Palliative care and spiritual friendship


One of the main reasons I am a global advocate for universal palliative care is that palliative care is a unique bio-psycho-social-spiritual approach to serious illness whose practitioners see “spirituality” as an essential element of being with dying. Not being with “the dying” necessarily, but being with dying as a process to which, all life is subject.  Spiritual care includes both providers and patients, and creates provisional communities, or ecclesias of care. Ecclesia originally meaning “those who are called out, or summoned.” Palliative care practitioners are “summoned” to accompany those who are seriously ill, and to alleviate their suffering, physical, emotional, and spiritual.

Moreover, palliative care teams that escort the dying and their loved ones to the frontiers of the unknown, exemplify what ancient and medieval philosophers called the virtue of friendship, or being for the other. Aristotle described friendship as a relationship that wants only the good of the other, for the friend [not for oneself].  In the Christian context, the virtue of friendship, or spiritual friendship, prefigures the friendship with, and of God. Indeed, in the Sufi spiritual tradition, Rumi calls God “the Friend.”

Both secular friendship and friendship with God demand commitment and practice. As the ancients saw it, the virtues had to be practiced in order to take hold in an individual or a community. When I was taking my RCIA (Roman Catholic Initiation for Adults) courses before my baptism several years ago, my teachers told me that friendship with God was like any friendship, requiring dedicated time, maintenance, attentive conversation, etc. And just as human friendships die when those things are neglected rather than nourished, so does friendship with God. Or it just never gets off the ground. The bottom line is that unless we get naked with God, whether in prayer, or in intentional activities embodying service and love of neighbour, we simply can’t think of ourselves as God’s friends.

It seems to me that we can practice for, or rehearse this friendship with God by hanging out and speaking our truth with our friends in this world. Our friends are people who challenge us spiritually, emotionally, and intellectually. They challenge us while loving us for who we are. And by loving them for who they are, we imitate what scripture tells us is God’s love for us. This sort of friendship in the world gives us, or at least gives me, the fortitude to be out in the world and to toil, as Jesus describes it, in the vineyard, one of the metaphors for the kingdom.

Palliative care volunteers, clinical providers, spiritual counselors, and social workers accompany, or escort, patients and families to the frontiers of the kingdom, whatever any of their individual conceptions of that unknown space happen to be. The gospels describe the kingdom as an energetic space where there is no fear. “Fear not” are the two words spoken most authoritatively throughout the New Testament, often by angels, God’s ambassadors.

The kingdom of Jesus’ praxis — he doesn’t just talk about it, he enacts it — is a space where the outsider, the weak, the vulnerable, and the dependent, are accepted and welcomed. It actually invites the seriously ill, weak, paralysed, and actively dying, to enter this space configured and prefigured by the frequencies of committed friendship. Palliative care is a practice, or praxis, of committed friendship, based on truth-telling, courage, and generosity, the other cardinal virtues.

Of course the more secularly minded can take God and the kingdom out of the equation altogether, and make the practice of escorting the dying and their families, both spiritually and clinically, a practice of friendship tout cort. Many palliative care providers I know do that. That would be enough. It is more than enough, given that so much energy is needed for palliative care to take root in the world, and for its potential as an agent of social change to grow and flourish. Palliative care prefigures the kingdom whether or not its practitioners think of themselves as “spiritual” or religious. It simply emerges from their work.

One of the hardest aspects of friendship is allowing it to go, either when the friend dies, or when the friendship itself dies a natural death. This is the “black river of loss” Mary Oliver talks about and the need to do three things:

to love what is mortal;
to hold it

against your bones knowing
your own life depends on it;
and, when the time comes to let it
to let it go.

But what about loving the immortal? Practicing friendship, the loving and the letting go, both among ourselves and with our patients and families, brings what Jesus called “the kingdom” to life, and teaches practitioners, through many fits and starts, to be friends of God’s. That is a status I covet, meaning I have a lot of spiritual work still to do!!

