It’s been five and a half months since my father took his last breath.  He was under the care of hospice and lay dying in the very room that he had requested to be in for his final step in the dying process.  He slipped in and out of consciousness, in and out of any sort of recognizable communication pattern, in and out of reality.  As I reflect on his death at the premature age of 69; succumbing to colon cancer, I cannot help but wonder what that last week was like for him.  Additionally, I wonder what my last week, should I be so lucky as to be granted a last week, will be like.

In his book Dying Well, Dr. Ira Byock makes a convincing argument that indeed dying instantly, without prior knowledge or preparation time, is NOT the blessing that many of us see it as but rather the dying process, slowly and with purpose, is in fact the preferred method of passing on; it is the manner in which to Die Well.  Dr. Byock is fundamentally responsible for developing our hospice system in this country.  His compassion for people that are in their last, and his knowledge of and ability to provide comfort for both the patient and their families and loved ones is perhaps unparalleled.  Having read this book as a means of comfort after my father passed I have come to a few conclusions.

1.  The dying process for each of us is virtually the same.  Each step is virtually identical.  The steps that we endure, the process that takes place, is in a strange way comforting.  That we are all different I have no doubt, but it was through my fathers dying and the dying process that I can also identify the manner in which we are all connected.

2.  The “pain” factor of passing is wholly manageable.  The fear of death, which I believe is universally part and parcel to the fear of the pain associated with passing, should be a non-factor. 

There is another factor in the end of life process that while initially shocking, indeed otherworldly, has become a final and perhaps conclusive bit of comfort.  In his last days my father would communicate with people that I couldn’t see, refer to things I couldn’t comprehend.  Science has offered biological, chemical, physical answers to explain away these occurrences, and pharmaceuticals have been given the credit for such things as well.  However, after having seen them with my own eyes, I can say without reservation that my father’s experiences were quite real.  Not a biological response and not a chemical response but a part of the dying process.  Some parts of the transition from this world to the next cannot be explained away by formulas, x-rays or monitors.  While all these things certainly serve a purpose and they are indeed in their own rights amazing, life and death are both miracles.  The completion of a cycle is just that; complete.  We have 9 months to begin our lives, to form and become whole.  To think that death does not involve preparation that is equally complicated and intricate is foolhardy.

My last days, whenever they may occur, will be less scary, perhaps even comforting.  Death is a part of life.  While cliché, truer words there may not be.  It is universal, it misses no one and it is just.  Sometimes our narcissism acts as a defense mechanism for things we truly don’t understand and fear. It appears to me the Dying Well is indeed a process to revere and to embrace. 

The idea of caring for the terminally ill began in the 11th century and was started in the United States in 1970.  Hospice is not a “death panel”.  It is the widom of families and medical professionals to recognize death is inevitable and there is dignity in dying and a time to say goodbye. 

When the elderly are terminal (and many times express a wish to die) placement of feeding tubes may prolong their life but with what quality of life?  As a seasoned long-term care nurse, I have seen residents live out their days in total anguish.  What is it about human nature that makes us strive to overcome it?  Why with our religious belief of Heaven do we choose not to let go?  It’s called selfishness.

There is only so much physicians, nurses, and medication can do.  People with endstage diseases most likely won’t survive an operation.  How much torture do we want to inflict on the dying?  Can we not call upon the professionals of Hospice to help the terminal die pain and anxiety free, with dignity?

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Introduction

Spirituality has been viewed by some as a non-measurable aspect of the person, but there has been some investigation into empirical evidence concerning spirituality measures.  Some measures of spiritual maturity have been studied, and the researchers seem to have found that overall spiritual maturity increases with age over the lifespan.  Other aspects of spirituality that have been investigated include religious attribution themes, proximal-distal explanations of causes of events, and the effects of spirituality on mental and physical health, along with the effects of spirituality on coping skills.   With these themes and their findings in mind, valid measures of spiritual maturity are needed for continued research.  Surveys to address the stages of spiritual maturity have been developed, which distinguish between simple acts of religiousness and true spirituality.  These have also attempted to identify specific aspects of spirituality, which may be more objectively measured than the abstract concept of spirituality in general. 

