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Palliative Medicine 2000; 14: 149–155

Spirituality and palliative care: a model of needs

Allan Kellehear Professor of Palliative Care, Faculty of Health Sciences, La Trobe University, Melbourne

Abstract: This paper provides a theoretical model of spiritual needs in palliative care
based on a review of the palliative care literature. Three sources of transcendence, the
building blocks of spiritual meaning, are identified: the situational, the moral and
biographical, and the religious. After these areas of transcendence are described and
explained, implications for future theory, research and practice are identified.

Key words: models, psychological; needs; religion; spirituality (nonMeSH); theory;

transcendence (nonMeSH)

Resumé: Cet article fournit un modèle théorique des besoins spirituels en soins palliatifs
d’après une revue de la littérature. Les trois sources de transcendance, les fondements
de la pensée spirituelle, sont identifiées: le situationnel, le moral et le biographique, le
religieux. Après une description de ces domaines et une explication des implications
pour une théorie future, la recherche et la pratique sont identifiées.

Mots-clés: modèles; psychologie; besoins; religion; spiritualité (non référencé),

transcendance (non référencé)

Introduction Other more overtly religious literature has

The concept of spirituality has been the subject of
endless debate and attempts at definition.1–4 Writ-
ers such as Heyse-Moore,5 McSherry and Draper6
and Martsolf and Mickley7 believe that spirituality
is purely subjective and indefinable. Much of this
previous literature on spirituality has not been the-
ory building, instead beginning with dictionary-like
definitions and illustrating the components of that
definition with case material.
Address for correspondence: Professor Allan Kellehear,
Palliative Care Unit, Faculty of Health Sciences, La Trobe
University, Bundoora 3083, Australia.
© Arnold 2000
sought to locate ideas about spirituality into defin-
itions of selfhood, which incorporate ideas about
the ‘soul’ or ‘spirit’ of persons, much of which is
‘indefinable’. But a certain level of definition is pos-
sible, and more importantly desirable, although pre-
cision may be an ongoing source of debate. The
purpose of this paper is to outline a descriptive
framework that attempts to capture not the spiritu-
al essence of self but the pattern of its desire and
direction. This framework will take the theoretical
appearance of a needs model.
In his review of the concept, Walter8 employs an
historical strategy to attempt to tease out the dif-
ferent elements of current usages of the idea of spir-
0267–6591(00)PM306OA
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150 A Kellehear
ituality within palliative care. He identifies the
frankly religious definitions of spirituality associat-
ed with founding figures and organizations within
palliative care, the quasi-religious notions associat-
ed with the idea and practice of chaplaincy referral
and the currently ascendant idea of spirituality as
the ‘search for meaning’.
In the last case, Walter8 raises the critical profes-
sional question of how such humanistic ideas of
spirituality differ from ‘psychological care’. Indeed,
some conceptualizations of spirituality are even dif-
ficult to distinguish from common anthropological
ideas about knowledge, meanings, morality or con-
nection to community.9
The fundamental problem with past debates and
formulations, well illustrated by Walter’s attempt to
sort through them, is the dominance of the unhelp-
ful idea that such diverse elements of spirituality are
competitive. Past attempts to develop theoretical
models of spirituality have tended to be self-con-
sciously secular10 or ‘ecclesial’, emphasizing liturgi-
cal or theological concepts to the exclusion of all
others.11 In an ironically ‘ecumenical’ effort other
formulations have simply been overinclusive – an
attempt to satisfy all comers.
The central contribution of this paper, then, is to
attempt to clarify the different dimensions of spiri-
tuality by providing a descriptive model of needs
that is multidimensional in nature. The final part of
the paper will describe some of the theoretical,
research and practical advantages of viewing spiri-
tuality in terms of these various dimensions of need.
A multidimensional model of spiritual
needs
The basic concept of spirituality upon which the cur-
rent model is based is the idea that human beings
have a desire to transcend hardship and suffering.
In other words, people need to seek and find a
meaning beyond their current suffering that allows
them to make sense of that situation. This tran-
scendence may be achieved by searching for mean-
ing in situations, moral or biographical contexts,
and/or in one’s inherited or chosen religious beliefs
and ideas.
Situational transcendence may emerge from
basic enquiries and needs that people may ask of the
environmental or bodily context of serious, life-
threatening illness. Moral/biographical transcen-
dence may become important after situational
needs are satisfied and some implicitly religious
needs emerge. Overtly religious transcendence
may emerge from explicitly culture-specific needs
and contexts. The various types of transcendence
are discussed separately below for theoretical pur-
poses of clarity.
There is a narrow theoretical sense in which the
different needs for transcendence may follow one
