Introduction
The topic of dying and death is undoubtedly one of the most challenging, and not only in nursing. Dying and death are part of life, just like birth, but it is something that is realistically unimaginable for every person. It is hardly possible to prepare "adequately" or "well" for death. It is an event that is emotionally very demanding for everyone directly involved.
If even a partial recovery of the patient is not possible, the most important task of health professionals, including health and social workers, is to create conditions for the patient to die with dignity, i.e. to respect all the needs of the dying person, i.e. not only biological, but also psychological, social, cultural and spiritual needs.
Dying and death are phenomena that are considered from a philosophical, psychological, social, medical and ethical point of view. The future that faces the dying person, i.e. his death and human powerlessness to change this future in any way, significantly influence human thinking and actions. Death is considered to be the sharpest limit of human existence. (Kutnohorská, 2007)
If nursing care is to be effective, nurses must know and understand the "cultural context of each client". According to Madelaine Leiningerová (in Kozierová, Erbová, Olivierová, 1995), nurses should provide clients with care that respects their right to their own cultural values, beliefs and needs. The client expects that we will not only respect his culture, but also that we will create acceptable conditions for satisfying his specific cultural needs, even in the dying phase. In the nursing process, the nurse's emotional intelligence is applied, which should correctly evaluate the situation and be able to distinguish between deficit needs and manifestations of cultural differences. (Short, 2007)
It must be admitted that the psychosocial, i.e. cultural and spiritual needs of the sick are often neglected. Nurses often believe that their most important task is to take care of the basic biological needs of the sick (breathing, nutrition, defecation, hygiene, etc.), and that everything else is not so important, expendable, above standard.
However, cultural and spiritual needs are usually accentuated in the case of a sick, especially dying person. Sometimes they are even the most dominant component of his personality, because they fundamentally modify his thinking and experience, as well as his physiological needs and their satisfaction. We can demonstrate this by the need for nutrition, the need to defecate, the need for hygiene, etc. It may be far more important for the client to fast than to eat at a given moment, although health professionals are convinced that it is very important for a sick person (eg an oncology patient) to eat. The momentary need for "quietness" or even prayer can be much more urgent for the patient than the hygienic care that we want to provide him.
Awareness of the specific cultural and spiritual needs of the sick, their factual support is also necessary on the part of the health and social worker who comes into contact with the dying patient and his loved ones. Even the choice of a medical or social facility, as well as the choice of a hospice, which are matters that the health and social worker solves with the client and his family, can be influenced by whether the given facility is able to satisfy specific cultural and spiritual needs or not.
At the most general level, culture is a collection of opinions, beliefs and practices that are spread by people themselves and that pass from one generation to the next. The British anthropologist Edward Burnet Tylor defined culture as a complex whole that includes knowledge, faith, art, law, morality, customs and all other skills and habits that a person acquires as a member of society. (Davies, 2003) We can talk about culture both in terms of its universality, i.e. that much in human behavior or lifestyle is similar or even the same, whether we are members of one or another culture, in the sense of diversity, because much is typical, specific, unique to a given culture. A part of culture is also religion, which has a very close relationship with spiritual needs.
Spiritual needs are derived from spirituality, which can be understood as spirituality, as a path and relationship to the search for life values of truth, ethics, meaning and purpose of life, leading to life wisdom and humanity in accordance with certain higher ("cosmic") laws. (Irmiš, online) We can consider spiritual needs as a means to achieve the so-called spiritual well-being. What is spiritual well-being? According to Kánský, spiritual well-being is a way of life or a way of life that looks at life and experiences it as useful and pleasant, that seeks the possibilities of free choice of life-sustaining and enriching offers, and is deeply rooted in spiritual values and religious faith. (Kánský, 1991) The opposite of spiritual well-being is spiritual distress, i.e. a state in which there is a violation of the principles of life, permeating the entire human being. The individual then has a real or potentially disturbed faith in the system of values that provide him with strength, hope and the meaning of life. Therefore, spiritual needs certainly cannot be narrowed down to mere efforts to worship something or someone. Rather, they can be understood as a search and a desire for fulfillment that is inherent to all people. Spiritual needs are closely related to the search for the meaning of life and death. So they cannot be limited only to religiosity. However, for the purposes of this article, we will "narrow" them in this sense, and we will further focus on the religious needs of the dying.
Almost all religious groups believe that there is life after death, that death is not an irrevocable end, but a new beginning. However, they differ in the view of when this afterlife begins and how it proceeds.
