Kenneth J. Doka, PhD, MDiv

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1 Spirituality 9 End-of-Life Care June 8, 2011 Presenters: Kenneth J. Doka, PhD, MDiv Gary Fink, DMin, MAHL Lawrence W. Michael Kenneth J. Doka, PhD, MDiv Professor of Gerontology, College of New Rochelle Senior Consultant, Hospice Foundation of America Licensed Mental Health Counselor Gary Fink, DMin, MAHL Chaplain, Montgomery Hospice and Project Coordinator, Montgomery Hospice Dementia Initiative Rabbi Emeritus, Oseh Shalom Congregation Panelist and author for HFA s Living With Grief program on Spirituality and End of Life Care Lawrence W. Michael Senior Management Team, Dignity Memorial Network Licensed funeral director, embalmer, cemetery manager and crematory manager Played an extensive role in emergency situations requiring a coordinated effort between government officials and funeral directors Introduction Meaning Centered Therapy Ethical Wills Dignity Enhancement Therapy Meaningful Funerals Living Eulogies Meaning Making at the End of Life How have I made a difference in the world? What is the value of my life? What is my place and purpose in the universe? 1

2 Ego Integrity versus Despair Impact of Meaning Making and Legacy Work Ego Integrity Basic acceptance of one s life having been inevitable, appropriate and meaningful A coherent personal story/narrative Helps make sense of the past Helps us find meaning in the present (Haber, 2006) (Bauer & McAdams, 2008) Find or create coherence in one s life Affirm a sense of personal value Promote selfacceptance and integrity Enhance selfaffirmation, self esteem, and confidence Impact of Meaning Making and Legacy Work Impact of Meaning Making and Legacy Work Enhance relationships Coming to terms with death Cope more effectively with death anxiety Reduce Rd deep distress caused by painful memories Meaning based coping can diminish the impact of negative life experiences Adjustment of goals Reframing understanding Focus on positive events Application of spiritual beliefs or personal philosophy Impact of Meaning Making and Legacy Work Strengthen continuing bonds with the deceased Personalize patients in facilities while promoting equity. Spiritual Needs of Individuals Who are Dying What is spirituality? Whatever gives transcendent meaning and connection to our lives 2

3 Spirituality may include: How is Meaning Making Spiritual? Oneness with ih nature Connection to family Identification with community Affirms meaning within a person s life and the value of the life lived Philosophy of life Meaning of Life Legacy Connections that transcend death by affirming legacy How is Meaning Making Spiritual? Addresses fundamental spiritual question, What is the meaning of my existence? Meaning Making activities can apply to: Believers Atheists Skeptics Seekers Agnostics Dignity Enhancement Therapy Approach Dignity Enhancement Therapy Approach Intervention involving lifeaffirmation and legacy building Incorporates physical, psychological, spiritual and social aspects of the illness experience Addresses patients and families Directive and structured Patients discuss issues most important to them Life history How do you hope you will be remembered? Other words you want others to hear Lessons or thoughts you wish to pass on Conversations recorded, transcribed, edited After recalling and discussing life experiences, a generatively document is produced for family members or loved ones 3

4 Dignity Enhancement Therapy Enhances a patient s sense of purpose, dignity, and hope Impact Survivors find comfort in affirming the life of their loved one Research on Dignity Therapy Issues such as meaning, purpose, and hope need to be included within the realm of quality end of life care Chochinov, 2003 Research on Dignity Therapy Factors associated with existential suffering Depression and pain Being a burden to others Loss of sense of purpose, meaning and hope Loss of dignity Meaning Centered Therapy How can you live knowing you re going to die? William Breitbart Helps patients find a sense of meaning, peace, and purpose in their lives Meaning Centered Therapy Session 1 Introduces Frankl s book, Man s Search for Meaning Meaning Centered Therapy Sessions 5 Encountering life s limitations Session 2 Identity before cancer and after diagnosis Transcending the limits imposed by cancer Session 6&7 Focus on what can be done, not what can t Sessions 3 &4 Personal history as a source of meaning Session 8 Presenting a legacy project that symbolizes the meaning that participants found to pass on 4

5 Living Eulogies Provide comfort to alert and oriented people facing the end of life Messages, s and videos are sent to people who are seriously ill Living Eulogies Friends and family members share stories and reminisce about meaningful time Testimonials of enduring connections and contributions validate a person s life Living Eulogies Online portals and websites for living eulogies Funeral home support programs, such as: Making Everlasting Memories by Dignity Memorial Moral/Ethical Wills Documents prepared before death Reflections Blessings Instructions Personal histories Values to be passed on to other Moral/Ethical Wills Various forms of moral/ethical wills Letters Videos Audio recordings Spiritual and Psychosocial Functions of Meaning Making & Legacy Building For patient For patient For survivors For caregivers Spiritual Function Validates and affirms the value of patient s life journey & experiences Life after death: eternal/continuing influence or impact Ongoing transcendent connection with deceased Respectful regard for sacred or inherent value of each person Psychosocial Function Ego integration Generativity Emotional relocation Empathy 5

