Spirituality and Faith
What is spirituality?
Spirituality means different things to different people. For some, spirituality may mean belonging to a religious group and for others it may be a personal philosophy or a worldview. Integral to spirituality are important connections, such as with self, others, creativity, nature and/or a sense of something bigger than ourselves. Our spirituality is integral to our identity and sense of belonging. According to the 2016 Census, two in three Australians follow a religion, while one in three people do not identify with a religion. In all care contexts, spirituality is seen as different from religion, though religion may provide spiritual expression. People express their spirituality in different ways and not everyone will use or recognise the term ‘spirituality’.
As people age, particular spiritual aspects may become more important to them, such as finding meaning in life, transcending hardships or losses, affirming relationships, or finding hope in the face of deterioration or frailty. People can express their spirituality in many ways, including through cultivating compassion, kindness, and generosity toward themselves and others, reading texts, engaging with others, and through ritual, ceremony, prayer, service, song or dance. For some, spirituality can lower symptoms of depression and anxiety.
In Australia, understandings of spirituality and spiritual care have changed in the last two decades to better include those who do not identify as religious. It is relevant to all sectors and to all health professionals and care workers, and is not limited to religiously-specific care. ‘Spiritual care’ is an umbrella term which includes religious care, however spiritual care is not necessarily religious. Religious care is provided in the context of shared religious beliefs, values, liturgies, prayer, rites, rituals, support and lifestyle of a faith community. Spiritual care focuses on building compassionate relationships and active listening, and is integral to best practice aged care and palliative care. The terms ‘spiritual care’ and ‘pastoral care’ are very closely linked, and definitions are overlapping. Meaningful Ageing Australia suggest pastoral care complements the care offered by other disciplines while paying particular attention to spiritual aspects, including healing, guiding, supporting, nurturing and empowering people.
For Aboriginal and Torres Strait Islander people, ‘spirituality’ often refers to a more holistic view of life and emphasises cultural connection with the land, sea and air. For many Aboriginal and Torres Strait Islander people, this relationship confirms their identity and place as an Aboriginal person. Many Aboriginal and Torres Strait Islander people may also identify with a religious group in addition to cultural traditions.
Further information and resources on spirituality, spiritual care and faith groups may be found on the following websites: Catholic Health Australia, Meaningful Ageing Australia, Spiritual Health Association, Spiritual Care Australia and palliAGED.
Spirituality in aged care
Spiritual care can enhance well-being and improve quality of life for older adults. Palliative Care Australia and Meaningful Ageing Australia call for the universal acceptance of spiritual care in aged care, particularly for those receiving end-of-life care, their families, carers and staff. The National Guidelines for Spiritual Care in Aged Care are an essential resource for aged care organisations. Spiritual care is profoundly person-centred, and fundamental to identity. Spiritual and religious beliefs can impact decision making about treatment, medication, self-care, and expectations and relationships with health and aged care service providers. Aged care organisations must recognise the importance of spirituality and spiritual care for all older adults and respond appropriately to these needs. Many health professionals and care workers do not feel comfortable addressing spiritual or religious needs. The Aged Care Quality Standards for Australia expect best-practice spiritual care. Spirituality and spiritual care can contribute to most of the quality standards in different ways. For example, spiritual care can help to:
- maintain an older person’s identity
- make connections with others
- optimise health and well-being
- understand what is right for each person
- understand each person’s needs, goals and preferences
- create a sense of belonging and safety
- have services and supports to promote each person’s emotional, spiritual, and psychological well-being
- have a caring, respectful workforce which embraces each person’s identity, culture, and diversity
Some specific considerations for organisations and health professionals and care workers are listed below.
- include spiritual care support in aged care funding models
- recognise spiritual care practitioners and incorporate them as an allied health profession
- follow the ‘National Guidelines for Spiritual Care in Aged Care’
- train staff in spiritual care (for example, introduce the idea of spiritualty as more than religion and use modules related to cultural and religious differences in training courses and programs)
- accommodate preferences for the gender of health professionals and care providers, based on religious affiliation and belief
- recognise that a lack of faith understanding and sensitivity by professionals can result in poor communication and reduce the likelihood of certain people and groups accessing end of life care and services
- awareness of the older person’s spiritual needs is essential in providing appropriate spiritual care for each individual
- anyone can ask about people’s immediate spiritual needs to understand what gives meaning and purpose, and what helps them to cope with life. Explicitly using the language of spiritualty can be a conversation-stopper for many people. To begin the conversation, ask about a person’s important connections and what helps them to feel peaceful. You could also ask if people consider themselves religious, or if they have personal spiritual beliefs independent of religion. If they are religious, it is important to explore what this means for their life. Include this information in your case notes.
