Damian Sendler: It’s time for a paradigm shift to a more holistic, community-based approach to health care, as illustrated by the healing wheel, in light of the COVID-19 pandemic. According to this study’s findings, existential positive psychology (PP 2.0) holds great promise for meeting the escalating demand for palliative care. An important part of this framework is focusing on how we can cultivate our spiritual and existential capacities in order to achieve personal growth and flourishing, as well as how to transcend and transform our own suffering. Dialectical palliative counseling, as demonstrated by Wong’s integrative meaning therapy and the Conceptual Model of CALM Therapy in palliative care, can accomplish both of these goals at the same time. After that, we’ll go over the goals of treatment and the methods used by IMT when providing palliative counseling to people in hospice or receiving palliative care. According to our review of recent literature, as well as our own research and practice, PP 2.0’s hypothesized foundation for healing and well-being is indeed existential suffering in general and at the end of life in particular. Palliative medicine should also be holistic, which means that patients’ inner spiritual resources should be nurtured as well as the support of their families and the wider community, as symbolized by the healing wheel.
Damian Jacob Sendler: With over 4 million deaths and 100 million confirmed cases, the COVID-19 pandemic has revealed the deficiencies of palliative care. Even palliative care workers have faced serious challenges like a lack of beds and staff and long working hours [1,2,3]. Personal protective equipment has also been a problem for all healthcare workers. Palliative care should be integrated into COVID-19 management and optimized for the pandemic, as demonstrated by the situation in Toronto [4]. Increased life expectancy and an increase in psychological needs, such as meaning for living, the will to live, and acceptance of death, necessitate a strategic approach to palliative care [5,6,7]. People who are nearing the end of their lives are particularly vulnerable to the existential crisis.
Dr. Sendler: Companionship is the best medicine for those who are nearing the end of their lives. Compassionate care requires doctors to accompany their patients in their pain rather than merely being experts who tell them what to do.” [8]. Byock [9], a leading US palliative care physician, wrote: “We are at our best when we serve each other.” A philosophy of “fighting disease and illness at all costs” should not be the driving force behind the healthcare system, he said. When it comes to providing the best possible care for the elderly, we must not only restructure our healthcare system but also overcome our cultural aversion to discussing death.
When I think about the current pandemic, it brings back memories of the SARS crisis, whose failures exposed the ineffectiveness of the well-entrenched biomedical model of healthcare. The compassion, self-transcendence, and existential courage that frontline healthcare workers and volunteers demonstrated in my keynote on compassion, funded by the Hong Kong medical authority [10], demonstrated the crucial role of the spiritual dimension.
My holistic model (see Figure 1) aimed to improve healthcare services without increasing costs in a corresponding manner by drawing on spiritual resources. The historic Alice Ho Miu Ling Nethersole Hospital, where I delivered my speech in Hong Kong, served as a metaphor for a holistic healthcare system that is rooted in spirituality. “To bring Life to Mankind in its fullness through Enhancement and Compassionate Care for the Sick” has been Nethersole Hospital’s mission statement for more than a century, and they have consistently provided quality care to the residents of Hong Kong.
Even today, the Healing Wheel is still relevant. Healers (healthcare providers) need a spiritual connection with God (or a higher power) and a set of religious beliefs or rituals to be their best. It is their responsibility to serve as a spiritual conduit for others. They will have an impact on their patients and the medical community because of their love and faith. It is as if they are interceding for the patients’ well-being as they minister to them.
In a supportive and caring environment, compassionate human encounters can be a powerful source of healing. Healing is a way for healers to give back to those in need while also serving their own personal god or gods. It is through the compassionate care that the patients rediscover the meaning of hope and love. Volunteerism and compassion are a blessing to the community, not just for the patients, but for the volunteers themselves.
It is best to view the above holistic healthcare model through the lens of existential positive psychology (EPP), also known as positive psychology 2.0 (PP 2.0) [13], as opposed to Seligman’s original positive psychology [14]. Existentialism and positive psychology both emphasize the importance of happiness and well-being as the ultimate goals of life. Since EPP encompasses both our positive and negative sides, it promotes growth in character as well as well-rounded contentment. EPP’s main goal is to make a positive impact on all aspects of one’s life in order to complete the circle of health and happiness [15,16].
