Spiritual Care at The End Of Life : Western Views and Islamic Perspectives

The concept of spiritual and religious care, as core components of palliative care for patients at end of life stages, has achieved significant organized applications and advances in modes of intervention and tools. The past two decades have witnessed waves of secularization with impacts of the concepts of spirituality and chaplaincy that diverged away from religion, more so in the UK and some European countries as compared to US applications. Spirituality became more generic and broad that revealed itself in helping and education of patients and families to earth and think of meaning and purpose of life, suffering death and dying. The issues of spirituality and religiosity in the Islamic culture, teachings and attitudes towards patient care at terminal stages of life, is distinguished by clarity and harmony in view of clarity of Muslim beliefs and interpretations concerning purpose, meaning and mission of human life on this earth, end-of-life care and the afterlife. This paper will address the contemporary western diverse concepts of spirituality, its relationship with religiosity in terminal patient care, and will elaborate on the holistic Islamic views and attitudes towards this stage of human life.


Introduction
The past three decades have witnessed proliferation of interest in areas of palliative, spiritual and end of life care 1 .There is a wealth of literature on concepts of spirituality, religiosity, well-being, quality of life care and achieving a "good death".An extensive review of this topic 1 has covered the English-language literature from 2000 to 2010, which included spiritual care at end of life settings, spiritual assessment tools and ongoing intervention modes, with the contributions coming from the professional disciplines of chaplaincy, nursing, social work, and interdisciplincy studies.Historically, a chaplain was seen as the representative of a particular faith, a clergyperson commissioned to provide pastoral services in institutions or governmental entities, which may include crisis management, counseling, worship, education, help in ethical decision making, staff support and church coordination 2 .More recently, however, with the movement towards secularization, and the changes in definition of spirituality, the mission of chaplaincy has changed 3 .Chaplains are no longer perceived as representing any particular faith or religion.They became responsible for spiritual care of people belonging to all faiths, and to those with no faith 4,5 .They focus on a generic form of spirituality, offered to a broad range of people with diverse beliefs 5,6 .In the UK, and some other western countries, the concept of spirituality and spiritual needs is open for debate 5,7 .Spirituality is perceived as a generic characteristic of human being, which reveals itself in search for meaning (of life, illness, death…etc.) 8

The Nursing profession and spiritual care:
The nursing profession has a long historical association with spirituality and religiosity 9 , with historical heritage of tending to patient suffering, emotions and spiritual needs of the sick, the dying and the destitute.This spiritual heritage of nursing has gradually eroded in UK health care system run by the National Health Service (NHS), and expectedly in other western countries in the increasingly secular and materialistic societies, but survived in the context of charitable-run hospices 10 .The concept and claims that spiritual patient care has therapeutic benefits, with enhancement of quality of life, there is pioneering work, educational and practice-oriented to support this previously unsubstantiated thinking [11][12][13] .Research into spirituality has been extended to followers of various religions, ethnicities and culture denominations 14,15 .

Social workers and spiritual care
The first work looking at social work in end of life situations and bereavement was published in UK in 1997 16 .This national study revealed that majority of social workers acknowledge existential issues as significant.In the UK, social work literature continues to distinguish psychosocial from spiritual care, in contrast to that in US 17 .There is an increasing use of the psychosocial-spiritual model for social work directed to people who are dying or bereaved 18 .In many western countries, particularly in the UK, literature is more concerned with mental health and well-being 19 .Some studies in older adults report on importance of religiosity and spirituality to mental health and well-being 20 , including the importance of belief for a "good death" 21 .A US study showed a range of practices such as yoga, prayers and meditation frequently used by some social workers.Western narratives which distinguish religion from spirituality, and develop a secular perspective 22 are critiqued in the context of social work practice in multi-cultural settings, and the exporting of western models of education and practice to postcolonial contexts 23 .On the other hand, study of older African Americans highlighted spiritual resources and strength of belief as the most significant factors in end of life decisions 21 .Social workers were found to be more concerned with personal fulfillment and well-being, where chaplains focused on providing religious services and exploring psychological meanings 24 .Social workers are often seen to take a "problem solving" approach 25 , where chaplains start from acceptance of mystery and paradox 26 .

