no way of dying.’
of words.
(Nouwen, 1977)
We can expand our concept of language
This does not mean that the listener identi- so that we hear, read and speak with our
fies completely, but indicates a dropping of bodies as confidently as we do with our
personal defences that enables listening to words. If we understand the signs of a per-
take place in a realm of pure relationship. son’s posture and gesture we will know
Nouwen (1977) describes how the carer is how close to come, what space to give.
also nourished by the experience, by lis- Touch can reconnect a person. Sometimes
tening to what is said, unsaid and perhaps the experience of grief is like being cast
is unable to be said. Giving and receiving adrift and words can be meaningless and
are principles for the professional carer puzzling. Touch can re-establish a sense
acknowledged in a model for nursing care of being and self-relocating in the here
(Davies and Oberle, 1990). and now.

Grace Learning from pastoral care

Traditionally, theology handles spiritual When looking at what constitutes spirit-
awareness in terms of the experience and ual care, it becomes clear that nurses carry

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 Spirituality in palliative care: what language do we need? Learning from pastoral care

It is important to respect a patient’s religious and cultural preferences. To do this,

information should be available on the practices of different world religions

out a lot of this care. All care needs have a efit from the use of a tool for assessment.
spiritual component no matter how basic The chaplain can guide and support staff
or how complex and the manner in which to respond to what is perceived as spiritual
care is given is as important as who is giv- needs. The professional carer’s attitude to
ing the care. relationships with patients requires sensi-
Spiritual care involves ‘being’ rather than tivity in communication, confidence and
‘doing’. Today, patients may not have an an ability to engender hope. ‘Moderated
established, or a formally expressed, faith love’, a term introduced by Campbell
connection that can help in time of cri- (1984), falls between an absence or excess
sis. They may, however, require assistance of professional detachment that reflect
to address issues and questions that are expressions of caring. Campbell (1984)
not necessarily recognised as spiritual. implies that emotional involvement is nec-
They may also find it hard to articulate essary for caring and suggests companion-
spiritual issues. ship is the means of achieving ‘moderated
Greenstreet (2006) reminds us that we love’.
should nurture those with a faith but also Professionals studying and work-
support those whose spirituality is outside ing together in multidisciplinary teams
of a religious context. Not everyone will can improve communication but also
be in need of spiritual care because of dis- give mutual support to help each other
tress. However, they may need permission to be refreshed and thereby deepen and
to continue with established practices. develop practice.
When planning care, it is important to It could be suggested that the real train-
respect a patient’s religious and cultural ing for spiritual care is not primarily
preferences. To do this, information intellectual, and asks for a hard and often
should be available on the practices of painful process of self-emptying to make
different world religions. Spiritual assess- space for others. There is also a sense in
ment, according to Kelly (2002), begins which we cannot accompany another on
with self-awareness and an understand- a journey through territories that we have
ing of the assessors own spiritual journey. not to some extent explored ourselves.
Those who are experienced can observe The qualification for being there is our
and listen, guided by intuitive and tacit own personal commitment to our own
knowledge. The less experienced can ben- spiritual journey and crossing thresholds

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 Spirituality in palliative care: what language do we need? Learning from pastoral care

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