- conduct a ‘spiritual screen’ to see whether people have any special religious needs which may affect their care and their medical and end of life decisions; and/or other important connections that need to be considered. Spiritual screens involve asking a few short questions to identify people’s needs, hopes, and resources to build a spiritual profile and contribute to health and well-being. Ask how you can address this in the care and support you provide, and record people’s preferences.
- a spiritual care practitioner or a suitably qualified member of the care team can provide a more in-depth spiritual assessment
- a spiritual intervention for both those who identify as religious and those who do not can include a ‘life review’ process, support groups, creating artwork, enjoying nature, listening to music, or other activities that nurture their connection to themselves, others, and/or to ‘something bigger’
- if a person is religious, spiritual activities may include visits from healers, members of the faith community, particular prayers or rituals and/or religious counselling
- listen attentively and reflectively to people’s experiences and stories to hear what gives them meaning and connectedness in life. This can help people feel less alone.
- respect people’s expressions of their spirituality, faith or belief, even if it differs radically from yours
- do not impose your own faith or lack of faith on others
- acknowledge that many people use their faith to help them cope in difficult times. For some, it may be about finding meaning in what is happening.
- figure out if there are spiritual or religious beliefs or practices that are important to care and planning when nearing death or following death. Accommodate these beliefs wherever possible.
Spiritual screening questions which can start the conversation to establish the importance of religious or spiritual beliefs and practices may include:
- what helps/would help you to feel at peace?
- where do you find strength in difficult times?
- are you supported by a religious or spiritual community?
- do religious or spiritual beliefs influence how you care for yourself or your health?
- what is important for us to know about your faith or spiritual needs?
- what gives you meaning or purpose in life?
- people often find spirituality or religion helpful when dealing with serious illness. Is this true for you?
- how may your beliefs affect your medical care?
- how can we best support your needs and practices? Are there any customs or rituals to be observed?
People report lower satisfaction and quality of care when their spiritual needs are unmet. Spiritual training for staff can increase skills in managing and communicating about people’s spiritual needs. A video about key spiritual needs of older people can be viewed on the Meaningful Ageing website. For more information about spirituality in aged care, visit Meaningful Ageing Australia’s See Me. Know Me. website.
Spirituality and palliative care considerations
Recognising and responding to spiritual needs is in line with person-centred care. Palliative approaches should include spiritual assessments. Religious and spiritual beliefs, practices and support may impact people’s overall well-being, health and quality of life outcomes, and strategies for coping with illness. Spirituality, with or without a religious expression, is an essential component of many peoples’ health and well-being. It can enhance resilience, resources, pain management and sense of support. Spirituality and faith can increase hope, longevity and coping skills, and decrease anxiety, depression and suicide.
The experience of illness, suffering, and meaning of life and death are several spiritual care questions important to the healthcare environment. Spiritual care can help people to better prepare towards the end of life by encouraging reflection on their lives and contributions, resolving issues, reinforcing their worth, and feeling their preferences are recorded and respected. Self-reported spirituality impacts how people adjust to ageing, healing, recuperation and a peaceful death. Sensitive spiritual support can help families to increase overall satisfaction and to grieve after the loss of a loved one.
Some people may feel more spiritual and want to think more about issues when they are dying. For many, the chance to explore big life questions, in addition to attempts at reconciliation, forgiveness, legacy, and gratitude become important at this time. Some may embrace a belief system that they have never been interested in before or abandoned many years ago. Some find comfort and strength in prayer or meditation, and gain support from knowing that other people are praying for them or sending positive thoughts. Sometimes beliefs are challenged by certain situations and people may no longer find comfort and strength in religion.
Spiritual and religious beliefs can impact the experience and provision of palliative and end of life care. Many faith communities believe that life is a gift from God and that only God can determine the time of death, meaning they oppose voluntary assisted dying. People may have different views regarding withholding or withdrawing life-sustaining medical treatment when there is little likelihood of survival. Such issues are nuanced and complex. On 19 June 2019 the Voluntary Assisted Dying Act 2017 came into effect, meaning Victorians who are at the end of life and who meet strict eligibility criteria can now request access to voluntary assisted dying. Governments in some other states have established parliamentary committees to consider future reform, or are developing their own legislation. As with the general population, members of faith communities may not be well educated about what palliative and end of life care is, and the role of medication as a comfort measure.
