Preparing for death: a survey on rituals in the dying phase in the Christian context in Germany

Introduction

The facts of dying and death are universal and natural phenomena. However, the ways in which we deal with them are culturally characterised. A review of classical and contemporary literature reveals that the cultural context in which death is dealt with is highly diverse. The subject of funeral and mourning rituals has been extensively researched (1-4). These rituals structure the experience of the dying and their social environment, provide symbolic expression for the feelings and thoughts of those involved, and serve as religious and cultural coping strategies (5). Despite this extensive research on rituals after death, one central question remains largely unanswered: how do rituals take shape in the dying phase (6)?

Prior to an in-depth examination of this research gap, it is essential to define the term ‘ritual’. The function of rituals is to facilitate communication and negotiation surrounding significant changes in status, time, or space (3,5). Such rituals may comprise clearly defined, repeated actions that are confined to specific locations and times, or alternatively, less formalised, everyday practices that are more closely aligned with non-ritual reality (7). The latter are referred to as everyday rituals or micro-rituals. Rituals may be either religious or secular in nature. All rituals express cultural perceptions of what it means to be human, the meaning of life and death, and ideas of transcendence. They also facilitate the management of transitions and the preservation of collective memories (8).

As previously stated, a multitude of funeral and mourning rituals exist. In the Western context, the handling of dying and death in the modern era has long been professionalised, medicalised and institutionalised, which has progressively diminished the significance of rituals. Nevertheless, a resurgence in traditional rituals, an adaptation of existing practices and the pursuit of novel ritual forms have recently been observed. These developments can be seen as a response to the growing secularisation and individualisation of Western societies.

Nevertheless, there is a paucity of scientific literature on end-of-life rituals, particularly with regard to their forms, functions and symbolism.

This study addresses precisely this identified research gap. The study was conducted in Germany and sought to ascertain whether and which rituals exist in the dying phase. A comprehensive list of rituals is currently being compiled on the basis of the data collected. This inventory will also be used to develop rituals that are oriented towards the needs of patients and their relatives who are not comfortable with traditional rituals. Both the traditional and the newly developed rituals should be available to the dying, their social environment and the medical staff caring for them in the dying phase. We present this article in accordance with the COREQ reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-24-119/rc).

Methods

Design

We developed an online questionnaire (LimeSurvey^®, Hamburg, Germany) that consisted of two parts. Two of the authors are medical doctors (B.A.E., C.G.), two are ethnologists (G.S., J.T.M.), and one author is a theologian (J.E.). The following authors are professors and male (B.A.E., G.S., J.E.). J.T.M. and C.G. hold doctoral degrees and are female. J.T.M. is the research coordinator. The survey was developed for this study and has not been published before. The initial section of the questionnaire collected data pertaining to the socio-demographic characteristics of the respondents. The subsequent section comprised a combination of open-ended and closed-ended questions, focusing on the subject of rituals in the dying phase. This is illustrated in Table 1. The questions were informed by a review of the literature, drawing upon insights from ritual theory, palliative medicine and psychology within the context of palliative care (8-10). A pre-test was conducted with palliative care doctors, a social worker and a psychologist to ensure the questions were comprehensible and appropriate. One of the doctors is also a theologian. The online survey was conducted in an anonymous manner; therefore, no conclusions could be drawn regarding individual respondents.

Sample and setting

The survey was conducted in Germany. An analysis of religious affiliation in Germany revealed the following: 25% of the population identified as Roman Catholic, 23% as Protestant, 2% as Christian Orthodox, 44% of the population did not affiliate with any religious community, 4% of the population was Muslim, and 2% belonged to other religions (11). The questionnaire was distributed using the snowball sampling technique. The questionnaire was distributed to three distinct working groups, namely those engaged in the provision of spiritual and pastoral care. Additionally, it was disseminated to the German Society for Palliative Medicine (section for spiritual care), the German Cancer Society’s Working Group on Palliative Medicine (APM), and the mailing list of the German Palliative and Hospice Association. The author B.A.E. was already acquainted with these from his professional context. In order to provide religious diversity, the questionnaire was also sent to Muslim care institutions and a Buddhist hospice. These were identified through internet research. However, it is not clear from the survey results whether employees from these institutions completed the survey. It is not known how many people were reached in total.