6 Making a Meaningful Funeral Primary role of the funeral director: Listen to what the family wants Help to plan a meaningful service The Value of a Funeral Confirms the reality of the death Interprets the death in a spiritual framework Assists in living with grief Making a Meaningful Funeral Include family and friends Both in the planning process and the service Children s participation Memorial gifts provided in memory of the loved one The role of a funeral in relation to grief and loss: not the end of the grief process, but one stop on the journey Provides an opportunity to construct support system Provides an opportunity to publicly grieve Creates new meaningful memories Making a Meaningful Funeral Funeral homes have expanded the range of services to meet consumer needs Service at funeral home or place of worship Memory or picture boards Video tributes, such as the Everlasting Memorials Making a Meaningful Funeral Funeral homes have expanded the range of services to meet consumer needs Baby boomers coming of age Increasing cremation rate 6

7 Making a Meaningful Funeral Customization Military funerals Special requests Personalization How families choose to commemorate the life of their loved one can be individualized Unique tributes Cremation options Cemetery Options Choosing a final resting place allows families additional opportunities for meaning making Niches Gardens Customized headstone Mausoleum Bridge the gap between hospice and funeral care Hospices and funeral homes can work to improve the logistical process at facilities Good relationships can lead to a smoother transition and improved service for families Ensure that communication and expectations are clear to the family What can professional caregivers do while waiting with the family? Begin discussing initial arrangements Ask to see pictures and hear stories Ask, what would make the funeral meaningful for you? Partnerships and Education Form community partnerships to help further y p p p awareness about end of life options Provide continuing education opportunities for staff CEU course from select Dignity Memorial providers Have social workers and nurses host and teach an in service seminar for local funeral directors Please visit for more information 7

8 A Brief Review Emphasized techniques that assist meaning making Spiritual need to live a meaningful life Developmental need to review life Meaning and Ego Integrity A Brief Review A number of approaches and strategies Chochinov Dignity Enhancement Therapy Brietbart Meaning Centered Therapy Living i Eulogies Moral/Ethical Wills Funeral Rituals Life Review and Reminiscence (from earlier program) Two Additional Approaches Doula Programs Therapeutic Ritual New Innovations in Care of the Dying Doulas midwives The term Doulas can now also refer to volunteers who assist as midwives for the dying helping families and patients through the transition What would constitute a good death? What do you want to happen? Who would be around you? (Fersko Weiss) Utilize Ritual and Beliefs Liminal Making the commonplace uncommon Bridge to Culture and Spirituality Therapeutic Ritual Continuity Transition Reconciliation Affirmation 8

9 Creating Ritual Arise from narrative Objects are visible and symbolic Planned and processed Use primal elements (Fry) A Final Caveat Patient s Needs The Issue of Counter Transference Shneidman s Dictum For More Information: Hospice Foundation of America CEU Course provided by Dignity Memorial providers, Demystifying the Funeral Experience Please visit Visit us online Or call toll free For Additional Information: Spirituality and End of Life Care book available org Edited by Kenneth J. Doka and Amy Tucci Includes chapters by Gary Fink, Barry Kinzbrunner, Betty Ferrell and Christina Puchalski HFA s Hospice Information Center, funded in part by the Centers for Medicare & Medicaid Services (CMS), provides free online resources and education for professionals and consumers 9

10 Hospice Foundation of America s Webinar Series Continues Wednesday, July 13 th : The Dark Night of the Soul: Assisting Clients Coping with Spiritual it Distress at the End of Life with Betty Kramer and Robert Washington Go to to register Additional Reading on Ethical/Moral Wills Ethical Wills: Putting your Values on Paper, Baines, B. (2001) Legacy: The giving of Life s Greatest Treasures: Loving, Learning, Laughing, Lamenting, Linking, Living, Leading, and Leaving, Greiff, B.S. (1999) In the Checklist of Life: A working book to help you live and leave this life, McPhelimy, L. (1997) Additional Reading on Meaning Man s Search for Meaning, Victor Frankl The Will to Meaning, Viktor Frankl The Courage to Be, Paul Tillich Demystifying the Funeral Experience: The Role of the Funeral in the Grief Process PRESENTED BY DIGNITY MEMORIAL FUNERAL PROVIDERS AND HOSPICE FOUNDATION OF AMERICA for more information see: Staring at the Sun: Overcoming the Terror of Death, Irvin D. Yalom The Way of Transition, William Bridges Love and Death, Forrest Church 10

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