Spiritual Care for Dying Patients in Hospice

- Hui-ying Li, D. Litt.,
- Ekan Ikeguchi, Ph.D.,
- Tatsuya Hobara, M.D. Ph.D.
Dept. of Public Health, School of Medicine Yamaguchi University
1144 Kogushi, Ube, Yamaguchi, 755-8505, Japan
Email: keiei@po.cc.yamaguchi-u.ac.jp
Eubios Journal of Asian and International Bioethics 9 (1999), 74-76.


Human beings have benefited from well-developed medical technology. But during this medical development, there are still so many dying people whose treatment is unsatisfactory. Hence spiritual care will be increasingly valued in hospices. The important point of hospice care is not only reducing physical pain, but also comforting the spirit of the patient and family members. In a comparison between hospice care in Japan and Taiwan, we realized the great importance of religious spirit in the spiritual care of a hospice.


The idea of hospices started in England in 1967. Since then, it has become widespread. In 1990, the World Health Organization (WHO) gave a definition of "palliative care" as follows: Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount (1).

"What is the meaning of spiritual care ? The WHO report states that the definition of "spiritual" is: The spiritual aspect of human life may be viewed as an integrating component, holding together the physical, psychological and social components. It is often perceived as being concerned with meaning and purpose and, for those nearing the end of life, this is commonly associated with a need for forgiveness, reconciliation and affirmation of worth (2).

In the WHO's report, spiritual care includes forgiveness, reconciliation and affirmation of worth. It is also said that "spiritual" is not the same as "religious", though for many people the spiritual dimension of their lives includes a religious component (2). Therefore, in this paper, "spiritual care" means something like "the meaning of life", and it includes psychological as well as religious care. It is to extend a helping hand to:1.Pursuit the meaning of life. 2.To die with dignity. 3.The hope which overcomes the idea of dying (3,4,5).

The focal point of this paper is to compare the spiritual care aspects of palliative care in Japan and Taiwan. Based on a questionnaire survey , we have found an important difference in spiritual care between the two countries.


A "spiritual care" questionnaire survey was conducted among 1 hospital's hospice in Japan located in Yamaguchi and 2 hospital hospice's in Taiwan located in a suburb of Taipei and Kuohsiung between June and July 1998. The total number of persons were 66, 33 in Japan and 33 in Taiwan. In Japan 8 were patients and 6 were Taiwanese. 5 families in Japan responded while there were 9 families who answered from Taiwan. 20 staff members from Japan answered the survey, and 18 Taiwanese staff members.

These hospitals are non-religious facilities and the respondents were patients, their families and the medical staff. The patients responded to 11 questions, their families to 6 questions, and the staff responded to 10 of the questions.

Table 1: The questionnaire about spiritual care (extract)

1 .For Patients

Q1. What do you require from hospice?

Q2. Do you have fears and why?

Q3. What do you do when you feel depressed?

Q4. What do you wish from medical staff?

Q5. Do you think that religious beliefs are necessary?

Q6. Is religious support needed and important to you now? why?

Q7. What is the spiritual care of hospice for you?

2. For Patient's Family

Q1. Have you provided spiritual care to your family (the patient)?

Q2. In terms of spiritual care for the patient, do you think that religion is necessary?

Q3. What is the spiritual care of hospice for you?

3. For Medical Staff

Q1-1: As far as you are concerned, what do you usually do for patients in terms of spiritual care?

Q1-2: Do you think what you have done is enough for the patients?

Q1-3: Do you think that there are other better ways of spiritual care?

Q2. In terms of the spiritual care for the patient, is religion necessary?

Q3. What is the spiritual care of a hospice for you?


1. Results of the patient's questionnaire survey (extract)

Comparing the fears between Japan and Taiwan, the result from Taiwan shows that the anxiety that patients feel is lower than that in Japan. The reason behind this fear is that patients in Japan did fear the effect of treatment, while more of those in Taiwan feared how their families would cope when they died (Question 2).

For the most part, when feeling depressed, Japanese patients watched TV or did reading, and thought about their family members. In Taiwan the patients prayed . This point is very interesting. I think, possibly the difference was from the reason that in Taiwan non-religious hospitals have a religious place and volunteers for patients. But Japan's non-religious hospital had neither of these (Question 3).

Therefore, in response the question on the necessity of religious belief, 100% in Taiwan answered "Yes", compared with 33% in Japan who answered "Yes", with 38% "No", and no answers given by 24% (Question 5). In response to Question 6, 67% in Taiwan answered "Yes" compared to 25% in Japan. The reason given for the need of religious support in Taiwan was peace of mind and relief from the fear of dying.