Data analysis

Statistical analysis

A total of 299 individuals completed the online survey. The socio-demographic data gathered from the participants and the responses to the closed questions were subjected to descriptive analysis. The statistical calculation of the frequency distribution was performed using Excel^® (Redmond, USA).

Qualitative analysis

The qualitative data was subjected to a step-by-step analysis using MAXQDA^® (Berlin, Germany). The analysis was conducted using the qualitative content analysis method. First, the statements were coded and subsequently categorised thematically in accordance with the similarities and differences identified between the coded items. The coding and categorisation process was subject to continuous review and adjustment until data saturation was reached. This inductive approach was employed to identify the four main themes, which are described in greater detail in the results. As the responses provided by the study participants were predominantly brief and concise, it was decided not to code each answer twice (12). The quotes were smoothed to make them easier to read. No substantial changes were made, only minor ones such as deleting duplicate words. In the text, these changes are indicated by square brackets with three dots. The participants in the survey responded to the questions in writing, resulting in a majority of answers in the form of key words or short sentences. Abbreviations were used to assign the quotations to the individual occupational groups, with the following meanings: HC = hospital chaplain, P = physician, N = nurse, PS = psychologist, SSE = social service employee, BC = bereavement counsellor. ChatGTP^® (San Francisco, USA) was employed solely for the purpose of reformulating individual sentences in the article.

Ethics

According to the local ethics committee of the Medical Faculty Heidelberg, no ethics approval was needed, as no patients or relatives were involved. Completion of the survey was taken as sufficient evidence of consent to participate without an additional informed consent procedure. Thus, no additional informed consent was necessary and participation remained anonymous (12). This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Results

Demographic characteristics

The socio-demographic data yielded the following insights with regard to occupation, gender, place of work and duration of employment (see Table 1). When queried about their place of work, participants were permitted to select multiple responses.

Quantitative analysis—need for rituals in the dying phase

Participants from all professions recognized a (very) high to moderate need for rituals in the dying phase for patients and relatives (see Figure 1). A very high need was more likely to be identified for relatives than for patients (see Figure 2).

Figure 1 How high do you estimate the patient’s need for a ritual in recent weeks?

Figure 2 How high do you estimate the relatives’ need for a ritual in recent weeks?

When asked what a ritual can achieve in the dying phase, the participants could choose several answers. They supposed the three most important effects of rituals in the dying phase: (I) it can help to provide support and structure (14.27%); (II) it gives the opportunity to express emotions (13.76%); and (III) it makes it possible to experience community (12.96%). Further results—arranged in order of priority—were as follows: (IV) it helps to make the situation ‘bearable’; (V) it makes it possible to experience security; (VI) it can help to mark a closure; (VII) it can help to prevent a grief sequelae disorder; (VIII) it enables participants’ self-efficacy to be promoted; (IX) it can help to mark a feeling of completion; (X) it can help to mark a feeling of completeness (see Figure 3).

Figure 3 What can rituals achieve in the dying phase?

As the quantifiable survey questions delivered a good sense of the need for rituals in the dying phase, experiences and attitudes of the participants considering the conditions and performance of the rituals needed more elaborate work up.

Qualitative analysis—how to perform rituals in the dying phase

The free-text responses to the survey questions were subjected to qualitative analysis, which yielded four main themes. These were: (I) conditions for success prerequisites; (II) types of rituals; (III) functions of rituals; and (IV) symbols and action components of rituals (see Table 2).

Conditions for success

Establishing a relationship and knowing the life story

It is of the utmost importance to establish a relationship with the dying person and to gain an understanding of their life story before performing a ritual.