Diverse populations and spirituality
Caring for people from different ethnic backgrounds and belief systems can be challenging for health professionals and care workers. It is important that professionals and providers are educated about and aware of the impact of different cultures and religions on illness, suffering, death and dying, funeral and grieving preferences, and traditions, rituals, and practices. However, there are individual differences within particular spirituality or faith groups; people of the same faith may adopt different practices. Health professionals and care workers should avoid assumptions about how people may interpret or practice their faith. Culturally competent care recognises and responds to the individual needs of each person and their families. Cultural and religious beliefs and practices also influence people’s perception of quality of care. Being sensitive to the cultural and belief systems of patients and their loved ones can increase patient satisfaction and reduce stress at difficult times. There may be negative outcomes for people if their specific religious and spiritual beliefs and preferences are not honoured by providers. Mistrust can also influence people’s views of health care options at end of life.
There are particular spiritual considerations for Aboriginal and Torres Strait Islander people. They can have different and unique languages, customs, beliefs, healing practices and cultural practices depending on the community they are from. For many Aboriginal people, the topic of death and dying is very sensitive. However, generalising across all Aboriginal communities in relation to spiritual values and beliefs is not appropriate. It is important to ask each person about their cultural and spiritual values and preferences around their place of death, who should be there, what care is needed after death (including disposal of the body and associated rituals). For some, these cultural and spiritual needs may be more important than meeting physical needs, such as pain relief. Support can be accessed from state-based Aboriginal Community Controlled Health Services. Talk to a spiritual care worker in your organisation if you are unsure of how to best support Aboriginal and Torres Strait Islander people.
Spiritual care workers are part of aged care and palliative care teams, and are trained to help people work through their feelings. They can arrange visits from spiritual or religious leaders. They may also provide encouragement, companionship, rituals and support for families and carers. A spiritual care practitioner is sometimes called a ‘pastoral carer’ or ‘chaplain’. At the end of life, many people do not wish to be separated from their communities, and those close to them may require support to cope with their loss.
Palliative Care Bridge provides spiritual care resources for the end of life, and CareSearch provides information and clinical evidence on existential distress, hope, spirituality, and suffering. Watch Meg Hegarty discuss spirituality at the end of life, or listen to Dr Bruce Rumbold discuss nurturing the spirit at the end of life for patients and families.
Spirituality, faith and advance care planning considerations
Cultural, religious and spiritual factors are important to advance care planning, particularly around informing medical decisions towards the end of life. Knowing about religious beliefs and values around death and dying can prepare health professionals for advance care planning initiatives from people from diverse faith backgrounds. However, it is important to avoid assumptions based on religious or faith affiliation. For some people, their beliefs are a source of comfort and lessen concerns around death, while others find themselves increasingly worried about death. Interestingly, some studies suggest that terminally ill patients who use religious coping are less likely to have advance directives and more likely to opt for end-of-life measures.
Culture, religious and spiritual factors can influence palliative and end of life care in many ways due to differences in preferences, behaviours, perceptions and experiences, including:
- different beliefs about wanting to know about terminal diagnoses
- involving family as primary decision makers
- how people approach serious or life-limiting illness and end-of-life
- judgements about what constitutes quality of life and the meaning of pain and suffering
- treatment, pain management, and care preferences (e.g. dietary considerations, nutrition and hydration at the end of life, use of pain medication, withholding or withdrawing life sustaining treatment, using life support measures like resuscitation, feeding tube and intubation)
- perceptions of how treatment may impact quality or length of life
- family responsibilities for caring at the end of life
- sense of divine intervention (e.g. God’s will)
- preferences for location of death (e.g. home, hospice, hospital)
- choices around death and dying, such as blood and organ issues
- ritual acts and objects
Some people prefer not to be directly informed of life-limiting diagnoses, or do not believe in talking openly about life-limiting illnesses or diagnoses with family members or health professionals. As a result, they may not engage in advance care planning, or may believe that advance care directives are not needed because family or physicians already know their wishes. Encourage the people you care for to complete advance care directives so that their wishes are known to everyone involved in their care. ELDAC’s Legal Toolkit can provide further information.
The ACPTalk website was designed in collaboration with Australian religious and cultural leaders and organisations, to provide information for health professionals conducting advance care planning with people from different religious and cultural backgrounds. Information should not be generalised to all people of a particular religion, faith or culture. Within any particular religion or culture, there may be a range of spirituality or faith expressions. The following resource on Advance Care Planning Australia’s website may assist when focusing on advance care planning for CALD populations.
The material on this page has been adapted primarily from Meaningful Ageing Australia.