Saul Ebema, D.Min.
During my experience working with terminally ill patients as a Hospice Chaplain, I have noticed that the major concerns of terminally ill cancer patients with a prognosis of six months or less are existential, spiritual, familial, physical, and emotional issues. Several patients I have worked with over the years expressed the fact that although their disease was continually monitored and reassessed, the existential, spiritual, familial, and emotional aspects of their illness were rarely a focus of their care and that they would like help with these issues.
This is where chaplains can have an impact in assisting patients with these issues that are often not addressed by other health care professionals. Hidden within these various issues is the need to maintain and sustain relationships.
Chochinov maintains that there is a human urge to infuse life with purpose, meaning, and hope, thus leading a person to believe that to die a good death, those three elements must be fulfilled. When people are asked what makes their lives meaningful, the majority refers to their close, intimate relationships with others (Klinger, 1977).
In fact, Berscheid & Peplau (1983) acknowledge that being involved in stable and satisfying relationships is regarded by most people as a critical ingredient of happiness and well being in life.
The importance of relationships surfaced in the National Hospice Demonstration Study 1978-1985 (as cited in Kastenbaum, 2004), which was a major attempt to evaluate the effectiveness of palliative care in the United States.
The study focused mostly on medical and economic matters, but also asked terminally ill cancer patients two questions about their own views of the situation namely: “Describe the last three days of your life as you would like them to be”; and, “What will be your greatest sources of strength and support during these last days of your life?”
The most common responses for the last three days of life were as follows, I want: certain people to be with me; to be physically able to do things; to feel at peace; to be free from pain; and, the last three days of my life to be like any other days.
Sources of strength included: supportive family or friends; religion; being needed; confidence in self; and, being satisfied with the help received. Relationships were at the top of both lists. More than anything, these terminally ill people drew strength from their closest life companions and most desired their continued companionship to the end.
The dying person is part of a social network consisting of family friends, community members and new relationships within the health care network. Relationships are changed and challenged by serious illness. Kane, Brown Hellsten & Goldsmith (2004) state “the supportive value of human relationships becomes increasingly important as cure of disease becomes an unrealistic goal” (p. 183).
The presence of close relationships has been shown in recent literature to have both positive and negative health outcomes. For example, Berman (1985) and Reifman (1995) have noted the protective effects of close relationships on mortality, physical and psychological morbidity, and recovery from chronic diseases.
Other research has indicated that mortality rates are significantly higher among people who lack close emotional ties (House, Landis & Umberson, 1988) and report poor social integration (Berman, 1995).
Intrapersonal, Interpersonal, and Transpersonal Relationships
Intrapersonal relationships refer to how an individual gets along with him/ herself, self-concept, confidence, self- efficacy, etcetera. Neisser (1988) distinguishes between the “private self” which involves introspection on one’s own feelings, goals and thoughts, and the “extended self” which is the ability to think about oneself in the future. Evidence suggests that these abilities have evolved at separate times and may involve different cognitive abilities (Leary & Buttermore, 2003).
Interpersonal relationships are those that involve social associations and connections between two or more people. They vary in levels of intimacy and sharing depending on the type of affiliation.
A transpersonal relationship is one in which beings are drawn together by their spirits. As described by McColl, Bickenbach, Johnston, Nishihama, Schumaker, Smith et al. (2000), they are relationships of a “transcendent nature, with God, the world or nature” (p. 559).
In their study looking at spiritual issues associated with traumatic-onset disability, the authors build on theory developed in palliative care and ageing to describe spiritual issues related to five themes which arose directly form the data: awareness, closeness, trust, purpose, and vulnerability.
Their study offers clinicians a better understanding of spiritual issues that arise in the context of disability and illness. The results from Wlodarczyk’s (2007) investigation indicated that spirituality is an integral topic to be addressed with terminally ill patients and their families.
Relationships may come to an end without them being completed. According to Byock (2004) relationships are complete when we feel reconciled, whole, and at peace. Byock (1997) elucidates that there are five sentiments that permit relationships to reach completion once they are expressed. These are: “I love you”; “Thank you”; “Forgive me”; “I forgive you”; and, “Good -Bye”. These are sentiments that can be expressed to complete various types of relationships including intrapersonal, interpersonal, and those with a spiritual or transcendent connection.
The last weeks and days of life are often filled with unique prospects for healing and personal growth. Profound transformations are made possible with the urgency of impending death. The necessity to know one has made an impact in this life becomes a central focus for many patients, and exploring and reviewing the accomplishments and disappointments in one’s life may create the space for reconciliation, expressions of love, peace, and ultimately conclusions or closures.
Spiritual support has the potential to address the multidimensional needs of the patient and care providers. Enhancing quality of life and facilitating good deaths is contingent upon adequate management of both physical and psychological pain. As stated by Mills Groen (2007) if psychological, emotional and/or spiritual issues are not addressed; pain can become resistant to conventional treatment measures.
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