“It takes time beforehand to listen to those affected and their relatives. It makes sense to ask about sentences [e.g., quotes] or words that have played a role in their lives. This creates a hunch, in the best case a relationship that is sustainable” (HC).

Knowing the dying patient as well as a good relationship is important as well. One study participant wrote:

“Through curiosity, attentiveness and good observation. You can only use rituals that suit the patient. If I have not cared for the dying person in the past and do not know his/her wishes, dislikes and biographical details, I cannot offer rituals that are often very personal, but can only use more general actions, such as a hand massage […]” (N).

This information was instrumental in the provision of personalised and genuine rituals. Furthermore, it enabled the collection of significant data regarding the patient’s worldview and beliefs, which informed the design of the ritual.

Authenticity, open communication and knowledge on part of the ritual leader

The study participants indicated that the design of an appropriate ritual is contingent upon a number of factors. In the survey, some participants asserted that pastoral caregivers take on this task, while others did not clearly specify this or even mentioned other professions.

“In this very intimate moment you take over the guidance/prayer (as an offer)” (BC).

“It is usually these doctors or the nursing staff involved who first point us out as chaplains and ask if they would like support” (HC).

It is essential that the ritual leader, the dying person, and their relatives feel that it is appropriate for them. For the ritual leader, it is essential to demonstrate authenticity, facilitate open communication, and possess a comprehensive understanding of the rituals involved. “I stand by this ritual, have ‘tailored’ it to me; explain it. I am ‘authentic’ when performing it” (HC).

In other words, the ritual had to reflect the attitude of the person performing it. Authenticity also depended on the person conducting the ritual also knowing how to do it:

“You yourself should also be able to do something with it and be confident in its application” (BC).

The role of open communication and the empathy of the ritual provider was pivotal:

“Talking to each other about what they want. Often not much comes out of this stressful situation. Then […] listen to your gut feeling to see what fits” (HC).

This allowed the order to be clarified.

“In the order clarification before the ritual. This is where the conversation helps. Like a general rehearsal” (N).

Another crucial aspect was the competence and experience of those involved. For this, a specific training curriculum for Spiritual and Existential Care was developed (SpECI) in Germany (13). As one project participant stated, “Training staff in spiritual care SpECI” (BC).

Also, peer reflection on the experiences were also mentioned as useful:

“[Colleagues] can then also tell each other about their experiences, which can cause difficulties, e.g., completing the ritual.”

Framing

Time and space play an important role in connection with the performance of rituals, as they direct the focus on this. A ritual framework serves to distinguish rituals from everyday life. The act of ritual framing is exemplified by the performance of rituals in specific locations, such as a mosque or a church, or at designated times, such as during Muslim prayer times or the Christian Christmas celebration. Furthermore, objects can also serve to reinforce the designation of a location as a ritual space. In this project, a series of general measures for framing a ritual space were identified, as well as a range of (symbolic) objects that held either a religious significance or a personal connection to the individual who was nearing the end of their life (14-16).

The importance of framing the ritual became particularly clear in the following quote:

“The ‘rituals’ you mentioned require essential factors: […]; they need a safe space and time” (HC).

In a clinical setting, it is of particular importance to arrange the room in which the ritual is to be conducted in a way that facilitates the ritual taking place. General measures to demarcate the ritual space include, for example, ensuring that privacy is maintained:

“Ensuring privacy while at the same time guaranteeing constant assistance (noise reduction, single room if possible), creating a dignified environment (depending on the patient’s needs, tidying up, flower arrangements) […]” (P).

It is similarly important, when feasible, to eliminate sources of noise or objects that are primarily utilized for the medical care of the patient, “Quiet baroque music, clear away unnecessary care utensils, tidy, darkened room, fresh air, […] if animals live in the household, let them into the room where they are dying” (BC).

The room was also furnished with personal items, which were either integrated into the overall design of the room or displayed as standalone objects.