Statement of the Problem

The prior fieldwork and literature reviewed for this research, which seeks to compare spiritual maturity with age, generally supports the hypothesis that overall, spiritual maturity increases with age over the lifespan.  This research also looked at end of life choices to see whether or not the level of spiritual maturity affects people’s choices concerning end of life measures for both themselves and their loved ones.  End of life measures or life sustaining treatment, also known as life support, is any treatment intended to prolong life without curing or reversing the underlying medical condition and includes measures such as mechanical ventilation, artificial nutrition or hydration, antibiotics, and pain management. Artificial liquid nutrition may be fed to patients during hospitalization with a feeding tube, while artificial hydration is the process of giving intravenous fluids, which is used to prevent death from dehydration.

Review of Related Literature

The Fetzer Institute’s National Institute on Aging Working Group (2003) publication Multidimensional Measurement of Religiousness, Spirituality for Use in Health Research examined several key dimensions of religiousness/spirituality as they relate to health outcomes.  The authors state that some studies show that life-changing religious/spiritual experiences are significantly related to self-rated health.  This aspect of religious history seems to be significantly associated with both physical and mental health.  Further research on lifetime experiences of life-changing spiritual events is highly recommended by the authors.  The report breaks down several areas for investigation of spirituality and includes recommended instruments for each, along with a draft of the Brief Multidimensional Measure of Religiousness/Spirituality, which was developed by the group and is based on some of the questions from each area of their investigation.

The authors of the study previously mentioned, cited an earlier study by Benson and colleagues (1990, 1991), who developed a 38 item Faith Maturity Index to study protestant denominations.  It measures two areas of religiousness or faith, which they have labeled vertical religion and horizontal religion.  “Vertical religion” focuses on the relationship between the participant and God (spiritual factors), while “horizontal religion” focuses on the relationship between the participant and other people (social factors).   They believe higher scores on their inventory represent a higher level of spiritual maturity, with spiritual maturity increasing significantly with age.  The Faith Maturity Index also cross-classifies horizontal and vertical scores to discern 4 typologies of faith types:  Undeveloped Faith (low V w/low H), Vertical Faith (high V w/ low H),  Horizontal Faith (low V w/high H), and Integrated Faith (high V w/high H).  Benson sees Integrated Faith as being the highest point of spiritual maturity.  Those with this typology also increased as age increased in the sample population.  The authors of the Working Group’s publication (2003) say that one problem with Benson’s measure is that he gives equal weight to all items on the inventory without distinguishing a particular stage of maturity. 

The authors of the Working Group’s publication (2003) also report that researchers who seek to include religious or spiritual domains in their studies have various problems, with few of these researchers having a scholarly background in religiousness/spirituality and most not knowing of previous attempts to measure the specific components of religiousness and spirituality.  They purport that religious/spiritual variables cannot be combined into one scale that studies the effects of a single religious variable; but rather, that each component of religiousness and spirituality should be separately viewed for its effects on other aspects of humanity.  These authors believe that until recently, social and behavioral scientists have given very little attention to empirical evidence concerning religiousness and spirituality and that as a consequence, there is no standard measure of its key components. 

The Working Group (2003) authors distinguished between religiousness and spirituality, stating that while some may view them as indistinguishable, others believe religiousness has specific characteristics that involve a doctrinal system of worship shared by a group.  They propose that while religions nourish spiritual life, with spirituality being an important part of religiousness, it is possible to have the outward form of religion without having a strong spirituality.    Spirituality moves beyond the acts of religiousness, addressing the meaning of life, and assuming that there is something more to life than what we see or understand. Spirituality gives us our compassion for others, calling us beyond our outward observances of religiousness. The authors believe that combining these two areas into one instrument realizes this distinction. 

The authors of another study, The use of secular and religious attributions to explain everyday behavior (Lupfer, Brock, & DePaola,  1992), tested several hypotheses, all coming from the “availability hypothesis”, which concerns things that affect the use of religious and secular attributions. The subjects, who varied in their devotion to the teachings of Christianity, were given several scenarios describing everyday behavior and were asked to attribute them to religious causes or to secular causes.  Even though the results confirmed much about religious attributions, and little about secular factors, the subjects surprisingly attributed more everyday behaviors to secular than to religious causes.  Yet, the authors state that, for many people everyday events, as well as life-changing events are attributed to spiritual causes.  They believe that each person enters a situation with a general predisposition toward or against the use of religious attributions for explaining an event, which they termed a person’s “religiosity”. 