another but I acknowledge at the outset of their
description that there will be much interactive traf-
fic between them, depending on the particular social
and cultural background of the person. In this way,
it does not follow that people who are avowedly reli-
gious will predominantly express a need for reli-
gious transcendence anymore than an avowed
atheist might desire only situational transcen-
dence. These kinds of social and spiritual distinc-
tions need to be established by empirical research,
rather than during theory development.
The prioritization of the needs reflects the level
of perceptual immediacy of these needs as these may
occur to individuals entering a new phase of life
experience. In that general ordering, types of
psychological prompts arise from situational, moral/
biographical and religious types of experiences dur-
ing serious illness but I recognize that the different
needs may co-exist or develop in parallel ways. The
current model is modestly based upon the palliative
care literature debating the meaning of spirituality.
It is an early attempt to provide some organization
and clarity to a confusing but vitally important area
of discussion in palliative care.
Situational needs
A number of authors have stressed the importance
of a dimension of spirituality that relates to a ‘world-
view’. Rumbold,12 for example, argues that the idea
of spirituality as a world-view, a way of looking at
the meaning and purpose of life, is the most ‘func-
tional way’ of viewing spiritual issues. These issues
may express themselves as stories that sum up their
situation or link with causes or communities in
which they identify. The idea of attempting to dis-
cern a higher purpose behind a person’s current sit-
uation is also seen as important to spiritual goals by
Hamilton13 and Millison and Dudley.14
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Table 1 Situational transcendence
• Purpose
• Hope
• Meaning and affirmation
• Mutuality
• Connectedness
• Social presence
O’Connor and others15 argue that this ‘making
sense’ task is central to all ideas of spirituality and
may be considered its most fundamental character-
istic. They see ‘making sense’ as crucial to the task
of ‘making the most’ of the circumstances of living
with dying. These attitudes and values assist in pro-
moting a personal sense of quality of life.
Wendler16 sees this process of making sense apply-
ing to the different symptomotology of AIDS and
Hay17 and Heyse-Moore5 make these kinds of spir-
itual connections with physical pain.
Other writers identify topics such as the search
for hope, the need for companionship, particularly
with those people offering the qualities of listening
and affirmation, but also the need for advocacy and
simple presence on a difficult and sometimes
frightening journey.14,18–20
In summary, the need for situational transcen-
dence arises out of the immediacy of the situation
of illness and its attendant physical and social envi-
ronment – developing symptoms, various interven-
tions and treatments, the physical side-effects of
these, the impact of foreign environments such as
treatment centres, hospitals or hospices, or perhaps
the loss of familiar work and home surroundings.
These new personal and social experiences can cre-
ate a need to question and reflect about suffering
and life changes. There may be an attempt to dis-
cern a purpose, find hope, meaning and affirmation
in these experiences, and to look for experiences of
mutuality, connectedness and situational transcen-
dence within these reflective processes.
Moral and biographical needs
From these reflections on changing situations, many
of which will appear to the individual as permanent
or irreversible, other needs may arise of a semi-reli-
gious nature. These needs are not overtly religious in
the sense that the needs and problems themselves are
Spirituality and palliative care 151
not addressed, or rather not requested to be
addressed, by religious dogma or theological opinion.
They are, however, philosophically related to religion.
This is because much of the content and direction of
these needs and questions have parallel concerns in
traditional religious discourses. In a broader cultur-
al sense, the language and structure of some of these
needs frequently reflect the language and structure of
the same questions in religious discourse.
Baumrucker21 discusses the dramatic need of one
of his patients for peace and reconciliation. Oliver19
discusses another case history of a patient for whom
the existence or promise of an afterlife was impor-
tant, in whatever shape or form. It was not the reli-
gious idea of the final resting place of the soul (i.e.
eschatological concerns) that concerned this
woman but the simple idea of re-union. The need
to affirm the promise of transcendence of this life.
Kellehear22 and Emblem and Halstead18 write of
the importance of prayer, a need expressed by many
patients who were not necessarily overtly religious.
These writers emphasize the importance of prayer
in restoring personal morale and providing fertile
alternatives to intellectualism for the growth of
hopes and peace. Few people interviewed in those
studies mentioned prayer as a way of altering their
relationship with God or their ultimate fate.
Rumbold12 and Harvey20 discuss the role of the
pastoral care worker as someone who also assists in
the common desire to affirm the positives in peo-
ple’s lives but also to right the wrongs. In these
instances the pastoral care worker is also an assis-