In the conditions of the Czech Republic, we most often meet followers of Christianity. For a Christian, dying is only a short transitional stage, meaning the biological survival of the body, but in no case the demise of the soul and spirit. Christians believe that if they follow the teachings of Jesus, they will go to heaven after death. The Bible even calls for a fight against the fear of dying.
Most of us are Catholics who, like other Christians, believe in the resurrection with the second coming of Christ. For a Catholic, receiving the sacraments is of great importance, for the sick, or the dying patient, especially the sacrament of the Eucharist and the sacrament of anointing, possibly the sacrament of penance.
The granting of the sacrament of the Eucharist (Holy Communion) takes place either by a priest (or deacon) serving mass at the sick person's bedside, or by the priest bringing the sacrament to him, which is more common. However, the priest does not have to bring the Eucharist exclusively. It can be anyone who is baptized, remains in the Catholic Church and lives reconciled with God (without "grave sin") and with people (does not live in a state of active enmity, does not hesitate to forgive anyone), whose legal status does not prevent him from receiving the sacraments (he has not been given a church penalty, does not live in a church invalid marriage, etc.). Before receiving the Eucharist, a Catholic should observe the Eucharistic fast, under normal circumstances an hour before receiving the Eucharist, at least a quarter of an hour in case of illness. He can take water and medicine. If the sick person cannot receive even a fragment of the host, Holy Communion is possible through wine.
The sacrament of anointing, which is incorrectly called "the last anointing", is also important for the sick. It is granted by a priest or a bishop. After the opening prayers, the priest first silently places his hands on the sick person's head, then anoints him with oil in two places (usually on the head and on the hands) and then pronounces a blessing and asks God for the forgiveness of sins. The sacrament of the anointing of the sick is to be received by the sick when he becomes seriously ill or in old age, when his strength declines. It can also be given to unconscious people. The immediate preparation for death is the so-called the viaticum was not the holy communion for the journey (to eternity). It is the reception of the "body of Christ" near death, before which the sick person can renew his confession of baptism. After communion, the priest can grant the sick person a proxy indulgence for the moment of death.
A sick person, i.e. even a dying person, can also receive the sacrament of penance, which has a very personal character. It requires real trust in the forgiving Christ and sincere repentance for sins. It is definitely not enough to "just" confess your sins. This sacrament should be offered to the sick as a form of help, not required as an obligation.
There are relatively few Orthodox Christians in our country. Orthodoxy recognizes, just like the Catholic Church, seven sacraments, which it does not define precisely and refers to as "holy mysteries", i.e. as something beyond human understanding. They consider the Orthodox Eucharist, which can be brought to a sick person, to be the deepest secret. It is given after a previous interview, which requires privacy. Anointing with oil is a means for the forgiveness of sins for the Orthodox. It is also given to those who are sick and cannot confess. It is ideally awarded by seven clerics. In an emergency, one clergyman is "enough". The ceremony takes a long time (seven readings and seven anointings). It is of great importance for a dying patient. It is important that the ceremony begins while the patient is alive. If death occurs during the ceremony, it can be completed on the dead.
Evangelicals (Lutherans) and other Protestants approach life after death in a similar way. They recommend the last farewell to the dying person, but do not insist on it. A dying evangelical can wish for a "fraternal confession", i.e. confession of one's sins to a clergyman or another truly believing evangelical. Perhaps there is also the Lord's Supper, which is served in the hospital by an evangelical priest. The Hussites administer the "sacrament of consolation" to their sick. Either the parish priest or an officially authorized person has this authority.
Jews also believe that the deceased will be resurrected with the coming of the Messiah. Compared to Christians, however, Jews believe that this will be the first coming of the Messiah. Jews ritually wash the body of the deceased and do not leave the deceased alone until the funeral, which is very soon after the death. The male survivor, most often the son of the deceased, says the prayer "Kaddish jatom" (Kaddish of orphans).
Muslims believe that a good Muslim who observes daily rituals will come to Allah. The dying person must confess his sins and ask for forgiveness in the presence of his family. When a Muslim patient dies, his family members take care of him very intensively, ideally day and night. Relatives read to the sick person from the Koran and prepare him for the questions that will be asked of his soul in the grave: "Who is your God?", "Who is your helper?", Who is your prophet?", "What religion do you follow?". A dying Muslim patient usually wishes to sit or lie facing Mecca. Family members, elders of the local Muslim community, and Muslim clergy may require the presence at the bedside of the dying person. If the dying person is a woman, male members of the community and male clergy can only come if the woman wishes. The family then washes and prepares the body of the deceased (whereby, as during life, only a woman can touch a woman's body and vice versa) so that it can be buried as soon as possible. Only if it is not possible to establish contact with the family or members of the Muslim community, these ceremonies can be performed by non-Muslim health professionals. The body then turns towards Mecca. Black Muslims sometimes have specific rituals when washing and dressing the deceased.