The authors claim that attributions do not exist apart from the attitudes and values of a person, but are shaped by them instead.  According to the “availability hypothesis”, the context in which the attributions are made also influences the availability of religious interpretations.  For religious people, events which affirm their values are more likely to be attributed to God than are those which violate their values.  The precept embraced by Christians for centuries, that socially or morally unacceptable behavior might be caused by demonic intervention, supports the probability of some people attributing Satan as the cause of such an event, which increases the more the action is viewed in a negative light.  A factor is also important, the authors conclude, to the extent that it increases the availability of an explanation that satisfies one or more of three important psychological needs: the need to understand things in one’s life, the need to have control over things in one’slife, and the need for self-esteem.   Finally, the authors of this study claimed to have found little evidence of a particular attributional style in Christians. 

                In a later study Making Secular and Religious Attributions : The Availability Hypothesis Revisited (Lupfer, DePaola, Brock, & Clement, 1994), several researchers were said to have demonstrated empirically that many people, especially those with a strong religious outlook, often name supernatural forces when explaining others’ or their own behavior.  Citing the surprising outcome of the previous study, which showed the infrequent use of religious attributions, even by subjects who claimed strong devotion to the teachings of Christianity, the authors of the later study explored additional factors thought to affect the use of religious attributions. The authors stated that religious attributions may be used only when an event is unusual or life-altering, is highly relevant, or intense emotions are aroused, that is, only when no other causal agent can explain it.  The authors admit the method of assessment would not have recognized more distant religious attributions made by the subjects.

Also information about intentionality and outcome of the scenarios was provided to participants in this study of attribution (Lupfer, DePaola, Brock, & Clement,1994). The authors hypothesized that the infrequent religious attributions in the previous study may have occurred because subjects were only asked to explain the behavior and never asked to explain the consequences or outcome of the behavior.  Their results suggest that in general, people are more likely to use secular explanations, such as situational causes, rather than religious explanations when explaining everyday behavior.  Their results also clarified some of the earlier indications of the availability hypothesis. They claim that attributions to God are more likely when the participant is a conservative Christian, when the event evokes strong Christian values, and when the intentions and the result are approved of, and that attributions to Satan, are more likely to occur when the participant is a conservative Christian, when the event is linked to strong religious values, and when the intentions and outcome are disapproved of.  They state that the most reliable determinant of religious attributions seems to be how the event is perceived, regardless of whether the subject is explaining the intentions or the results. In either case, when making religious rather than secular attributions, they observed that subjects seem to simply be guided by whether or not they approve or disapprove of the event.  They believe that the results questioned the previous study’s conclusion that religious and secular attributions are made independently of each other.   The findings of their later study indicate that religious and secular attributions are not negatively related, as the availability hypothesis suggests, but that that people may use the two explanations in conjunction with one another. 

In Religious Attributions : Situational Factors and Effects on Coping, Miner & McKnight (1999), studied the religious attributions of 363 church members to see how they affected coping responses in several different situations.  The authors of that study purport that the theological arguments that subjects would assert God’s direct control because of their belief in God’s sovereignty were not supported.  They also claim there were significant effects of different religious attributions on adaptive coping.  They define the function of attributions as the reducing of uncertainty with an explanation of why things happen as they do, which gives people a sense mastery over the world.  They believe one of the most underdeveloped areas of attributional research is religious belief, which should be one of the more powerful influences on believers’ attributional styles.  Their focus is on the disengagement of personal belief and the causal explanation that sometimes happens when belief systems are challenged by the stressors of life. They claim that believers sometimes have to adjust their religious causal explanations to negative emotional experiences, which may lead to conflict between what they think and what they feel, cognition and emotion being the two major elements in religious belief.  The authors state that religious attributions are part of the explanatory systems of religious people because their emotional experiences shape their attitudes and values.  They claim that how people feel about what is happening to them directly impacts their worldview, which is often seen in the loss of faith that some experience when faced with an emotionally stressful life experience that they have come to view in a negative light. 

Miner and McKnight (1999) state that earlier studies suggested that the type of situation, the severity of outcome, and the outcome direction (positive/negative) are important predictors of religious attributions.  Attributing God’s direct control over an event shows subjects as seeing God as a proximal cause, whereas attributions of God’s allowing an event, or of acting through human agency, indicate them seeing God as a distal cause.  One study by Pargament and Park (1995)  that was cited in the Miner and McKnight article argued that religious people make positive judgments of negative events and that these judgments are related to reduced distress and better adjustment; and that religious beliefs are related to both active and passive coping responses.  Another study by Pargament et al. (1990) cited by these authors claims that the type of attribution may influence the choice of coping strategy which in turn would influence outcomes. 