2. Results of the patient's families questionnaire survey (extract)

The same pattern is found as with the patient's answer with the "Yes" answer in Taiwan being 89% and in Japan 20% (Question 2)

3. Results of the medical staff questionnaire survey (extract)

In terms of spiritual care, 85% of the staff in Japan felt that listening to patient's problems was important, while in Taiwan only 33% felt this way. However support in terms of religion and spirit was 0% in Japan and 38% for Taiwan's staff (Question 1-1).

But in both countries the medical staff did not feel that they had done enough for patients, as is shown in Japan's "No" answer of 85% and Taiwan's "No" answer of 94%. In Japan 10% did not know (Question 1-2).

The answers to Question 1-3 varied. In Japan, "No answer" was 47% and "Do not know" was 13%. In Taiwan, "Special knowledge about spiritual care is necessary" was chosen by 34%. If listening to patient's problems is left out, Japanese looked for other ways of spiritual care for patients.

In response to question 2, 67% in Taiwan said Yes while in Japan only 3% said "Yes", but 40% said it "Depends on patient". So, in Japan, religion is considered necessary but it depends on the patient.

Table 2: Example comments from the patient's questionnaire survey

Japanese patients

1-1 Male, 60s, Buddhism
A1: Longevity.
A2: Yes. The effect of treatment.
A3: Sleep.
A4: Spiritual support.
A5: Yes.
A6: Yes.
A7: Warm heart and love.

1-2 Female, 70s, Buddhism
A1: Longevity.
A2: Yes. Because health is necessary.
A3: Watch TV or do reading or pray.
A4: Treatment.
A5: Yes.
A6: Yes. Peace of mind.
A7: Be well.

1-3 Female, 40s, Shinto
A1: Reducing physical pain.
A2: Yes. Be afraid of adverse effect with drugs.
A3: Thinking about family members.
A4: Just being.
A5: Yes.
A6: No.
A7: Family members.

Taiwanese patients
2-1 Male, 40s, Buddhism
A1: Reducing physical pain.
A2: No.
A3: Pray.
A4: Palliative care.
A5: Yes. Spiritual support.
A6: Yes. Peace of mind and relief from the fear of dying.
A7: Peace of mind and no fear.

2-2 Female, 30s, Buddhism
A1: Reducing physical pain and spiritual support.
A2: Yes. Who looks after my kids when I die.
A3: Pray.
A4: Spiritual support.
A5: Yes.
A6: Yes. Peace of mind.
A7: Spiritual support. To talk about the terror of death.

2-3 Male, 60s, No religion
A1: Reducing physical pain.
A2: No.
A3: Pray.
A4: Treatment.
A5: Yes.
A6: No. Be ready to die.
A7: Living with family members.


It is apparent from the results of the questionnaire survey that Japan's spiritual care in the hospice examined is no more than "listening". Whereas in Taiwan, spiritual care is both listening to the patient and providing religious support. In both countries, there isn't enough spiritual care provided. In Taiwan, since religious support is seen as a necessity in most cases it is provided (6). Therefore the anxiety that patients feel is reduced, and death as being inevitable is accepted (6). The importance of more specialized knowledge about spiritual care is necessary and must be enriched. In Japan, listening to patients was deemed as important, and knowledge of spiritual care was high. On the other hand, the level of religious support is insufficient and therefore patients' anxiety is increased (7,8). The inevitability of death is not accepted and patients continuously deny that they will die (8). The Japanese hospice must provide the necessary religious support to suit the culture of the Japanese people, in non-religious hospitals.

But Japanese Buddhist belief is made up of many denominations, therefore I feel religious care is difficult in comparison to other countries. I think it is vital that Japanese strive for a non-denominational type of religious care in a hospice.


1) " Cancer pain relief and palliative care ". WHO Technical Report Series. Geneva 1990; (No.804): 11.
2) WHO Technical Report Series. Geneva 1990; (No.804): 50-51.
3) Millison M.B. "A Review of the Research on Spiritual Care and Hospice". The Hospice Journal 10 (4), 1995, 3-18.
4) Fish S, Sherry JA. Spiritual Care. Inter Varsity Press, 1978, 35-55.
5) Tillich P. The Courage to Be. Yale University Press, 1952, 24-36.
6) Lee M.H. "Caring for the Dying in Chinese Buddhism". Living and Dying in Buddhist Cultures. Hawaii University Press, 1996, 107-111.
7) Becker C. "Living and Dying in Japanese Culture". Living and Dying in Buddhist Cultures. Hawaii University Press, 1996, 159-172.
8) Kojima G, et al. "The Function of Pastoral Care Within the Frame-work of Death Education". Annual Report of The Life Planning Center, 17(1996) 1-18 (in Japanese).

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