Spirituality and Religiosity
Significant debates continued in the area of definition and exploring the relationship between spirituality and religion.The First Annual Report of the End of Life Care Strategy 27 identified concerns that many of the available tools for the end of life care have been developed in the US, regarded as more religious than in the UK, and may not transfer well in the UK.Spirituality is more generic, basic, and has wider implications than traditional religiosity 28 , it relates to the way in which people look at their lives, values, and perception of meaning and purpose of life, illness, wellbeing and death 29,30 .This renders spirituality as a diffuse term that is quite difficult to tie down 31 .The UK guidelines work to facilitate the needed environment for patients to die in the manner prescribed by their religion 32 .Religiosity is defined as participation in beliefs, rituals and activities of one of the traditional religions 33 .Religion is considered as a mode of spirituality, but both are not considered synonymous 34 .Not all western writers agree on the benefits of religion within the context of end of life care 35 .On the other side, however, some experts consider religious spirituality to have clear benefits in the form of the coping with illness and impending death 36 .The significance of both religion and spirituality is in providing people with capabilities to make sense of their lives, to cope with their health experiences and suffering, and maintaining hope, inner harmony and peacefullness at this final days of suffering and challenges of life 37 .In US literature, it is believed that religion and spirituality have positive impact on how patients perceive illness and end of life issues, and can be beneficial in terms of mental and physical health and well being 38 .The raising of spiritual needs must come from the patient, rather than from the health care professional.Patients during their terminal times, may express their spiritual needs to talk about meanings of life, suffering and death.In the UK literatures, a study showed most terminal patients expressed their top six spiritual needs, which are psychological in nature 7 :  To have time to think. To have hope.
 To deal with unresolved issues. To prepare for death. To express true feelings without being judged. To speak of important relationships.One of the required skills for health care professionals is to learn companioning and listening skills 39 that focus on hearing the patient's spiritual dynamics, which reveal concerns and worries 40 :  Being a burden on others. Abandoning loved ones. Regrets about unfinished duties and business. Fears of dying alone.The carer becomes familiar with patients' needs in meditation, contemplation, and prayers that may bring them peace and well-being 41, 42.Majority of patients would like their spiritual needs addressed by health care professionals, but this is not happening in practice 43 , in spite of the fact that spiritual care is a core component of palliative care 44 .Spirituality and Religiosity: Islamic attitudes at the end of life At the "end-of-life" stage, Islamic teachings and guidance are based on a set of foundational beliefs, as clearly outlined in Islamic original primary sources, namely: The Qur'an and the Prophetic Tradition (Sunnah) 45 .This guidance forms the basis of medical and spiritual care provided to patients and their families at this terminal stage of human life which is rampant with sufferings, fears, emotions and hopes.The first cornerstone is the belief in the one God of all, the Creator of humans and Universe.Allah (the Arabic equivalent to God) Has the divine attributes of glory (Jalal), grace (Jamal) and immanence, yet He is loving, forgiving, merciful and very close to the human, even closer than his/ her jugular vein 45,46 : "We created the human being, and We know what his soul whispers to him.We are nearer to him than his jugular vein" 46 .The second concept: Allah (SWT) is the owner of everything and the ultimate of all.This concept implies that humans do not "own" their lives, health or wealth in the absolute sense 45 .The Human body is a trust from Allah (SWT).The humans ownership is temporary, a trustee-type of ownership 45 .The Qur'an states that Allah (SWT) created the human being to be His trustee on earth.
"Behold, thy Lord said to the angels: "I will create a vicegerent on earth."They said: "Wilt Thou place therein one who will make mischief therein and shed blood?-whilst we do celebrate Thy praises and glorify Thy holy (name)?"He said: "I know what ye know not." 47 .This principle of trusteeship implies a trustee is not at full liberty to make life decision such as suicide or active euthanasia, or to unjustly behave in health and wealth decisions 45 .The Qur'an is quite clear in answering universal questions pertaining to the human being, the human nature, mission on this earth, and where the human is going from here?. "Such is He, the Knower of all things, hidden and open, the Exalted (in power), the Merciful";-"He Who has made everything which He has created most good: He began the creation of man with (nothing more than) clay", "And made his progeny from a quintessence of the nature of a fluid despised: "But He fashioned him in due proportion, and breathed into him something of His spirit.And He gave you (the faculties of) hearing and sight and feeling (and understanding): little thanks do ye give!" 48 .Human Life, health, wealth and all resources available in this universe are means to help humans to fulfill that trust."And He has subjected to you, as from Him, all that is in the heavens and on earth: Behold, in that are Signs indeed for those who reflect" 49 .The Qur›an states that Allah (SWT) Has created death and life, to test the human as to his/her conduct in this earthy life, which is but a temporary stage of human life.The real and eternal life is the life hereafter."Every soul shall have a taste of death: And only on the Day of Judgment shall you be paid your full recompense.Only he who is saved far from the Fire and admitted to the Garden will have attained the object (of Life): For the life of this world is but goods and chattels of deception" 50 ."O my people!This life of the present is nothing but (temporary) convenience: It is the Hereafter that is the Home that will last" 51 ."He Who created Death and Life, that He may try which of you is best in deed: and He is the Exalted in Might, Oft-Forgiving;-" 52 .The third central belief is the certainty of death, resurrection, the life hereafter, accountability before Allah (SWT), reward, forgiveness and punishment 45 .The fact that everybody is going to die is absolutely certain, even to those who do not believe in God, or are unaware about the existence of God 45 .
