Faith, dying and palliative care in multicultural Britain

First published April 2007, updated December 2021

Key points:

• Britain is a multifaith society.
• Different faiths approach death in different ways.
• An understanding of faith issues at the end of life is essential to provide good care.
• The hospital chaplaincy is a useful resource.

Britain is a multifaith society (see Table 1)¹. Not all faiths approach death in the same way and awareness of religious variation can improve patient care at this emotive time². The importance of spiritual well-being is recognised in palliative care³.

Table 1. Demographics of religion in Great Britain

Table 2. The five €˜Ks’

Christianity

Roman Catholic, Protestant and Eastern Orthodox are divisions of Christianity. The variety of beliefs is wide, however all believe in an afterlife. Orthodox and Catholic patients who are dying may request a bible, crucifix and prayer book. The Orthodox may request a family icon. A rosary for prayer and holy water from places associated with miraculous cures, such as Lourdes, may comfort Catholics. Many Christians may wish to receive one or more sacraments from a priest or hospital chaplain prior to death, including baptism, confession, holy communion and the sacrament of the sick (anointing with oil and laying on of hands, often called the last rites). Differing denominations afford varying degrees of importance to the sacraments; in the Roman Catholic Church they are very significant, while for Protestants there are fewer observed last rites. After death, patients are laid out with no restrictions to touching the body. Prayers and blessings may be recited. A Catholic’s hands are often placed in an attitude of prayer holding a crucifix or rosary. Orthodox Christians are usually buried. For others, cremation is also acceptable. There are no religious objections to post mortems.

Islam

Islam is the religion of Muslims. A dying Muslim may wish to turn towards Mecca (southeast). The patient can either be turned on their side with the face towards Mecca or laid on the back with the feet in that direction and the head slightly raised. A religious leader (Imam or Maulana) may attend. Alternatively, family members may read from the Qur’an (Koran). Muslims believe in life after death. While devout Muslims curtail their emotions at times of death, believing this is God’s wish and to struggle would suggest rebellion, it is not uncommon for family members to show grief by crying and wailing. Ideally the body should not be touched by non-Muslims. If unavoidable, healthcare workers should wear gloves. The family may wish to prepare the body, which should remain covered. The eyes are closed and bandages applied around the head and lower jaw to prevent gaping. The body is straightened and head turned to the right shoulder. Washing of the body is performed by a same sex Muslim. Passages are read from the Qur’an and the family prays. The body must be buried as soon as possible, preferably within 24 hours. Muslims are never cremated. Post mortems are forbidden in Islam unless required by law.

Hinduism

Hinduism is often believed to be a collection of early religions; others would say it is more a way of life. Huge diversity in beliefs and philosophies necessitate careful discussion with patients and their families to ensure their particular needs are met. Hindus often prefer to die at home. The patient may be comforted by readings from holy books, such as the Bhagavad Gita, and by the close proximity of pictures or images of gods in addition to praying beads and blessings. Lying on the floor symbolises closeness to Mother Earth. A priest (pandit) may be called to perform) may be called to perform holy rites including tying sacred thread around the neck or wrist, blessing with sprinklings of holy Ganges water and placing a tulsi leaf or drops of ghee (clarified butter) in the mouth. Hindus believe in a return to earth in either a better or worse form, depending on one’s karma (i.e., what a person does in this life affects what will happen to him in the next). After death, customs vary. The body may be placed on the floor with lighted lamps and burning incense. There is no restriction to non-Hindus handling the body provided it is wrapped in a sheet or gloves are worn. The eyes are closed and limbs straightened. Jewellery and religious objects should remain with the body. Post mortem examinations are acceptable if legally required. Traditionally, the eldest son washes the body and dresses it in new clothing. Adult Hindus are cremated within 24 hours wherever possible. Ashes may be scattered in any flowing river, preferably the Ganges. There follows a period of mourning for 10€“13 days.