tant ethicist, among other roles. In a complemen-
tary set of observations, Millison and Dudley,14
Muncy23 and Walter8 identify the importance of for-
giveness – of self and others – in one’s reflections
and actions toward the end of life.
These particular concerns about right and wrong
and the problem of forgiveness are not necessarily
directed towards one’s relationship to God nor are
these issues seen as particularly relevant to the wel-
fare of one’s soul. Rather, the need to ‘put things
right’ and to forgive and be forgiven is about the
need for closure and moral transcendence.
In summary, moral meanings are those arising
out of the immediacy of a person’s biographical sit-
uation and its attendant social and ethical needs –
past griefs and grievances, the need to combat feel-
ings of abandonment, vulnerability or isolation, the
need to gain a sense of closure before moving on
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152 A Kellehear
Table 2 Moral and biographical transcendence
• Peace and reconciliation
• Reunion with others
• Prayer
• Moral and social analysis
• Forgiveness
• Closure
psychologically. The dawning realization that life
may be coming to a close often emerges from life
review and reminiscence. There may be an attempt
to find peace and reconciliation, desires for
reunion, resolution of past and present dilemmas,
and identification and use of a variety of support
systems. In this context people may look for oppor-
tunities for prayer, forgiveness, or moral self and
social analysis – all of which can assist them in a
moral and biographical sense of transcendence.
Religious needs
From these autobiographical reflections overtly
religious questions and needs may arise. These may
precipitate from a current and active belief system
now being interrogated by the new experience of
dying or they may occur as a recent interest in
matters and topics frankly religious in nature. A num-
ber of writers have made the observation that con-
temporary palliative care discourses seem reluctant
to speak about God and are careful to distance them-
selves from overt religious meanings.8,14,24 Dyson and
others,25 for example, consider religion to be one of
the ‘hindrances’ in any attempt to define spirituality.
Traditional religious ideas are carefully eschewed by
these authors. The term ‘God’ for example, is
defined as ‘the highest value a person holds in life’, a
definition which breaks with traditional anthropo-
logical, theological and lay understandings. One must
question the value of such radical redefinition when
the definition itself becomes so divorced from
common understanding. Bradshaw24 expresses simi-
lar incredulity over the reticence of palliative care dis-
course toward religion when she observes that death
is no longer what is taboo – God is.
Notwithstanding debates about the secularization
of modern society, religious questions are common
among modern people, dying or otherwise. Baum-
rucker21 describes how the performance of an inpa-
tient baptism was important to one patient under his
care. Purcell26 argues that open and frank discussions
about religious matters are important to many
patients and the problem is not the content but the
risk of unwanted proselytizing or ‘religious abuse’. In
a two-country survey of GP attenders, Charlton27
found that a significant number of those patients
thought that a person of the clergy would be ‘the most
important person in their care if they were dying’.
Speck28 and Emblem and Halstead18 argue that
religious writings; scripture readings; discussions
about God, salvation, grace or possibilities about
the soul’s final resting place; and the use of religious
ritual have been, and remain, important supports
for this dimension of a person’s spiritual concerns.
As Bradshaw24 argues, the evidence for the effects
of secularization on patients is poor. Palliative care
has been better at acknowledging the importance of
other religions to patients than it has in its recog-
nition of the importance of past and present ele-
ments of Christianity.
In summary, the religious dimension of spiritual
need is that which arises out of the immediacy of a
cultural situation and its individual presence in past
socialization or current personal practices. These may
include past religious instruction and upbringing, the
need to resolve unresolved religious questions and
issues, or the need to gain a sense of hope and expec-
tation about eternal life as part of an attempt to move
on psychologically with these particular issues.
The dawning realization that religious issues may
be important emerges from a realization that such
issues may be most relevant now, in the present con-
text of suffering and dying. There may be an attempt
to seek religious reconciliation or redemption, a
desire for divine forgiveness (rather than human),
mercy, or grace and strength from God, a sense of
healing and the use of an old or usual religious sup-
port system in the service of a new challenge. In this
context people may look for opportunities for
sacred rites, religious visitation, religious literature
and discussion opportunities to assist them in their
quest for religious transcendence.
Table 3 Religious transcendence
• Religious reconciliation
• Divine forgiveness and support
• Religious rites/sacraments
• Visits by clergy
• Religious literature
• Discussion about God, eternal life and hope
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Spirituality and palliative care 153