Resilience and flourishing through transforming suffering is explained in the above model. It’s important to remember that life isn’t always a smooth ride because of our inherent flaws and foibles, as well as the inevitable suffering that occurs at every stage of human development. Suffering is an inevitable part of life in many cases. Even though medical or cognitive models may be able to alleviate some forms of suffering (such as pain), there is no guarantee that all forms of suffering can be eliminated. As a result, they cannot be eliminated by pursuing happiness, since the pursuit itself may be a source of pain from greed and disappointment. Positive psychology’s emphasis on chasing happiness doesn’t work in a pandemic, for this reason. As a second part of this new paradigm, the approach and avoidance systems work together, any setback in the pursuit of happiness will activate the aversive system, and in coping with inevitable suffering, we are able to transform it into strength and joy through personal growth. When we embrace suffering instead of running from it, we give ourselves a better chance of overcoming the obstacles we face on our path to happiness.
For existential positive psychology, all emotions—even the painful ones—are beneficial because they help us build our resilience, meaning, and well-being. [13,14]. Death, in a strange twist of irony, holds the key to a full, rich, and fulfilling existence [22]. Although death’s physicality can destroy us, the concept of death has saved many lives, according to Yalom [23]. For PP 2.0, the challenge is how to transform fear of death into acceptance of death, a meaningful life, and mature contentment.
The dual-system model [20] offers the most insight into the positive psychology of death anxiety. This model states that the best way to adapt is to face and transform the negative aspects of life in order to achieve the positive ones. Indeed, a strong offense is the best form of defense. Despite the looming threat of death, the best defense against the paralyzing fear of dying is to devote our lives to something worthwhile. If we are ever going to free ourselves from the shackles of death fear, both the approach and avoidance systems are necessary. Death fear and death acceptance can coexist and contribute to our well-being when viewed from this dual-systems perspective.
Spiritual resources can be developed in order to restore a lasting sense of calm and equilibrium in order to avoid emotional rollercoasters and getting stuck in the dark pit of painful memories and emotions. The central point of intersection of all possible human dimensions, both horizontally and vertically, is the best representation of such mature happiness. It’s possible to be happy in any situation, regardless of our ethnicity or religious beliefs [25,26].
An inner sanctuary of serenity and spiritual blessings awaits those who find themselves here. Symbolically, it represents the paradoxical truth that one must go through Hell in order to get to Heaven, and one must lose oneself in order to find others [27]. There are examples of this mature happiness in Jesus Christ, Buddha, and Lao-tzu.
The dual-process model underpins numerous palliative therapies. Cancer and Living Meaningfully (CALM) in palliative care, for example, aims to help patients cope with both their emotional distress as well as their desire for growth and wellbeing. To help the patient cope with their illness/symptoms, CALM sessions focus on helping them maintain a sense of significance and purpose. As Reed’s theory of self-transcendence points out, vulnerability to suffering must be turned into personal growth and well-being through self-transcendence [30,31].
Every stage of life, from childhood to adulthood, presents both an existential crisis and an opportunity for personal development. To Erickson’s stage model [32,33], this model adds an existential positive psychology dimension to the stages of adult development. Consequently, life is seen as an all-out battle at every stage of human growth. How we handle our current crises may determine whether we live a life of virtue and flourishing or a life of pain and suffering as a result of the bad decisions we’ve made in completing our developmental tasks.
Our ancestors’ “Why?” cries could be heard in my mind: Why has my child been kidnapped by a beast? What makes God so enraged, and why do we suffer as a result of his wrath? Why is it so difficult to live? What’s the point of putting up a fight if we’re all going to die? Life is full of suffering and existential crises at every stage of human development, so he has never stopped searching for meaning.
At some point in their lives, all of us have asked ourselves, “Who am I?” What am I supposed to be doing here? What am I supposed to do with my entire life? What is the most important thing to me? What and where can I do in order to be happy? Can you give me some tips on how to steer clear of making poor life choices? Where do I fit in? What is the location of my permanent residence? All of this effort is for nothing. What am I?
Self-evaluation and regret are more prevalent in the lives of the elderly [23,35,36]. Is my life what I envisioned it to be? Is it even worth living? The point of suffering is lost on me. What’s the point of dying, anyway? In the afterlife, what happens to me? Forgiveness can be found and given, but how do I go about doing so? What should I do with the rest of my life? In the face of impending death, how can I find solace, solace, and hope?