Rebirth is a fixed part of the teachings of Eastern religions, especially Buddhism and Hinduism. Karma is a Sanskrit word (an ancient Indian literary language) and means the law governing human destiny, especially reincarnation. Believers of karma believe that dying is like falling asleep and there is no reason to be afraid of it, because we actually only get a kind of finer and lighter clothing in which we continue to live. According to them, no person is alone at the moment of death. He is surrounded by helping angels and deceased relatives who come to show him the way to the next world. Dying patients should not be left alone. Accompanying persons should remain calm, quietly pray and sing with him or for him, talk to him or listen to him. A caress on the face, a gentle touch on the arm, holding the hand - all of this is considered pleasant by the majority of the dying. However, it is necessary to avoid stroking the forehead or head, as this causes headaches, according to Karma followers. Only precisely defined parts of the head can be touched. The emphasis is on confession of guilt or sins.
Buddhists believe that life is a cycle and that the dead are reborn at different "levels" of life depending on how they lived their lives. They believe that it is possible to reach nirvana, ie. dissolution, state of bliss, peace, oblivion. They usually burn their dead.
In Hinduism there is a belief in personal rebirth. Hindus believe that reincarnation is achieved by those who have lived a good life and that it is possible to follow Brahma, the supreme being. The goal of the Hindu is the ultimate spiritual liberation from the cycle of life and death (moksha). After death, the priest pours water into the deceased's mouth and ties a string around his wrist or neck as a sign of blessing, which no one can remove. The family washes the body of the deceased. The deceased is then burned and his ashes are thrown into the water to cleanse him. Hindus believe that in the first ten days after death, the soul goes through a transitional period. Pious people are convinced that she is looking for or creating a new body with which she could enter the next life.
Many cultures observe a certain number of days called a period of mourning when people express their grief over the loss of a loved one. For example, among Jews there is a seven-day period of mourning (Shiva). Orthodox Jews usually mourn the whole year. They show their grief by tearing their clothes. In Islam, men do not cut their hair for 40 days after the death of a close relative. Hindus, on the other hand, do not cook for seven days after a death in the family. Food is delivered to them by friends. While in some cultures mourning is a more or less intimate affair, in others it is common to mourn in public. In many cultures, mourning clothing is worn as a sign of sadness, but there are also cultures in which, on the contrary, it is common to wear clothing symbolizing life in such a situation. Knowledge of these specifics is important with regard to the care of survivors, which should not be neglected by health professionals.
Using the above examples, we documented the religious needs of dying patients and their relatives. The relationship of the patient (including his loved ones) to "God" can take different forms, from a relationship filled with trust and love to a relationship based on fear. Any serious illness is both a physical and psychological burden for a person. In such a situation, faith is usually a great help to the patient. Occasional bad moods and ill will are completely natural even in healthy people, even more so in sick or even dying people. However, every religious person does not have to go through illness, dying and death easily and without difficulties. There are also situations when faith is an obstacle for a sick person. And vice versa. Even those who do not have a religious faith can approach death calmly and calmly.
A dying religious person usually pays special attention to religious rituals, because he is preparing not only to deal with his life, but also to meet his God and his new afterlife. Already at the very beginning of hospice care, we enable the dying patient to contact his spiritual shepherd. The priest is usually a great support for the dying person and his loved ones in all stages of dying. That is why we respect his person, just as we respect the religious rituals of a religious dying patient, such as a specific daily, weekly,... schedule of activities, including prayers and related procedures, a specific way of eating, including fasting, ... and other rituals that bring mental balance, satisfaction and reconciliation to a religious person during the dying period.
If possible, the health professional should support the dying person's communication options about matters of his faith. It does not mean that he has to communicate about the topic himself, but it also does not mean that the matter has to be left only to the relevant clergyman. A person talks about his inner needs, hopes and fears, and about matters of his faith with someone he trusts and whom he chooses as a conversation partner for certain reasons. It is wrong to ignore or even trivialize the faith of a sick person. In the same way, it is inadmissible to abuse the topic of faith to promote any goals that pursue the health professional's own interest, not the patient's interest. In any case, it is inadmissible to impose anything on the patient. Everything must be in accordance with his choice, his will, his wishes. Regardless of one's own spiritual orientation, the nurse must avoid everything that could harm the patient in his difficult condition. In the spiritual realm, every person is very vulnerable. As already mentioned, from the point of view of the patient, questions of faith may seem more important than the treatment / treatment itself.