Miner and McKnight (1999) suggest that attributions should play a more proximal (direct) role when people face stressful situations, but are doubtful, because they believe religious attributions have little impact on psychological outcomes.  They observed that committed Christians with strong beliefs in God’s sovereignty have high levels of religious attributions across a range of situations, that religious attributions are made more strongly in situations where there is little control over the cause, and that religious attributions will be made more strongly in situations having extreme outcomes, whether positive or negative, which must have an answer in order to find meaning in the situation.  They found that when both religious and secular attributions are considered, God may be perceived as a background cause with circumstances or human agency as the immediate cause of an event, with highly religious people distinguishing between God directly causing events, or God allowing a situation to run its course.

Miner and McKnight (1999) believe religious attributions may affect outcomes indirectly, through a person’s choice of coping method.  They state that their subjects strongly agreed that God allowed events, followed by causal attributions to self and others, which suggested an interaction between divine and human causes.  These findings, they concluded, implied that subjects held a view of a distant, sovereign God who sometimes achieves purposes through humans (intermediate level of control) but rarely intervenes miraculously (strong direct control).  The authors suggested that highly religious subjects hold a general view of God’s transcendence (allowing events) together with more direct control (through people or miraculously) depending on their perceptions of agreeableness, extremity, and controllability of the situation.

To help understand the proximal-distal model of religious attributions, Weeks & Lupfer (2000) presented two experiments examining the proximal and distal use of religious and nonreligious supernatural attributions. Their results support the hypothesis that supernatural attributions are perceived as having a greater distal impact than proximal impact and helps to explain the infrequency of religious attributions consistently found in the religious attribution literature just discussed. These earlier works suggest several reasons religious attributions are infrequent, including problems with experimental methods and the near availability of secular causes. Lupfer and colleagues (1994) first suggested a Proximal/distal attributional model, with God/ Satan being a more distant explanation than secular attributions. Miner and McKnight (1999) have more recently found support for a proximal-distal model.  For example, religious explanations may be cited as proximal causes in certain circumstances, but they are used more frequently as a distant explanation in the chain of events than had previously been understood.

Their results offer considerable support for the new explanation. First, they reason that God is an explanation for such supernatural causes like fate and chance, which increase with the level of religiosity. The participants in their study were not likely to cite God as a distal explanation to a natural cause.  God was not usually used to explain an attribution such as a characteristic of a person or event, but rather as controlling a person’s fate or the event.  In other words, God was used most often to explain a nonreligious supernatural attribution, but rarely used to explain a natural attribution.  Secondly, the participant’s level of religiosity/spirituality must be considered.  Earlier research has shown the likelihood of making religious attributions increases with the level of religiosity or spirituality. This study showed that the level of spirituality affects proximal and distal attributions to supernatural causes, but not to natural causes. In other words, someone who is higher in spirituality is more likely to see God/Satan as an explanation, who has causal responsibility. Someone who is less religious often explains it with another supernatural explanation such as chance. The groups in this study (Weeks & Lupfer , 2000) differed in their use of attributions, with the highly spiritual turning to God and the less religious turning to secular explanations of supernatural events, such as luck or chance.

While most research investigating attribution theory has focused on more immediate causes, Weeks and Lupfer believe there is evidence of the importance of distal causes in the chain of events.  They state that there are two considerations for religious attributions’ place in a causal chain that leads to the eventual outcome. First, they propose that when finding the cause of the event, it is not often necessary to look beyond the immediate, natural explanation in order to have a good explanation.  Secondly, they propose that the common view of God being omnipresent satisfies the two conditions of God always being present before an event and always being active during an event.  They state that because it is difficult to observe the actions of God, the natural causes are more prominent in explanations of events.  Explaining such events as surviving a catastrophic event or being miraculously healed, they believe, shows that God is a “necessary” factor. That is, the positive outcome would have been unlikely if God had not been present.

