Elder Care Interprofessional Provider Sheets

Religion and End of Life Part 1: How Different Religions View the End of Life

Amanda Moale, MD, Department of Internal Medicine, Johns Hopkins Hospital Matt Norvell, M. Div., B.C.C, Department of Spiritual Care and Chaplaincy, Johns Hopkins Hospital

June 2019

TIPS FOR DEALING WITH RELIGIOUS ISSUES NEAR THE END OF LIFE

  • Identify a patient's religious views as part of goals-of-care discussions, as they may influence a patient's medical decisions and events surrounding the dying process.
  • Although individuals may self-identity with a particular religion, do not assume their beliefs and customs. Discuss and clarify their religious views.
  • When a patient's religious preferences near the end of life are uncertain, involve clergy to help with decision-making.

Religion is defined as a set of beliefs concerning the cause, nature, and purpose of the universe. An individual's religious beliefs may affect how they perceive death, the dying process, and the afterlife.

Basic knowledge of how different religions view death may help clinicians better understand and respect patients' behaviors, goals of care, and treatment decisions near the end of life. This Elder Care will review the end-of-life beliefs and death rituals of the major religions in the US. Note that the discussion represents general guidelines based on standard religious doctrines. Not all members of a particular religion will ascribe to all of their religion's beliefs.

Christianity

Death is viewed as the separation of the eternal spirit from the physical body. Comfort and dying with dignity are desired; but a belief in miracles and the sanctity of life may prolong an individual's desire for aggressive care.

Among Christian religions, the Catholic church often considers nutrition and hydration as ordinary care that must be administered. More aggressive interventions, however, such as cardiopulmonary resuscitation and endotracheal intubation, are not considered obligatory if they do not offer a reasonable chance of leading to a state of well-being or if they would be excessively burdensome.

Post-death rituals vary among the Christian denominations. When a patient is approaching death, therefore, the pastor/priest should be notified so appropriate rites and sacraments can be performed and funeral planning can begin. Christians practice both cremation and burial.

Judaism

Jews believe death is a natural process that should be allowed to occur. Orthodox and some conservative rabbis may regard nutrition and hydration as required care, but many Jews feel these measures are unnecessary if death is imminent. Likewise, do-not-resuscitate and do-not-intubate orders are permitted if recovery is unlikely.

Post death, a rabbi or funeral home should be contacted as soon as possible, as ritual washing and prompt burial is required. Observant Jews generally believe in an afterlife. Jews also believe in the sanctity of the body. Therefore, interventions that scar the body, including autopsies, are generally discouraged unless a compelling reason exists. Cremation is generally not acceptable.

Islam

Death is accepted as part of the overall divine plan, marking the transition from one state of existence to the next. During the dying process, treatment should be sought and suffering should be relieved if possible. Belief in sanctity of life may prolong aggressive care, but withholding/withdrawing life-sustaining treatments is allowed if physicians determined that brain death has occurred. DNR/DNI is allowed if resuscitative efforts will be of no avail.

As death nears, it is common for immediate family to stay near the patient's bedside reciting the Qur'an. Muslims pray towards Mecca, which is northeast. Position the patient towards Mecca if possible.

Post-death ritual washing, draping, and burial soon after death is required. Prompt completion of death certificates can avoid family distress. Cremation is not allowed.

Buddhism

Buddhists believe in reincarnation and that deeds from prior lives (karma) influence future suffering through the cycle of rebirths with the goal of ending the cycle and attaining nirvana. Buddhists prefer honest and full information about forthcoming death to allow for preparation. Prolonging life and resuscitation near death are generally not favored.

A clear mind at death is important as the state of a person's mind determines the type of rebirth they will experience. Therefore they may wish to avoid opioids and benzodiazepines.

The body should not be disturbed or touched for 3-8 hours after breathing stops, as Buddhist believe the soul does not immediately leave the body and can be affected by what happens to the body. Cremation is preferred.

Hinduism

Hindus believe in reincarnation and that the soul passes through a cycle of successive lives (samsara), until liberation from reincarnation, pain, and suffering occurs and enlightenment (moksha) is attained.

Hindus also believe that karma influences the form of rebirth a person experiences. They also believe that suffering is an integral part of life and is the results of past negative actions and thoughts. By enduring suffering, a Hindu may satisfy the debt incurred for past negative behaviors.

Death is viewed as a natural experience. Therefore, artificially prolonging life is often not favored. Hindus also desire a clear mind at death and may wish to avoid opioids and benzodiazepines.

Family support is important while dying. An individual surrendering peacefully and willingly would be considered a "good death," which may also be facilitated by a Brahmin priest. Hindus prefer to die at home if possible. Cremation is preferred.

Religion

Christianity

Judaism

Islam

Buddhism

Hinduism

View on Death

  • Separation of eternal spirit from physical body
  • Brain death supported as death by Christian denominations
  • Natural process that  should be allowed to occur, although hastening death is not permitted
  • Cardiac death generally accepted as death; brain death not accepted as death by some Jews, including many orthodox rabbis
  • Transition from one state of existence to the next
  • Brain death generally accepted; some only apply brain death criterion if three physicians agree brain death has occurred and is irreversible
  • Reincarnation until one attains nirvana
  • Death distinguished from life by absence of vitality, heat, and consciousness; some agree brain death meets the criteria for death while others do not
  • Reincarnation until one is freed from the death/rebirth cycle and enlightenment (moksha) is attained
  • Brain death generally accepted as death

DNR/DNI

  • Permitted if interventions would be futile or burdensome
  • Permitted if interventions will delay the dying process and recovery is unlikely
  • Permitted in certain situations
  • Permitted if interventions will delay the inevitable or interfere with natural death
  • Permitted if interventions will delay inevitable or interfere with natural death

Rituals

  • Prayer
  • Sacraments
  • Burial or cremation allowed
  • Prayers/psalms
  • Ritual washing and dressing in shrouds
  • Burial within 24 hours when possible
  • Cremation generally not acceptable; reform Jews may allow
  • Prayer from Qur'an
  • Body towards Mecca (NE in US)
  • Ritual washing and draping by family
  • Burial within 24 hours when possible
  • No cremation
  • No formalities/rituals required
  • Body undisturbed for 3-8 hours after death; then handled with care
  • Body wrapped in sheet without emblems
  • Cremation preferred
  • Prefer to die at home with family support
  • Prayers, hymns, chants
  • Head facing south
  • Cremation, ideally in 24 hrs

References and Resources

  • All Faiths: Religious Needs
  • Irwin S, Fairman N, Montross L, Hirst J, Siegel J. Essentials 2: Psychiatric, Psychological, and Spiritual Care. American Academy of Hospice and Palliative Medicine
  • Leong M, Olnick S, Akmal T, Copenhaver A, Razzak R. How Islam influences end-of-life care: education for palliative care clinicians. J Pain Symptom Manage. 2016; 52(6), 771-774.
  • Moale AC, Rajasekhara S, Ueng W, Mhaskar R. Educational intervention enhances clinician awareness of Christian, Jewish, and Islamic teachings around end-of-life care. J Palliative Med. 2018; epub ahead of print.
  • McCormick AJ. Buddhist ethics and end-of-life care decisions. J Soc Work End Life Palliat Care. 2013; 9(2-3), 209-225.