It is generally said that a person of firm faith goes through all the stages of reaction to dying as a non-believer, but usually more quickly and with less disturbance than a person without faith. Piknett's comparison of reconciliation and coming to terms with fate in the dying of different religious groups (1992) is interesting. According to him, people who believe in reincarnation or people who believe in the religion of Eastern cultures mostly accept death with incredible calmness and serenity, while Christians often accept death with difficulty.
Many believe that the help of a psychologist or psychiatrist is either unnecessary or unworthy of a believer. The area of faith and the area of the human psyche are very closely related, in many ways they depend on each other, but they are not interchangeable. It is not true that psychology or psychiatry is a kind of "secular alternative" or a substitute for religious faith, as is often mistakenly believed. The intervention of a psychologist and a psychiatrist can help a sick believer to be able to live well in his faith, and thus have support in it.
Equally important is the respect of a health professional (medical social worker) for funeral rituals. The funeral ritual includes everything that happens from the moment of death to the final deposition of the remains of the deceased. Even though it is greatly simplified in our society, its actions and functions remain basically intact. We can also perceive a great variety of funeral rituals and ceremonies. They are historically variable, different, not only between individual cultures, but also within the cultures themselves. (Dorková, 2006)
Nursing, nursing is a culture. Caring for people in health and illness is one of the cultural manifestations of a given society. Although cultural phenomena are often hidden, they are of great importance in treating clients and improving their quality of life, and therefore it is necessary to pay attention to them. (Kutnohorská, 2004) The same can be said about health and social care. If it is to be of high quality, it must also take into account the cultural needs of the client, i.e. be provided with regard to the specific cultural context in which the given person lives.
Conclusion
The goal of this communication was not to provide exhaustive information about the cultural and spiritual needs of dying clients, but to seek insight into this extensive and challenging issue. I tried to draw attention to the urgent need to identify the client's needs, with an emphasis on the above-mentioned needs. For quality nursing care, as well as professional health and social care, knowledge of cultural, ie communication, linguistic, religious, value and other specifics. From the point of view of both the nurse and the health and social worker, it is important to know the client's medical history, also focused on the evaluation of his spirituality. Our questions, as well as our observations, should aim to obtain information about the client's views on God or the Supreme Being, to find out what effect this view has on the client's illness, his condition in general. It is important to become familiar with a specific religious practice and the degree of its importance for the client, i.e. to know the ways of fulfilling the spiritual needs of the sick (e.g. the need for prayer, fasting, the desire to see a clergyman, the desire to participate in religious services, etc.), to become familiar with the client's religious rituals, symbols, as well as recommendations, orders and prohibitions, e.g. in the field of catering (dietary restrictions and preferences, hygiene requirements, etc.). It is advisable to know specific persons (family members, relatives of the dying person) who are helpful in the client's spiritual life. For a good and constructive understanding of the spiritual component of life, in addition to empathy and a willingness to listen, the application of the general principles of cooperative conversation is also useful. (Adamczyk, 2003) In normal hospital operations, it is not possible to fully respect all culturally and religiously determined prohibitions, orders and recommendations. However, it is always possible to show an effort to implement what is possible in the given conditions, to listen, understand, advise, at least partly to help practically. And that presupposes an educated, professionally acting nurse. The same should be required from a health and social worker. All the more, we consider it a matter of course in hospices, even if a person dies in an environment that is intimately close to him, at home. Quality hospice care, which takes care of the saturation of a person's spiritual needs, is first and foremost a philosophy that can be applied anytime, anywhere, figuratively speaking "with bare hands". A sufficient level of empathy, the ability to empathize with the feelings of a person who is saying goodbye to everyone he loved, and with whom everyone who loved him is saying goodbye, is enough. It is enough to imagine that our closest ones will one day experience the same thing, that we ourselves will one day experience the same thing.
Author: doc. Mgr. Martina Cichá, Ph.D.Institute of Applied Social Sciences, Institute of Health Studies Faculty of Humanities TUB in Zlín
List of bibliographic citations
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__________The lecture was given at the international scientific conference Applied ethics in social work and other helping professions, which took place on October 20-21, 2010, in Piešťany and was published in the proceedings of this conference: MÁTEL, A. – SCHAVEL, M. – MÜHLPACHR, P. – ROMAN, T. 2010. Applied ethics in social work and other helping professions. Proceedings of the international scientific conference. Bratislava : VŠZaSP St. Elizabeth. 413 p. ISBN 978-80-89271-89-4.