Each and every cry for meaning serves the dual purpose of making pain bearable and finding a reason to live, thus increasing our likelihood of moving towards a life goal despite difficulties and suffering. Real-life encounters with human evil, suffering, and death often come as a surprise to those going about their daily routines.
To answer the “Why?” questions, people will have to look for a reason or purpose for their existence. One does not need to understand or use the word “meaning” to live a meaningful life. Human nature and the facts of life combine to make us yearn for a richer, more meaningful existence.
For Peterson [37], religiousness and spirituality are essential for human survival in a world full of perils, wrongdoing, and ambiguity. Heroism in the face of widespread evil comes primarily from everyday heroism of taking responsibility for making the necessary sacrifices and aiming for some greater good. In Peterson’s view, evil and significance are connected by a mechanism that evolved to protect us from our own inherent vulnerability as finite beings in the face of immeasurable power.
Existential crisis becomes more intense at the end if people haven’t dealt with their issues early on, as vividly depicted by Tolstoy in his novel [38]. Ivan Ilyich’s death. When Ivan finally realized that his life was not what it should have been in the midst of his mental and physical anguish, he was spiritually reborn. He discovers the meaning of life and relief from suffering only after he resolves to make amends to his wife and apologize for his actions. Before he dies, his heart is filled with joy.
Akira Kurosawa’s classic film Ikiru is another example [39]. It’s not until cancer strikes Watanabe’s character that he begins to contemplate the meaning of life in this film. Rather than dwelling on her impending death, Ikiru shows us the triumph of a life well-lived. A cesspool was transformed into an amusement park thanks to the sacrifice of Watanabe and his happy death. Following his cancer diagnosis, he began the process of a good death by attempting to find meaning in his final days.
Damian Jacob Markiewicz Sendler: When it comes to medicine, logotherapy is a supplement, according to Frankl [40]. Patients often ask themselves, “Why me?” or similar existential questions. Why is this happening now? Why do we have to go through this? Why am I being taken from this world at such a tender age? People experience existential pain when they can’t come to terms with the enigmas of evil, pain, and death.
Existential distress is measured by the Patient Dignity Inventory (PDI) [48] and includes items like “Not feeling worthwhile or valued” and “Feeling life no longer has meaning or purpose,” while peace of mind is measured by items such as “needing future meaning, meaningful contribution, and spiritual life.
Damian Sendler
As a result, resolving these existential conflicts is critical to the well-being of palliative care patients. Three factors in the subscale of spiritual well-being, according to the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being [49], depict mature happiness in terms of inner peace and harmony due to spiritual beliefs, faith, reasons for living, and sense of purpose.
Palliative care patients face existential anxieties on a daily basis as they near the end of their lives, and recent research has shed light on this issue. There is no doubt that these fears have many facets [59] and are the cause of a great deal of misery [60]. Although they have been studied, they are still largely ignored in palliative care research and discussions [61].
Existential anxieties can have a significant impact on the level of distress palliative care patients experience. For example, older age, higher spiritual well-being, attachment security, and meaning in life are all associated with less distress [62,64,65]. Existential anxiety is a common problem among palliative care patients, their loved ones and caregivers, according to previous research. We’ll go over a few of these concerns now.
Many people have anxiety about death, which can range from practical concerns (such as how they will die or whether they will be a burden to their caregivers and family) to more existential ones (such as what will happen to them after they die) (e.g., missed opportunities, impact, or burden of death on others). For palliative care patients, fear of “running out of time” was the most prevalent among the 15 different death and dying-related anxieties measured by Vehling et al. [68]. There is a negative correlation between death anxiety and social connectedness, but a positive correlation between death anxiety and demoralization, characterized by feelings of hopelessness, loss of meaning, a sense of failure, and meaninglessness [70].
In palliative care, grief comes in many forms. “Grief and palliative care are interrelated and perhaps mutually inclusive,” writes Moon [71]. Grief and palliative care are both concerned with the phenomena of loss, suffering, and a desire to alleviate the burden of pain.” (p. 19). As an example, the COVID-19 lockdown procedures, which prevent families from seeing loved ones in palliative care, have led to a rise in anticipatory, disenfranchised, and complicated grief among patients, families, and healthcare providers[ 72]. Families who are caring for children in Pediatric Palliative Care (PPC) go through three stages of grief: anticipatory, post-mortem, and post-death. Patients may experience numbness, shock, fear, anger, and survivor guilt as a result of their spouse’s death before or during palliative care [74].