Weeks & Lupfers’ (2000) insight can help to understand the proximal and distal use of supernatural attributions, but many other questions in the research of spirituality are still unanswered.  How making religious attributions affects our coping skills, which in turn may affect our mental and physical health, and can further affect the aging process is yet to be determined.  Miner and McKnight (1999) believe that some of the confusion in the literature on spirituality and religiousness, some of which has just been reviewed, could be the result of different types of measurement (scales, single-item ratings, and qualitative responses) and designs incorporating hypothetical scenarios and actual situations.  They state that direct comparisons of different measures and designs are needed, but that the study of control beliefs in religious subjects has been beneficial in exploring discrepant findings from spirituality and religiousness research in the psychology of religion.  They believe that measures of God’s control in the attribution research needs to include components of immanence and transcendence in the future. They believe that attributions of God as controller of all events, directly intervening in people’s activities, strongly suggest a view of God’s immanence, while attributions to God as allowing the event to run its course, suggest the dimension of transcendence. They also believe that measures of expectations of God’s control over the outcomes of specific situations are needed. They state that there is some indirect evidence that religious attributions improve meaning, control, and self-esteem, but they do not directly influence outcomes, though religious attributions may have an indirect effect on psychological outcomes of stressful situations by their impact on expectancies of God’s control over outcomes and coping choices.

The choice of end of life measures for both self and others may be related to the coping skills we have developed along with the growth of our spiritual maturity and our sense of God’s control over the outcomes of end of life issues.  Those who are less spiritually mature may lack a sense of God’s control over end of life issues and therefore may seek more control in those areas.  They may choose to assert their own control in matters such as the two most common end of life decisions: whether or not to use artificial nutrition and hydration when a chronically ill person can no longer eat and drink on their own, and whether or not to use a ventilator when someone can no longer breathe on their own (Family Caregiver Alliance, 2003).  If the person is totally unable to eat and drink and does not use these measures, the body will slowly shut down over a period of one to three weeks, which some people, including the author of this paper, consider a painful way to die, and could possibly have moral implications from a Christian standpoint.  Making the choice not to use certain measures like artificial nutrition and hydration may be seen by some in the Christian community as taking matters into our own hands and seeking control over areas of life and death that rightfully should be in God’s control.

Angela Morrow (2008) in Deciding to Withhold or Withdraw Life Sustaining Measures discusses life sustaining treatment, also known as life support, which is any treatment intended to prolong life without curing or reversing the underlying medical condition and includes measures such as mechanical ventilation, artificial nutrition or hydration, antibiotics, and pain management. Morrow purports that this kind of medical technology helps prolong the lives of those who couldn’t sustain life on their own. She rightly states that the decision to withdraw life support or whether to begin it usually brings up strong emotions along with moral and ethical questions. Though the article seems a bit one sided in favor of withholding and withdrawing life support by using words like “prolonging life’ rather than preserving life, it does bring up important ethical concerns.

Secretary White from the Florida Department of Elder Affairs states in “Making Choices: Beginning to Plan for End of Life Care” that education about future choices is most helpful when it occurs long before it is needed (2002). He states that advanced planning allows for preparation of medical, legal and spiritual decisions. Some of the issues he discussed are the “Moral and Legal Equivalency Between Withholding and Withdrawing of Treatment” and “Pain Management.” The article purports that there is no ethical difference between withdrawing treatment already begun and the withholding of treatment that might be given, which the author of this paper agrees. It also states that cultural and religious objections can contribute to the lack of aggressive pain management, and that pain may be viewed as divine punishment that is deserved for certain lifestyle habits. And since bearing pain may be equated with a reflection of character and inner strength, the article states that giving in to pain may be seen as a sign of weakness.

End-of-Life Ethics: Benefits and Burdens (1994-2008) discusses the difference between curative and palliative types of treatment, the later dealing primarily with comfort measures and pain issues, and seems to be favoring the argument that no one should suffer prolonged pain, and that the removal of or withholding of certain end of life measures are ethical if they end the suffering of pain, which may be considered passive forms of euthanasia by some in the Christian community.  Giving up some forms of life sustaining treatments, which preserve a patient’s life often conflicts with religious and moral beliefs. Kenneth R. Overberg, S.J. states in End-of-Life Ethics: Preparing Now for the Hour of Death that we should look to the Scriptures to help us understand and respond to end-of-life issues. He explores euthanasia, assisted suicide, life support and advanced directives from a moral and ethical standpoint in light of the Catholic Church teaching. The Catholic Church supports the idea of  keeping a person alive without using “extraordinary” means.  But according to Catholic teaching, artificial hydration and nutrition, the supplying of food and water to keep someone alive, are not extraordinary procedures. When death is inevitable and very close, one may in good conscience make the decision to refuse certain forms of treatment that would only prolong life in a burdensome way, as long as the normal care due to the sick person is not interrupted. Such measures must not be withdrawn in order to cause death, but they may be withdrawn if they offer no reasonable hope of sustaining life or pose excessive risks or burdens. John Paul II (2004) stated “The sick person… still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed… the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.” Although withdrawing medical treatment from dying patients may be morally acceptable to some people, the Trustees of the Southern Baptists Christian Life Commission (CLC) have also drawn the line at artificial nutrition and hydration, considering the provision of nutrition and hydration by medical means to be compassionate and ordinary care (”On Euthanasia and Assisted Suicide” 1992).