The following three quotations illustrated the significance of personal items in the context of ritual framing, “Decorating the room: pictures of relatives who are important and may not be present: grandchildren/great-grandchildren […] music […]” (HC).

“[…] making familiar objects available such as pictures, cuddly toys, favourite pillows” (P).

“[…] Bring pictures and important objects into focus” (N).

The use of religious objects was also important. These ranges from “simple” items like a postcard to fully equipped boxes.

“[…] important book (Bible; watchwords); postcard from ‘my collection’, e.g., Leipzig cards (I write a dedication on the front, on the front are various motifs, e.g., path; flowers, etc.) on the back a Bible word, a prayer, a poem)” (HC).

“If at all possible, the room is decorated by the nursing staff. We have equipped the wards with mourning boxes (decorative fabrics in 2 colours purple and silver, a cross, Protestant/Catholic hymn book, death blessing, literature, electric candles), some of the wards also add their own material” (HC).

“In the form of a farewell box at each station with candles, water jug, text compilations, Bible, cross, Muslim symbols that do good…” (HC).

It can be concluded that the ritual framework helped to focus the attention of those present on the ritual.

Types of rituals

The study participants identified both Christian rituals and secular acts as rituals. This distinction was clearly evident in the following quote:

“Church rituals: confession on request, communion for the sick, blessing of the sick, anointing of the sick, prayer [.] Everyday rituals: singing, giving something into the hand, blessing, singing, silence, being present” (N).

Secular rituals had the same characteristics as religious rituals. But they did not have a transcendental reference (6).

A significant proportion of the rituals could be classified within the category of “Christian rituals”. These rituals exhibited a range of complexities, from traditional forms to more flexible arrangements. They encompassed a diverse array of prayers, including both personal prayers and established prayers such as the Lord’s Prayer.

“Anointing of the sick, communal prayers and blessings” (HC).

Blessings and the celebration of the sacrament of the Last Supper also played a role.

The following quotation provided an illustration of an intricate ritual belonging to Christian tradition:

“In the church context, various models of rituals in the dying phase have been developed in recent years. In our diocese, a farewell blessing is used which contains the following elements: opening of the ceremony, prayer, biblical promise, blessing of the dying person with sign action (cross on hands and head with reference to the prayer of blessing that focuses on the person with his or her thoughts and actions), invitation to relatives to bless the dying person, to give him or her good wishes once again on the way (spoken aloud or in silence), common Lord’s Prayer and a blessing for the relatives. This sequence provides the framework for the ritual. Songs or pieces of music can be incorporated into the ritual. The prayer is formulated freely in order to include the reference to the situation of the dying person and their loved ones. Life history adaptations are also possible when blessing the dying person” (HC).

One participant even mentioned the recitation of suras.

The appreciation or performance of secular rituals also played a role. As the quote illustrated, even secular rituals required a temporal and spatial framework:

“Often simple things such as maintaining certain routines (type and time of certain activities” (N).

The following quotations provided examples of such secular rituals:

“[…] Sometimes we smoke a cigarette together and send all our wishes to heaven with the smoke. Sometimes we drink [a] coffee or red wine and with every sip we mention names that are close to our hearts” (HC).

“Praying and eating together [.] A glass together at the same hour” (N).

“Rituals such as eating together on a weekday, watching a TV programme” (N).

The statements made by the participants revealed that shared moments are perceived as significant and symbolise a form of connectedness. Everyday actions are charged with special meaning and symbolism in order to provide comfort, community and meaning in a difficult time. Thus, like religious rituals, they play an important role in the dying phase, as they can help to cope with the situation of dying, strengthen the relationship between those affected and their relatives and place death in a larger context of meaning.

Functions of rituals

The participants evaluated the various functions of the rituals. In addition to the quantitative result indicating that rituals facilitate the expression of emotions, the free-text responses provided further insights into the processes of remembrance, the creation of new memories, and the formation of legacies.