Allah (SWT) predestines the moment and place of death for all.No one can delay or hasten his/her own death, or that of others."But to no soul will Allah grant respite when the time appointed (for it) has come; and Allah is well acquainted with (all) that ye do" 53 ."Nor can a soul die except by Allah's leave, the term being fixed as by writing.If any do desire a reward in this life, We shall give it to him; and if any do desire a reward in the Hereafter, We shall give it to him.And swiftly shall We reward those that (serve us with) gratitude" 54 ."To every people is a term appointed: when their term is reached, not an hour can they cause delay, nor (an hour) can they advance (it in anticipation) " 55 .The Qur'an has vivid pictures of this eternal life in the hereafter: "Whoever works righteousness, man or woman, and has Faith, verily, to him will We give a new Life, a life that is good and pure and We will bestow on such their reward according to the best of their actions" 56 ."This will be) their cry therein: "Glory to Thee, O Allah."And "Peace" will be their greeting therein!And the close of their cry will be: "Praise be to Allah, the Cherisher and Sustainer of the worlds!" 57 ."Their salutation on the Day they meet Him will be "Peace!";and He has prepared for them a generous Reward" 58 .Say: "O my Servants who have transgressed against their souls!Despair not of the Mercy of Allah.for Allah forgives all sins: for He is Oft-Forgiving, Most Merciful" 59 .This eternal life is glorified and distinguished by human dignity, forgiveness, purity, piece, love, harmony and complete absence of injustice or tyranny, as exemplified by many Qur'an verses: "Then those who believe in Allah, and hold fast to Him, -soon will He admit them to mercy and grace from Himself, and guide them to Himself by a straightway" 60 .«… We shall expel out of you all the evil in you, and admit you to a gate of great honour» 61 ."That Day will every soul be requited for what it earned; no injustice will there be that Day, for Allah is Swift in taking account" 62 .The Qur'an makes it clear that every soul shall taste death, including the greatest prophets.That in itself is a sort of consolation and alleviation of human fear of death, and of better coping in the critical times of suffering, grief and mourning 45 .Muslim's beliefs of death and the afterlife has deep influence on patients and families' attitudes in consolation, harmonious/coping, and confidence of trust, belonging and connection to their Creator."For them will be a home of peace in the presence of their Lord: He will be their friend, because they practiced (righteousness)" 63 ."We are your protectors in this life and in the Hereafter: therein shall ye have all that your souls shall desire; therein shall ye have all that ye ask for!-" 64 .A terminally ill patient who is used to performing his/her daily prayers and other acts of worship, including charity, is likely to pursue this conduct whenever and however possible, even during terminal illness, and feels more connected to his Creator with no intermediary 45 .These times are appropriate to remember certain obligations and debts for other people and work to fulfill them, either directly or through his/her advance directive.As for the rights and obligations toward Allah (SWT), there are many divine assurances to forgive and wave them after death of the believer.Say: "O my Servants who have transgressed against their souls!Despair not of the Mercy of Allah.for Allah forgives all sins: for He is Oft-Forgiving, Most Merciful" 65 .The medical practitioners and all concerned in caring and counseling of terminally ill patients have leading roles to provide caring and proper communication to alleviate distressing symptoms, fear, anxiety of patients and family members, guided the above holistic Islamic guidance.Conclusions Spiritual care has risen in health services over the last two decades, and became an integral part of health care systems across the world particularly so in palliative care at end of life care, towards patients, their families, and their carers.This review uncovered a substantial literature on spirituality and spiritual care at the end of life issues in Western countries reaching two main conclusions.First, there is work to be done in applying conceptual debates and theoretical models with specific illustration on end of life care in practice.Second, there is a need for end of life care training programs at all levels to build knowledge and understanding (and by implication, confidence) in spiritual care ,focusing on the rising objective of enabling more people to die at home (including care homes) for all, regardless of religion, belief, or affiliation.On the other hand, the issues of spirituality and religiosity in the Islamic teachings and guidance towards patient's care at terminal stages of life is clearly outlined in the Islamic original primary sources namely: the Qur'an and the Prophetic Tradition (Sunnah) as basis of medical and spiritual care, with clear fundamental concepts of faith and outlook towards life, death and the hereafter.Following this holistic guidance, medical practitioners and all concerned in caring and counseling of terminally ill patients, are qualified to provide communications and vision in alleviating distress, fear, anxiety and emotions of patients and families.