Discussion and implications
The multidimensional nature of the model dis-
cussed in this paper (see Figure 1) assumes that
many types of needs may co-exist in the one indi-
vidual. People may hold needs for situational,
moral–biographical, and religious transcendence.
For one person those needs may be largely situa-
tional, with only one or two religious needs or one
or two moral needs. For another person the bulk of
their needs will be in the direction of religious tran-
scendence and this person may only express one or
two needs that relate to his or her specifically ill-
ness-related predicament.
Theoretical implications
The advantages of moving our discussions about the
nature and definition of spirituality into dimensions
of need is the ability to move that discussion into
more sophisticated epistemological territory. Like
definitions of medicine or sociology, it makes no
sense to look for pithy dictionary-like definitions
that do not reflect the complexity of the issues in
theory or practice. Furthermore, brief definitions
that do not allow for dimensions of practice or
meaning tend to be overinclusive, encouraging
charges of imprecision and vagueness.
Moral and
Situational
Biographical
• Purpose • Peace and
• Hope reconciliation
• Meaning and • Reunion with others
affirmation • Prayer
• Mutuality • Moral and social analysis
• Connectedness • Forgiveness
• Social presence • Closure
Religious
• Religious reconciliation
• Divine forgiveness and support
• Religious rites/sacraments
• Visits by clergy
• Religious literature
• Discussion about God, eschato-
logy, or eternal life and hope
Figure 1 Dimensions of spiritual need
Brief definitions of medicine as the study of, and
care for, people in health and illness would in fact
include dentistry, medical anthropology, health
policy and, at times, electrical engineering. In most
of these cases we might speak of a ‘medical’ aspect
of these disciplines, rather than classify them as part
of ‘medicine’. A working definition of medicine
needs to operate with an awareness of the different
types of medical specialty that we are referring to
in any one discussion of health and illness. ‘Medi-
cine’ is defined differently if we are discussing men-
tal illness, population health, or a gastric ulcer, for
example.
So too, when we speak about ‘spirituality’, we
must ask ourselves which dimension of spirituality
we are addressing in our discussions. The different
aspects of spirituality are not in competition with
one another but rather evolving aspects of the
human need to transcend, to go beyond the imme-
diacy of suffering and to find meaning in that expe-
rience. The model presented in this paper observes
at least three ways to achieve that transcendence. In
theoretical terms, such dimensions have the poten-
tial to become ‘domains’ of measurement and the-
oretical development for future research.
Research implications
The current model has at least three implications
for further research. First, there is an ongoing need
to assess spiritual needs in patient populations to
improve understanding about the level of such
needs in the social, psychological and physical
sphere, but also to understand the nature of these
needs. Situational, moral/biographical and reli-
gious dimensions of the current model provide early
theoretical indicators from which to operationalize
and test hypotheses or to generate exploratory qual-
itative studies. Furthermore, once empirically sub-
stantiated and revised these dimensions can
provide benchmarks for differences between popu-
lations; for example, differences in spiritual needs
in AIDS, cancer or motor neurone disease patient
groups.
Second, some writers have argued that ‘spiritual
pain’ can express itself or exacerbate physical
pain.5,17,29 Because of the theoretical ambiguity sur-
rounding different views of the term ‘spirituality’ it
is not at all clear what aspect of this concept and
experience we are implicating. Further research
employing a dimensional approach to spirituality
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154 A Kellehear
may assist in identifying which aspect(s) of
spirituality are responsible for compounding
physical pain and how these may or may not relate
to social and psychological issues.
Third, the theoretical issue raised by Walter8