One function was remembrance, in which the patient reflected on their life experiences. When contemplating the life of a dying person, both negative and positive experiences were considered. “Elements of looking back (‘beautiful’) and forgiveness (‘difficult’)” (HC).

“Walking along the path of life, lighting a light for highlights, etc., naming guilt/anger/injustice” (BC).

This remembrance was framed both religiously and secularly. Both challenging and positive moments in life were represented.

“Begin processes that involve the passing on of ‘legacies’ through acts of giving and receiving, possibly including a ceremonial entrustment to God (ritual knowledge required)” (BC).

The other one was the creation of new memories together for themselves and their loved ones. The review identified several key elements that were deemed to be of significance. These included the presence of videos or photos of loved ones, as well as music, sounds or texts that the dying person had previously related to. Additionally, the sharing of memories was identified as a crucial aspect. It was notable that this aspect is less about the patient as an individual and more about the relational component, that is to say, the relationship between the dying person and their environment. The creation of new memories was observed to occur collectively, for instance, through the celebration of festivals that held particular significance for the dying person.

“Country festival (we then all dress accordingly, e.g., bring a guitar), […] involve everyone who also takes this moment in the service, i.e., all professional groups, relatives, pet if applicable; […]” (N).

A further significant aspect was the establishment of legacies, whether in the form of written documents, audio recordings or boxes of personal memorabilia. “For some patients, the creation of legacies—documents, recordings, boxes of memories, important personal items—to be passed on to family or friends”.

By engaging in reminiscence, individuals could preserve a connection with the deceased while integrating their memories into daily life. An often-highlighted feature of grief rituals, deemed particularly significant, is the involvement of others.

The act of including others in the grieving process allowed individuals to recognise that they are not alone in their experience of loss. This was particularly important in reducing feelings of isolation and alienation that can often follow the death of a loved one.

One of the key functions of rituals was to create a space in which a range of emotions could be expressed during the dying phase, “Being allowed to show grief (shape or express it). Expressing forgiveness together” (N).

“Conversations in which relatives talk about the guest [patient] from [good] times in their lives > often activate positive feelings and gratitude” (N).

Such activities facilitated the emotional processing of challenging life situations. Furthermore, the importance of forgiveness was highlighted.

Ritual actions and symbols

A number of symbols and ritual actions can be identified that played a role in shaping the ritual character of palliative care. These were fundamentally located in the bodily and sensual dimension. The symbols that occurred in rituals in the dying phase refer to three different “realities”, as in a triangle: firstly, the reality of the dying person. Secondly, the reality of the person’s significant others who have departed from the dying person. Thirdly, there was the reality of the final reference. The final reference refers to the meaning-making dimension. It may be of a religious nature, but it can also exist in another context, such as a family tradition.

These symbolic components included measures such as body-related elements. Two illustrative examples among numerous others were the following quotations:

“Prayer of blessing with laying on of hands: blessing of the forehead (all that would be thought…), of the hands (all that was given to you in life… and: all that you have created in life…), of the heart (all love…) with the concluding words: be now arrived, completed and blessed” (HC).

“Massages, building a nest so that the person can feel themselves when they can no longer get up” (BC).

Other elements that came into play include the use of aromatic oils and fragrances, the deliberate use of light and candles, and the power of music and sound, “Candle as a light that we associate with the loved one (where was he a light person for us) and as a sign of God’s presence (God is my light and my salvation, Psalm 27)” (HC).

“Blessing with oil (fragrance, valence)” (HC).

“[…] Experienced it myself: singing the stadium anthem of the home club. […]” (HC).