Patients in palliative care may feel isolated or lonely due to a variety of reasons, including the death of their spouse, loss of autonomy, deterioration of motor or cognitive abilities, or the recent COVID-19 pandemic [75,76,77]. More illness symptoms (such as pain, difficulty breathing, or severe exhaustion) and the use of life support in the final two years of life were found in elderly people who were lonely [78]. Sundström and colleagues [79] found that patients’ existential loneliness in home and residential care was centered on the past and present, whereas patients’ existential loneliness in hospital and palliative care was centered on the patient’s impending death. All four settings, on the other hand, reported exceptionally high levels of existential loneliness. Loneliness can lead to mental health issues, which is why some researchers believe that community-hospice settings should be implemented now.
For palliative care patients nearing death, DR-ED (dignity-related existential distress) is common. Bovero and colleagues [81] found that self-discontinuity and loss of personal autonomy accounted for 58% of the DR-ED variance in their study. Physical and cognitive decline may cause patients to stop participating in meaningful activities, resulting in self-discontinuity. Taking on new responsibilities as a grandparent or elder in the community may also be a factor. Physical and cognitive deterioration may also be a factor in the patient’s loss of independence and personal autonomy, as elderly couples often compensate for one another [82].
Damien Sendler: Every now and then, whether as a result of past mistakes or squandered opportunities, we all feel a pang of regret. Having regrets at the end of life, on the other hand, can exacerbate suffering at the end of life due to the knowledge that one cannot undo the damage done in the past [35]. Her best-selling book [36] mentioned five common palliative care patient regrets, including the wish that they had lived a more authentic life, the desire to express their feelings, and the desire to keep in touch with their friends and loved ones as they neared the end of their lives. This “unlived life,” which may play a role in the generation of death-related anxieties, is a common source of these regrets [23].
For palliative patients, meaning-centered therapies proved to be effective in improving spiritual wellbeing, senses of dignity, and meaning as well as reducing depressive symptoms and the desire for. “Dignity” is defined as “the quality or state of being worthy; honored; or esteemed” [27]. Dignity Therapy [86] focuses primarily on the significance of the patient’s life and the legacy he or she wishes to leave behind.
Meaning-Centered Psychotherapy (MCP) is another scientifically validated meaning-centered therapy for advanced cancer [87]. In the face of existential crisis, it aims to maintain and enhance a sense of meaning. Meaning-Centered Psychotherapy [88] is based on Frankl’s logotherapy and consists of 7–8 sessions in which patients reflect on the concept of meaning and the impact cancer has had on their life and identity.
Patients in Breitbart’s meaning-centered group therapy for cancer patients [89] learn about the philosophical underpinnings of meaning, engage in group exercises and homework, and engage in open-ended discussions.
Denial, anger, bargaining, depression, and acceptance are all stages of the Kubler-Ross [58] stage model of coping with death. The Death Attitudes Profile (DAP) [90] and the Death Attitudes Profile Revised (DAP-R) [91] are the results of a comprehensive study Wong and his colleagues conducted about 30 years later. Both scales have been used extensively around the world..
Three distinct types of death acceptance were identified by Wong and associates: (1) neutral death acceptance—accepting death rationally as a part of life; (2) approach acceptance—accepting death as the gateway to a better afterlife; and (3) escape acceptance—choosing death as an alternative to a painful existence.
Belief in a desirable afterlife is the root of approach acceptance. For those who hold such beliefs, the afterlife is more than a metaphor for immortality, providing encouragement and consolation to those facing death as well as those who have lost a loved one. Accepting death as a way out of the agony and meaninglessness of life is a primary factor in a person’s willingness to die. The idea behind neutral acceptance is to rationally come to terms with the fact that one’s time on this planet is finite and to make the most of it while one can.
Damian Jacob Sendler
It’s possible to accept the fact that we’ll all die, but the belief in an afterlife provides a source of comfort and hope in the face of it. Because of this, many people believe in an afterlife or heaven [92].
According to Wong’s model of two systems, death anxiety and acceptance can exist simultaneously. More than one factor contributes to a person’s death anxiety: death itself, the pain and loneliness it brings, not completing one’s life’s work, annihilation anxiety (fear of nonexistence), and concern for one’s loved ones after death. Death acceptance can be achieved through three stages: (1) avoiding death, (2) confronting or facing death, and (3) accepting or embracing death, even if death anxiety is present all the time.