about the ambiguity of spirituality – how, if at all,
this differs from psychological care – might also be
addressed in terms of theoretical development and
empirical research. In either case, the need to iden-
tify each of the elements of the different dimensions
in greater detail and to examine how each of these
inter-relate to one another moves Walter’s question
from how these elements might differ to where they
might differ.
Some elements of spirituality will no doubt ben-
efit from psychological approaches, particularly
transpersonal or existential approaches from that
discipline. Many (but perhaps not all) situational
needs for transcendence might benefit from these
approaches but many of the religious needs, how-
ever, might not. Pastoral care practice research will
be important to testing and exploring the relevance
of the different traditions or models of profession-
al help here.
Practice implications
There is some debate about who should provide for
the spiritual needs of the dying person.30 Nursing,
for example, has a long-standing interest in the spir-
itual aspect of care, seeing this as an extension of
the secularized ‘vocational’ role of nursing as an
institutional form of compassion.24 Social work, psy-
chology and pastoral care have all made claims
about the ‘pastoral’ origins of their respective pro-
fessions, based upon similar arguments.
There can be little doubt about the validity of
such histories, claims and commitments from these
different professions. However, recognition of the
complex dimensions of spirituality, combined with
the conflicting demands on all professionals to pro-
vide other types of services also identified with
them, create obvious barriers for any one of these
professions to meet most of the ‘spiritual needs’ of
dying people.
Clearly, the recognition of the theoretical,
dimensional complexities goes some way to review-
ing the role that any one profession might have with
a view to servicing different kinds of spiritual need.
For example, the professional with the most
patient contact – this may frequently be a nurse –
might play a crucial role in assessment and moni-
toring at the very least. Religious dimensions of spir-
ituality will be dealt with most effectively by those
so trained, and if social workers, nurses or psychol-
ogists are all to take some measure of spirituality to
be a normal part of their work with dying people,
someone whose training is solely in this area – such
as a pastoral care worker – may be a crucial part of
the clinical team for staff needs.28
Conclusion
Spiritual needs are complex needs. Some of these
may indeed be really social needs. Others are psy-
chological needs overlaid or underpinned by reli-
gious desire. Some other forms of human desire are
openly about a need to connect with the sacred, the
supernatural or divine. All of these are dimensions
of spiritual need but they are not all of the same
kind. It can be useful to tease out at least three
major dimensions of these needs without dismissing
the influence of other dimensions of human expe-
rience – social, psychological, or physical. In this
way it is possible to move forward with research and
practice that appreciates different dimensions of
spiritual experience without destroying the common
well spring of its unique source – the desire for tran-
scendence.
It is also not important to be epistemologically
purist. In other words, it does not matter that some
of these needs seem more ‘social’, or more ‘psy-
chological’. The practice of medicine, for example,
is no less medical when it too becomes ‘social’ or
psychological, or indeed, ‘spiritual’. In fact, such
blending of dimensions of care is ideal, something
to aspire for, something characterizing ‘good med-
icine’ and the promotion of wellness.
‘Good spiritual care’ may mean a similar recog-
nition of interdisciplinarity, understanding that the
meaning of wellness in this particular context is
dependent on the successful ability of all of us to
transcend the ordinariness of everyday life, and to
gather meanings in the unseen worlds of the spirit.
Acknowledgements
I would like to acknowledge the helpful assistance
and critical feedback of my friend and colleague, Dr
Bruce Rumbold, on an earlier version of this
paper.
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