Tend to the spirit of the dying

Responding to earlier articles on euthanasia, a doctor advocates better spiritual care of the dying.

We humans must be the only creatures in this universe who grapple with the awareness that our existence in this world will come to an end some day in the future.

Death awareness starts from the age of five when one attempts to make sense of events, people and the surrounding world. In trying to find the meaning of life, existence and death, we contemplate the past, present and future in relation to the universe that we live in. The why, how and what-if questions plague most humans at various points in life regardless of what our belief systems may be and whether we are atheists or profess a religion.

This existential or spiritual dimension of humans is part of the multi-dimensional human model first described by the late psychiatrist George Engel in the 1970s.

As one nears the end, spiritual issues take on greater significance. The late Dame Cicely Saunders, founder of the palliative care movement, proposed the concept of "total pain" based on Dr Engel's model of the human.

Pain in terminally ill patients emanating as physical or psychological pain may progress into spiritual pain when the patient doubts the value and worth of his existence. This may be compounded by the perceived hopelessness, meaninglessness, guilt and a sense of being a burden to family and friends. A sense of fear, foreboding, confusion and grief compounds the situation, further leading to a desire for a quick death.

Patients who wish death upon themselves for whatever reason almost invariably have some degree of spiritual pain. For such patients, addressing the root causes, such as uncontrolled physical suffering, clinical depression and complex grief, may not suffice for the crux of the problem could be an underlying spiritual pain.

Individuals seeking to end their lives, another feature of human spirituality, via euthanasia or suicide may look towards a wonder drug that can "save them from the misery".

Doctors are increasingly called upon to provide the miracle "cure" for existential and spiritual pain. "Aid-in-dying" and "physician-assisted suicide", euphemisms for euthanasia, are means to providing death in a controlled, sanitised and quick manner by way of prescribing a drug or cocktail of drugs.

This approach, however, does not consider the spiritual dimension of the human and seemingly affords a quick-fix physical solution to what is essentially a spiritual problem.

The balm for spiritual pain does not come in the form of a medication or drug. Dr Harold Koenig, director of the Centre for Spirituality, Theology and Health at Duke University Medical Centre, remarked that building a personal narrative, aided by a healthy perspective of spirituality or religion, is important in people undergoing severe trauma.

Dr Viktor Frankl, another renowned psychiatrist who was incarcerated in a German concentration camp during World War II, observed in his seminal book, Man's Search For Meaning, that finding meaning in the most difficult of times, amid pain and suffering, determines whether a prisoner would survive or succumb quickly. Those who held a purpose or hope in life were more resilient and survived longer.

Spiritual care remains an underdeveloped facet of holistic care in this part of the world. Health issues and illnesses serve as catalysts for spiritual questions to emerge. Spirituality is often confused with religiosity.

For many, the latter provides a framework of beliefs and practices to answer questions of the former. Many of the principles of spiritual care are secular in nature and can be applied universally.

Spiritual care is journeying with patients and seeing them off in a compassionate and loving way, neither hastening nor slowing that journey. It is to restore meaning, purpose and hope to patients right to the last moment of their life and impressing upon them that their continued existence, no matter how difficult it may be for others, is important.

There is increasing evidence in scientific literature showing the association between spiritual wellness and resilience in the face of trauma, pain and suffering.

We are discovering, just like Dr Frankl did 60 years ago, that resilience, suffering and survivability are all interrelated and are founded on a strong sense of meaning, worth and personhood of the human spirit.

Unfortunately, a recent study by researchers from the University of Bristol, across nine countries, found that spiritual distress, though highly prevalent, is hardly recognised and, therefore, not managed well at the end of life. The participants reported a need for staff to be trained in spiritual care.

Spirituality and humankind's quest for longevity gave birth to medicine. The early practice of medicine was steeped in spiritual and religious traditions. This preceded the development of the science of medicine. It will do our society well to pay greater heed to spiritual care for the sick and dying.

Spiritual or pastoral care, as it is known in some countries, is fast developing into a much-needed aspect of healthcare. Should the last piece of the healthcare jigsaw be put in place, it would seem that medicine has come a full circle from where it originated.

• The writer is a council member at the Singapore Hospice Council and a senior consultant at Khoo Teck Puat Hospital.

A version of this article appeared in the print edition of The Straits Times on December 28, 2017, with the headline 'Tend to the spirit of the dying'. Print Edition | Subscribe