Sikhism

Sikhism was founded in the Punjab, India. Sikhs have five symbols of faith €” the five Ks (see Table 2) €” that should be given special regard when nursing a patient and not removed without discussion. A dying Sikh may be comforted by recital from the holy book, the Guru Granth Sahib, either by a relative or a reader from the Gurdwara (temple) known as a Granthi. After death, the family wash and dress the body while reading passages from the scriptures. Non-Sikhs may touch and prepare the body if necessary. The eyes and mouth should be closed followed by cleaning of the face and the limbs straightened. Men are wrapped in a white shroud and turban, while young women are wrapped in red and older women in white. The body should be released as soon as possible. Post mortems are accepted when legally necessary. An open coffin is commonplace. Sikhs cremate their dead still wearing the five €˜Ks’, preferably within 24 hours followed by prayers at the Gurdwara. The ashes should be scattered in running water and are often taken back to the Punjab for this purpose. A period of mourning lasting approximately 10 days follows.

Judaism

Judaism is the religion of Jews. If a dying Jew asks to see a rabbi it is important to establish whether the patient is orthodox, reform or liberal as attitudes vary widely. The patient may wish to hear or recite a special prayer (the shema) or Psalm 23. A silent confession (vidui) may be performed. At the time of death a feather is placed over the mouth and nostrils to observe for signs of breathing for eight minutes. Non-Jews should not touch the body. If no signs of life are found, the son or nearest relative closes the eyes and mouth, binding the jaw. Fingers extended, the arms are placed by the sides. The body is covered and placed on the floor with the feet towards the door, a lighted candle by the head. The body should not be left alone until it is removed, preferably by a Jewish undertaker and ideally not on the Sabbath or religious festivals. Orthodox Jews are required to bury their dead (usually in their own cemeteries) as soon as possible following death and after the ritual purification by the chevra kaddisha, the holy assembly. Non-orthodox Jews do not have this ritual and the liberal may even opt for cremation. Post mortems are not permitted unless advocated by law. Following the funeral is a formal seven-day period of mourning.

Buddhism

Buddhism is more a philosophy of life and holds no god as creator. Buddhists believe in rebirth €” individuals must be responsible for their actions in this life as this will influence the next stage. There are many schools of Buddhism and attitudes vary, although meditation is universal. Buddhists often accept approaching death calmly. Keeping a clear mind to allow meditation and reflection is important meaning drugs that relieve suffering but cloud consciousness, such as analgesics, may be refused. A dying Buddhist may wish to hear readings from scriptures or chanting. Religious artefacts, such as statues or pictures of Buddha, may offer comfort. Some appreciate a visit from a monk or nun. The most important thing when a Buddhist dies is that a priest is informed as soon as possible. Ideally, the body should be moved as little as possible until the priest is able to say the necessary prayers. This can be performed in a temple rather than at the bedside. The body should be wrapped in a plain white sheet. Relatives are usually accepting and calm. Post mortems are not met with any objection. Buddhists are cremated with the ashes being returned to the earth. Often a tree is planted at the site of scattering symbolising the rebirth and completion of the cycle.

Conclusion

Britain is becoming more culturally and religiously diverse. Influenced by their faith, patients and their families deal with death differently. Understanding their needs is essential to provide a good standard of care and is recognised by the Department of Health⁴. Customs can easily be accommodated with guidance from hospital faith leaders within routine clinical practice.

References

1. United Kingdom Census April 2001 http://www.statistics.gov.uk/cci/nugget. asp?id=954
2. Neuberger J. Caring for Dying People of Different Faiths. 1994; Times Mirror International Publishers Ltd, London
3. McClain CS, Rosenfi eld B, Breitbart W. Effect of spiritual well-being on end-of life despair in terminally-ill cancer patients. The Lancet 2003;361:1603-08
4. Department of Health 2003. NHS Chaplaincy: Meeting the religious & spiritual needs of patients & staff. http:// www.dh.gov.uk/PublicationsAndStatistic s/Publications/PublicationsPolicyAndGuid ance/PublicationsPolicyAndGuidanceArti cle/fs/en?CONTENT_ ID=4073108&chk=rynt0L