The subcategory of light and candles played a distinctive role, encompassing the utilisation of candles, lighting design, subdued illumination and light symbols such as a starry sky beneath the ceiling. Candles served a dual purpose: they facilitated a connection with the deceased, and they symbolised the presence of God. Another key element was the use of scents and aromatherapy, which included scented oils, aromatherapy, and the use of scents that the dying person liked. Music, whether classical or a personal favourite, as well as sound elements such as drums or tongue drums, fostered a sense of connection and community. The inclusion of music, whether by relatives or staff, added an extra personal touch. In addition to this component, the presence of significant people like relatives or caregivers, was also important:

“If possible, celebrate the ritual together with the relatives; ask who is missing and include them by name, also say that we are celebrating the ritual here on behalf of many” (HC).

Another area of interest was the role of accompanying objects and religious symbols. One hospital chaplain stated:

“[…] The image of the angel goes a long way, even with those who are not close to the faith […]” (HC).

A nurse said:

“Preferably personal belongings, favorite items, photos, and visits from family/friends… the singing or humming of familiar melodies/songs, including religious songs and those like the Irish blessing”.

The integration of personal objects, pictures of loved ones and religious symbols such as crosses or angels created a familiar environment. The latter facilitated a spiritual connection, provided they have a connection to the dying person.

The incorporation of natural elements constituted a further aspect of the ritual design. The act of immersing oneself in the natural environment, attuning to the sounds of nature, and engaging in symbolic actions such as casting stones into water, served to establish a profound connection with the natural world. “[…] airing > figuratively, it also airs the room of overly stressful emotions or worry/grief about the guest” (N).

“[…] An open window is often desired in the dying process—the soul can breathe a sigh of relief and go towards God. […]” (HC).

“Our terrace is also an important element, free sky” (N).

“If possible, celebrate the ritual together with the relatives; ask who is missing and include them by name, also say that we are celebrating the ritual here on behalf of many” (HC).

Some of the nature-related elements served to symbolically relieve those present. The need for an open window during the dying process was mentioned as a frequent wish. This was interpreted as a symbolic act, indicating that the dying person is on the way to God.

Discussion

We conducted an online survey and performed a qualitative and quantitative analysis. The described diversity of rituals in the dying phase was impressive. Both religious services and secular acts such as a communal meal were regarded as rituals (17,18). The vast majority of the rituals described originated from the Christian context and range from traditional prayers and blessings to anointings of the sick. The spectrum encompassed a range of practices, from individualised rituals to the performance of traditional rituals, where the performers also drew on patterns, texts and symbols that were already familiar to them (10). The appreciation or performance of secular rituals played a role in this context. By framing these everyday activities, they were elevated to the status of a ritual and removed from their everyday context. Some of these rituals contained elements from various religious and popular contexts (3). The performance of the rituals moved in a field of tension between ritual order on the one hand and personal organisation on the other, through which the personal situation of those involved was considered (10,11). For the design of new rituals as well as in the performance of existing rituals, there were certain conditions for success, such as the authenticity of the ritual leader, as well as the right timing, and the design of the room in order to frame the ritual as such. All of these rituals staged the moment of dying, whereby they had different inherent functions. These included the remembrance of one’s own life, but also the creation of new memories and legacies as well as the opportunity to express emotions. The creation and passing on of legacies involved the use of pre-existing possessions such as photos or personal items, which connected the deceased with the bereaved and represented their relationship with the past and the future (12). In undertaking an inventory of the rituals, it became evident that the significance of the symbols was of particular importance. During the dying phase, the symbols served to represent two distinct realities: firstly that of the dying person and secondly that of those who survived them and were now bidding farewell. Thirdly, the symbols also indicated an ultimate reference. An exemplar of such a symbol, which was frequently employed in both religious and secular contexts, was the candle. The light of a burning candle thus signified eternity, but also stood for hope or the light of life (6). The study indicated that healthcare professionals perceived a need to provide dying people and their relatives with rituals in the dying phase, even before death. A comparison with the results of the initial phase of the study highlights the significance of developing new rituals. One of the key findings was that in the majority of cases, relatives tend to exhibit greater fear of death and dying than the patients themselves. The rationale provided for this was that the relatives were concerned about the loss. This is because the dying person is a relational being and embedded in a network that changes as a result of their dying and death. The advantage of death rituals is that both the patient and those around them can, at best, organise and experience them themselves. This makes them particularly valuable in a socio-cultural environment in which opportunities to organise are highly valued, but death puts an end to them (19,20). The aspects mentioned above are closely related to the functions of rituals, which were identified as one of the central themes in the survey. Rituals can provide support, orientation and structure in times of transition or crisis, allow the expression of emotions, and facilitate community experience. These effects are similar to those described for rituals in the mourning phase (6,16). Rituals also provide a structured process for individuals who might feel overwhelmed, offering a sense of control and a scheduled time for processing emotions (21). They create community through shared experiences and represent a social context for integrating external challenges (22). Rituals can enable the dying to look back on their lives and create a legacy for posterity. This enables to promote the generativity aspect and enable a resource-oriented view of oneself (11).