In light of the literature just reviewed, some aspects of spirituality have been shown to be somewhat measurable.   By distinguishing between religiousness and spirituality, by looking at the key aspects of spirituality, by looking at the religious attributions of spiritual people, and by looking at its affects on other aspects of life, such as one’s choice of end of life measures both for self and loved ones, spirituality studies can provide the empirical evidence that current researchers seek.  Previous research on aspects of Spiritual Maturity seems to show a significant increase along with an increase in physical age.  Since it is believed that life experience in general and religious/spiritual experience in particular generally increase over the life span, it can be hypothesized that the overall scores on Spiritual Maturity Inventories will generally increase as physical age increases and that the differing levels of spiritual maturity will also affect the coping skills needed to make end of life decisions.  Though some younger people may have unusually high scores for their respective age, it is because they have likely been through more extreme life experiences that have brought them into a more spiritually mature category than their general age group.  Overall more elderly people should fall into the Spiritually Mature category than will their younger counterparts and should have better coping skills to deal with end of life choices.  While it is proper to discuss and make end of life choices before they are needed, the moral implications of those choices should also be considered when making those kinds of decisions.  The difference between extraordinary care and ordinary care needs to be better clarified and seriously looked at through a moral lens so that loved ones are not put in a moral and spiritual bind when making those hard decisions during a crises situation. 

Annotated Bibliography

American Academy of Family Physicians. End-of-Life Choices for Families (2004). Retrieved October 22,

2008 from: <http://www.aafp.org/afp/20040815/725ph.html> This brochure by the American Academy of Family Physicians is a brief overview of End of life choices.  It covers such fundamental questions as “Who has the final say about end-of-life choices?” “How do I figure out what my loved one would want?” “What choices do I need to make?” and “Can I change my mind?”  It is very informative, but a somewhat brief coverage of the subject matter.

Family Caregiver Alliance. (2003). End-of-Life Choices: Feeding Tubes and Ventilators Retrieved 10/11/2008

from: This article discusses two of the most common end of life decisions: whether to use artificial nutrition and hydration when a chronically ill person can no longer eat and drink on their own, and whether to use a ventilator when someone can no longer breathe on their own. If the person is totally unable to eat and drink and does not use these measures, the body will slowly shut down over a period of one to three weeks, which some people, including the author of this paper, consider a painful way to die, and could possibly have moral implications from a Christian standpoint. 

Fetzer Institute, National Institute on Aging Working Group.  (2003).  Multidimensional

Measurement of Religiousness, Spirituality for Use in Health Research.   Kalamazoo, MI: Fetzer Institute. 

This publication examines several key dimensions of religiousness/spirituality as they relate to health outcomes. The report includes brief literature reviews and recommended instruments for each area.  A draft of the Brief Multidimensional Measure of Religiousness/Spirituality: 1999 is included, which is an instrument that is based on questions selected from each area of the study of spirituality.

Florida Department of Elder Affairs, The Florida Partnership for End-of-Life Care. (2002). Making Choices:

Beginning to Plan for End of Life Care. Retrieved October 11, 2008 from: <http://elderaffairs.state.fl.us/> Secretary White from the Florida Department of Elder Affairs states that education about future choices is most helpful when it occurs long before it is needed. He states that advanced planning allows for preparation of medical, legal and spiritual decisions. Some of the issues discussed are the “Moral and Legal Equivalency Between Withholding and Withdrawing of Treatment” and “Pain Management.” The article purports that there is no ethical difference between withdrawing treatment already begun and the withholding of treatment that might be given, which the author of this paper agrees. It also states that cultural and religious objections can contribute to the lack of aggressive pain management, and that pain may be viewed as divine punishment that is deserved for certain lifestyle habits. And since bearing pain may be equated with a reflection of character and inner strength, the article states that giving in to pain may be seen as a sign of weakness.