One can no longer fear death if they have found a cause they believe in and are willing to die for. We can overcome our fear of death by making meaning out of our lives and pursuing a goal that is greater than ourselves. I (the first author) have also experienced the same existential struggles of trying to make sense of cancer [93] and the loneliness that comes with being in the hospital [94].
When it comes to understanding and facilitating death acceptance, Wong has used the meaning management theory (MMT). The dual-system model and existential positive psychology are the foundations of MMT. Instead of avoiding our fear of dying, MMT advises that we confront it head-on while also dedicating ourselves to an important goal [22,96].
MMT is a lot more than a reframe or a rationalization of one’s thoughts. It takes a fundamental shift from the mindset of pleasure seeking to the mindset of meaning [97] and from self-centeredness to self-transcendence [45]. In the darkest moments of life, meaning therapy [39,98] gives people the tools they need to extract meaning and hope from their circumstances.
Connections and love for one another show that each of us is part of a larger whole, a source of meaning in our lives [105]. People die of loneliness and a lack of purpose when love is withheld from them. Love is the most powerful force on the planet, don’t we know it yet? The ability to endure anything, face any danger, and enjoy making sacrifices for others are all a result of love.
It is just as vital to our mental health as it is to our physical health to have faith, hope, and love. The golden triangle represents this positive triad, which has been essential to human survival since the dawn of time. It is also critical in the fight against depression, addiction, and other forms of suffering, as well as in building a brighter future. Even in palliative care patients, the golden triangle can be used to conceptualize well-being.
Courage, Acceptance, and Transformation form the “Iron Triangle.” Even in old age, with all the inevitable losses, life can be difficult. At the end of life, one must have a great deal of courage to face the many difficulties that come with dying and passing away [106]. To deal with the agony of illness and death, to come to terms with one’s own mortality, and to make the final transition, one needs courage. One must also have the courage to connect with their own inner resources as well as their family and community in order to enhance their dignity and well-being. If we are awakened to our spiritual nature and cultivate our psychological resources, [107] our genes and brains can handle any adverse situation, as long as we are aware of our spiritual nature and cultivate our psychological resources.
Fearlessness in the face of uncertainty is a sign of existential courage ([108], p. 4). According to our previous discussion, we need existential courage at all stages of our lives: The ability to face and overcome all of life’s setbacks and obstacles is only possible when we have the guts to face our darkest selves and confront what we cannot change or control. Yang et al. [109] provides the most comprehensive treatment of courage. To them, “courage is like the existential thoughts of the will to power” in terms of spirituality. This can be found on page 13. For them, “The will to power is a process of creative energy or psychological force that is aimed at putting one’s will into action in order to overcome life’s difficulties.” (p. 12). It is also similar to Frankl’s [44] defiant power of the human spirit, which is courage.
For those who have overcome hardship and adversity before, courage is an attitude of affirmation that says “Yes” no matter what comes their way [110]. Courage is the strength and optimism we have hidden within us that allows us to push forward in the face of danger, obstacle, or suffering.
Authenticity, horizontal self-transcendence, and faith in God or a higher power are all examples of existential courage, which is a combination of these three characteristics (vertical self-transcendence). The golden triangle protects three crucial connections because it encompasses such existential courage. In the end, courage is a matter of the heart and the will.. Having the true grit to face whatever life throws at you is made possible by having an attitude of affirmation and optimism.
Professional healthcare providers who want to provide excellent end-of-life care must first accept their own mortality and have resolved their own existential conflicts about the meaning and core beliefs of their own lives. It’s easier for them to build meaningful relationships with their patients when they’re more in tune with their own sense of calling, personal values, beliefs, and attitudes.
Palliative care is founded on spirituality. The ultimate meaning and purpose of religion and spirituality are typically addressed, and certain spiritual practices or religious beliefs and rituals are often included. This sense of sacredness can be found in some transcendental beliefs (27). The spiritual maturity of the caregiver has a direct bearing on the quality of palliative care they provide. Caregivers’ commitment to self-care and spiritual growth is critical in this context. They must recognize the importance of first connecting with the source of their own well-being, peace, and harmony, which has its own spiritual component.
Considering that we’re all going to die at some point, we might as well make this final journey the most memorable and meaningful of our lives. If we want to succeed, we must begin planning now. If you want to live and die well, this may be your best option.