Another key topic was the requirements for performing a ritual. In terms of the prerequisites for the creation of a ritual, the study emphasises the importance of authenticity and the personal relationship between the ritual leader and the dying person. This finding serves to highlight the necessity for comprehensive training and sensitisation for all those involved in order to ensure that the individual needs and preferences of the dying are met. The increasing individualisation, secularisation and religious diversity of German society are leading to a situation in which there are no longer any rituals that are acceptable to all members of society. Instead, it is necessary to engage in a dialogue with those affected in order to determine which elements, such as the use of songs and candles, are appropriate.

A limitation of the study was the absence of data on religious affiliation or practice. However, the analysis of the data indicated that the majority of responses were provided by pastoral care workers who identified with the Catholic or Protestant churches. It would be beneficial to survey a larger sample of healthcare professionals representing a broader range of worldviews and religions to gain a more comprehensive understanding of the diversity within this field. Additionally, the response rate remains unknown, which introduces a potential source of bias in the findings. The results demonstrate that rituals in the dying phase extend beyond religious practices and may serve as adaptable and potentially beneficial tools. Designing rituals in the dying phase is a complex undertaking that necessitates meticulous preparation, a profound comprehension of the dying individual and their needs, as well as their surrounding environment, and a high degree of sensitivity.

Conclusions

The study has made an important contribution to ritual research per se and especially in the context of palliative care. The study offers preliminary guidance for the design of rituals in the dying phase, including strategies for involving the dying person and their loved ones, if desired. The importance of “biography work” and relationship-building was emphasised. This approach allows for the creation of a tailored ritual that aligns with the needs of the dying individual. Concurrently, it is essential to have qualified and trained staff who can respond to the needs of the dying with sensitivity and respect.

Acknowledgments

Funding: This work was supported by Marsilius Fellowship from Marsilius Kolleg, University of Heidelberg, Germany (to B.A.E., G.S. and J.E.).

Footnote

Reporting Checklist: The authors have completed the COREQ reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-24-119/rc

Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-119/dss

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-119/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-24-119/coif). B.A.E., G.S. and J.E. were supported by Marsilius Fellowship from Marsilius Kolleg, University of Heidelberg, Germany. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. According to the Ethics Committee of the Medical Faculty Heidelberg, no ethics approval was needed, as no patients or relatives were involved. Completion of the survey was taken as sufficient evidence of consent to participate without an additional informed consent procedure. Thus, no additional informed consent was necessary and participation remained anonymous. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Hertz R. A contribution to the study of the collective representation of death. In: Needham R, Needham C, editors. Death and the right hand. New York: Free Press; 1960:29-99.
2. Bloch M, Parry J, editors. Death and the Regeneration of Life. Cambridge: Cambridge University Press; 1982.
3. Metcalf P, Huntington R. Celebrations of Death: The Anthropology of Mortuary Ritual. 2nd ed. Cambridge University Press. Cambridge: Cambridge University Press; 1991.
4. Silverman GS, Baroiller A, Hemer SR. Culture and grief: Ethnographic perspectives on ritual, relationships and remembering. Death Stud 2021;45:1-8. [Crossref] [PubMed]
5. Heller B, Winter F. Tod und Ritual. LIT Verlag Münster; 2007.
6. Quartier T. Ritualisierungen des Sterbens. Rituelle Dimensionen der Seelsorge. Jaarboek voor liturgieonderzoek. 2010;26:135-48.
7. Bell C. Ritual: Perspectives and Dimensions. New York: Oxford University Press; 1997.
8. van der Weegen K, Hoondert M, Timmermann M, et al. Ritualization as Alternative Approach to the Spiritual Dimension of Palliative Care: A Concept Analysis. J Relig Health 2019;58:2036-46. [Crossref] [PubMed]
9. Kreinath J, Snoek JAM, Stausberg M. Theorizing Rituals, Volume 1: Issues, Topics, Approaches, Concepts. Leiden: Brill; 2006.
10. Radde-Antweiler K. Ritual-Design im rezenten Hexendiskurs: Transferprozesse und Konstruktionsformen von Ritualen auf Persönlichen Homepages [Internet] [Dissertation]. [Ruprecht-Karls-Universität Heidelberg]; 2008. Available online: https://archiv.ub.uni-heidelberg.de/volltextserver/11536/
11. Gramm J, Trachsel M, Berthold D. Psychotherapeutisches Arbeiten in Palliative Care. Verhaltenstherapie 2019;30:323-33. [Crossref]
12. Religionszugehörigkeiten 2022 [Internet]. fowid.de. 2023. Available online: https://fowid.de/meldung/religionszugehoerigkeiten-2022
13. Arndt Büssing M. Befunde aus dem Projekt Spirituelle Begleitung am Lebensende. Schulungs-Teilnehmende, Patient*innen und deren Zu-/Angehörige [Internet]. [cited 2024 Oct 29]. Available online: https://speci-deutschland.de/wp-content/uploads/2023/05/Arndt-Buessing_SpECI-Praesentation-Berlin.pdf
14. Luckett T, Donkor A, Phillips J, et al. Australian specialist palliative care's response to COVID-19: an anonymous online survey of service providers. Ann Palliat Med 2021;10:2747-57. [Crossref] [PubMed]
15. Handelman D. Framing Borders in Literature and Other Media. Brill eBooks; 2006:571-82.
16. Sas C, Coman A. Designing personal grief rituals: An analysis of symbolic objects and actions. Death Stud 2016;40:558-69. [Crossref] [PubMed]
17. Rusted G. The role of the Chaplain in the strategic facilitation of multi-faith sacred space to alleviate the suffering associated with death and dying Item [Internet]. 2024 [cited 2024 Oct 29]. Available online: https://chesterrep.openrepository.com/bitstream/handle/10034/344054/giselle%20rusted.pdf
18. Warburg M. Graduation in Denmark: Secular Ritual and Civil Religion. J Rit Stud 2009;23:31-42.
19. Sprenger G. Neue Rituale in der Begleitung Sterbender – Eine ethnologische Perspektive. Jahresbericht des Marsiliuskollegs [Internet]. 2024;24(159-164). Available online: https://journals.ub.uni-heidelberg.de/index.php/forum-mk/issue/view/6972
20. Strupp J, Köneke V, Rietz C, et al. Perceptions of and Attitudes Toward Death, Dying, Grief, and the Finitude of Life-A Representative Survey Among the General Public in Germany. Omega (Westport) 2021;84:157-76. [Crossref] [PubMed]
21. Running A, Tolle LW, Girard D. Ritual: the final expression of care. Int J Nurs Pract 2008;14:303-7. [Crossref] [PubMed]
22. Wulf C, Zirfas J. Performativät, Ritual und Gemeinschaft. Ein Beitrag aus erziehungswissenschaftlicher Sicht (Performative, Ritual, and Community: The Perspective of Education Science). SSRN Electronic Journal; 2002. 10.2139/ssrn.375072310.2139/ssrn.3750723