Learn Well Resources, Inc. End-of-Life Ethics: Benefits and Burdens (1994-2008) Retrieved October 11, 2008

from: <http://www.learnwell.org/bioethics.htm> This is an online Continuing Education course that offers certification. It has been reviewed by the National Continuing Education Review Service (NCERS) of the National Association of Boards of Examiners for Nursing Home Administrators (NAB). The objectives of this course are for learners to understand the ethical principles of health and the use of Advance Directives, Withholding of Treatment, DNR Orders, Euthanasia and Assisted Suicide, and Medical Futile Treatment. The instructor for the course is Rudolf Klimes, PhD (Indiana University), MPH (Johns Hopkins University).  The information in this online course is a very thorough discussion of end of life issues.  It discusses the difference between curative and palliative modes of treatment, the later dealing primarily with pain issues, and seems to be favoring the argument that no one should suffer prolonged pain, and that end of life measures are ethical if they end suffering.

Lupfer, Michael B.; Brock, Karla F.; DePaola, Stephen J.  (1992). The use of secular and religious attributions to

explain everyday behavior.  Journal for the Scientific Study of Religion 31 D, p 486-503.  Retrieved from:

http://search.ebscohost.com/login.aspx?direct=true&db=rfh&AN=ATLA0000859139&site=ehost-

live”> The use of secular and religious attributions to explain everyday behavior..  This experiment

tested several hypotheses coming from the “availability hypothesis”, which concerns the use of religious

and secular attributions. 189 subjects who varied in their devotion to Christianity were given several

scenarios describing everyday behavior and were asked to attribute them to religious or to secular causal

causes.  Though results confirmed hypotheses about religious attributions, and none about secular factors,

subjects attributed more to secular than to religious causes.

Lupfer, Michael B.; DePaola, Stephen J.; Brock, Karla F.; Clement, Lu. (1994). Making Secular and Religious

Attributions: The Availability Hypothesis Revisited.  Journal for the Scientific Study of Religion 33 Je, p

162-171. Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=rfh&AN=

ATLA0000881397&site=ehost-live” >Making Secular and Religious Attributions : The Availability

Hypothesis Revisited.  This experiment tested several hypotheses based on the “availability

hypothesis”, which identified conditions that compel people to make religious rather than secular

attributions.  202 subjects who varied in their devotion to the teachings of Christianity were given several

scenarios and ask to attribute its cause to a religious (God, Satan) or secular cause (chance, disposition, or

situation).  Secular attributions were given much more often than religious attributions.

Miner, M H.; McKnight, J. (1999).  Religious Attributions : Situational Factors and Effects on Coping.  Journal for

the Scientific Study of Religion 38 no 2 Je, p 274-286.  Retrieved from: http://search.ebscohost.com/

login.aspx?direct=true&db=rfh&AN=ATLA0000920115&site=ehost-live”>Religious Attributions :

Situational Factors and Effects on Coping. The religious attributions of 363 church members were

studied to see how they affected coping responses in several different situations.  Theological arguments

that they would assert God’s direct control because of their belief in God’s sovereignty were not supported. 

There were also significant effects of different religious attributions on adaptive coping.

Morrow, Angela. (2008) Deciding to Withhold or Withdraw Life Sustaining Measures. Retrieved October 11, 2008

from: <http://dying.about.com/od/lifesupport/a/life_support1.htm> This article discusses life sustaining treatment, also known as life support, which is any treatment intended to prolong life without curing or reversing the underlying medical condition and includes measures such as mechanical ventilation, artificial nutrition or hydration, and antibiotics. This article purports that this kind of medical technology helps prolong the lives of those who couldn’t sustain life on their own. The decision to withdraw life support or whether to begin it usually brings up strong emotions along with moral and ethical questions. Though the article seems a bit one sided in favor of withholding and withdrawing life support, it is very informative and does bring up important ethical concerns.