Death aversion and the spiritual identity of palliative care

Disclaimer: palliative care as a multidisciplinary clinical “approach” to serious illness is not identified with any particular religious tradition. Palliative care does, however, have an essential spiritual component that distinguishes it from other medical specialties. What follows is a meditation on the spiritual identity of palliative care from snippets of both the Christian and Buddhist traditions.


Where the corpse is, there the vultures will gather.” Luke 17:37

The roots of death averse culture lie in preoccupation with the self and the life of the body. Modern physicians and patients seek to preserve life at any cost, preferring to ignore the gospel teaching that “whoever seeks to preserve his life will lose it.,” which precedes the pronouncement about vultures. The medical profession’s business, its very identity, depends on its ability to preserve life above all else, rather than to “lose” it. Doctors and patients alike consider it a failure to lose what they conceive of as a battle with cancer.

But wait, doesn’t Jesus himself bring people back to life and restore seriously ill people to health? He is even known as the “divine physician.” So what’s up with not “preserving” life and using corpses and vultures as teaching props?

Jesus heals and brings people back to life out of compassion for their suffering and to manifest God’s power, not because he believes the life of the body to be of supreme importance. His teaching that we will “lose our lives” when we try to preserve them points to how we cause suffering by fixating on the life of the body and fearing death (the corpse), rather than nourishing the life of the spirit. Jesus is pointing his followers to the the spiritual poverty of mistaken identity, warning those who identify primarily with the body, that they will lose their lives. They won’t just lose their bodies by dying physically, they will die inside and suffer spiritual poverty while still embodied.

The Tibetan Buddhist practice of meditating on corpses and vultures, in graveyards, and at “sky burials,” also resonates with this teaching. The explicit aim of Chod practice is to dis-identify with the corporeal body while appreciating the precious opportunity it provides for liberation. The practitioner observes disintegrating corpses, reflecting that his own body will be a corpse one day, ultimately seeing clearly how the body serves simultaneously as a vehicle for liberation and as food for the vultures. Human life, which by definition is mortal, and death’s very inescapability, make committed spiritual practice an urgent priority. Reminding themselves of this, many Buddhists, echoing the 13th century Zen master Dogen Zenji chant

Life and death are of supreme importance.
Time passes swiftly and opportunity is lost.
Let us awaken,
Do not squander your life.

Likewise, Jesus points out that excessive preoccupation with self, with the life of the body, makes us miss the connection with the larger life spirit that enfolds it and originally brought it forth. He is saying that this is a great loss, worse than the loss of physical dying.

One reason modern westernised cultures fear the corpse so much is because death and dying are no longer part of ordinary life in countries not experiencing war (or ebola). Before the advent of the medical industrial establishment, which sees death as a failure of its mission, people died at home. Women washed bodies and prepared them for the cemetery at home. Now that dying is hidden inside hospitals and nursing homes, and corpses are whisked away as soon as possible, modern consumers of medical care can put off thinking about what inevitably awaits them. And the medical profession is only too happy to collude in that procrastination, having taken it upon itself to “preserve” life for as long as possible at any cost.

The desire to medicalise and preserve life beyond its natural span has produced a death-denying culture that causes great physical, spiritual, and financial suffering to patients and families. The rapid ageing of our societies, though, added to the movement to bring dying back out of the hospital and back to the home will help to remedy our illiteracy about death. This move to bring dying home must also include clinical, spiritual, and emotional support for caregivers though, since demographic and employment structures have changed since the days when people routinely died at home.

One such support, of course, is palliative care. Palliative care does not seek to “preserve” life at any cost, but offers patients and families sophisticated clinical, spiritual, and psycho-social skills to alleviate the symptoms and sufferings of serious illness. It serves both patients who are not terminal, as well as those who are actively dying. Palliative care thrives on an ethic of accompaniment, which places the dignity and wellbeing of the individual patient and family at the center of the team’s concern. Rather than labouring to preserve the life of the body, spiritual counsellors on palliative care teams support patients and families connection with the life of the spirit, thereby “saving” that life as the other slips away.

Future blogs will focus on how palliative care alleviates spiritual suffering of patients and caregivers.