Overberg, S.J., Kenneth R. (n.d.) End-of-Life Ethics: Preparing Now for the Hour of Death. Retrieved October 11,

2008 from <http://www.americancatholic.org/Newsletters/CU/ac0806.asp> This article looks to the Scriptures to help show how Catholics should respond to end-of-life issues. This Catholic Update explores euthanasia, assisted suicide, life support and advanced directives in light of Church teaching, morals and ethics. End-of-life issues touch the depths of our being, stirs our emotions, and raises profound questions in our minds that call for careful moral reasoning. The author shows insights from a long Catholic tradition for guidance and wisdom in making these kinds of moral decisions and makes a valid argument from a Christian perspective. 

Weeks, Matthew; Lupfer, Michael B.  (2000). Religious attributions and proximity of influence:

an investigation of direct interventions and distal explanations.  Journal for the Scientific

Study of Religion 39 no 3 S, p 348-362.  Retrieved from: http://search.ebscohost.com/login.aspx?direct=

true&db=rfh&AN=ATLA0000004430&site=ehost-live”>Religious attributions and proximity of influence:

an investigation of direct interventions and distal explanations.  Research into religious attributions

have focused on the immediate causes of events, rather than their underlying explanations. To explain the

low incidence of religious attributions and to further a new model of proximal-distal attributions, the

authors presented two experiments investigating the use of attributions. To account for religious

attributions, the authors state that some researchers suggest that those who adhere to the teachings of

Christianity have two separate explanatory systems: natural schemas and religious schemas.  This

“availability hypothesis” determines which is used to explain events. The authors claim that newer research

has shown that secular and religious attributions are not always used in this way, but might also be used in

conjunction with one another. 

1. Go to the hospital or hospice and be there as much as your friend wishes
2. Offer to do anything, anytime, to help and repeat this offer, also look for things you can do
3. Care for young children at home, their home or your home
4. Look after pets, make sure they are fed or arrange this
5. Take nutritional snacks and drinks to the hospital/hospice for those watching over their loved one. Make coffees and teas as needed, in the visitor’s kitchen.
6. Sit quietly but be available to talk and give a shoulder to cry on. Pray.
7. Leave, go home and do something useful there if this is what is wanted
8. At your friend’s house: clean house, do dishes and washing, take in mail from letterbox etc. Mow the lawns, or arrange this.
9. Field phone calls. Be a go-for and go for whatever is required.
10. Be a support at the funeral, offer transport, food, and if necessary, keep out of the way until needed. Extended family often take over on arrival, so graciously step backwards. After the funeral, allow time and space for grieving, then be there when and if you know or feel you are needed. Short visits, phone calls and written support are good. Praying and letting your friend know that you are praying expresses spiritual love. Be understanding, everyone grieves differently and for different lengths of time. Grief can be triggered at any moment and understanding from close friends is a comfort and help.

Brown bag it for one day and donate you lunch money to a worthy cause.

You do not have to give a lot of money (unless you want to and can afford it), even a very small amount can do good works and it will make you feel so much better, it will be worth every penny. You can go online, give $5 and smile.

Here is a list of verified charities that have passed the scrutiny of several charity watchdog groups.

1. Special Operations whose mission provides college scholarship grants, financial funding and counseling to children of those in the Special Operations of our Armed Forces who have been killed.
   Founder: Col. Arthur D. “Bull” Simons
2. Accelerate Cure Project for Multiple Sclerosis whose mission is to cure MS.

   Co-Founders: Art Mellor (entrepreneur and MS patient) and Dr. Vartanian.

3. The Humane Society of The United States whose mission is to rescue animals from those who are not “humane.”
   President, CEO: Wayne Pacelle
4. Boys & Girls Club of Greater Memphis, TN whose mission is to provide a safe place to grow and learn.
   Founder: John “Buddie” Thompson
5. America’s Promise Alliance whose mission is to provide healthcare for children, reduce the dropout rate. It is working to help children lead happy,healthy productive lives.
   Founder: Colin Powell
6. National Organization for Rare Disorders whose mission is dedicated to the cure and treatment for those patients with rare diseases.
   Founders: Patients & families of those with “orphan” diseases.
7. Keep America Beautiful whose mission is to create and hands on work to make America cleaner, safer, greener and livable.
   Founders: American civic groups
8. American Hospice Foundation whose mission is to improve access to quality care hospice through public education and training.
   Chairman: Samuel Warburton, MD
9. American Red Cross is America’s premier emergency response organization.
   Founder: Clara Barton
10. Armed Services YMCA whose mission is to provide relief to the Armed Forces
    
    Founder: Volunteer YMCA members