Clinical hypnosis, mindfulness and spirituality in palliative care

Introduction

“Life is a rubbed match whose flame should be used as quickly as possible to light something else, because, if you wait, it goes out and it becomes too late.” —Stephan Enter.

According to the latest definition of the World Health Organization (WHO), palliative care aims to improve quality of life for patients and their families facing life-threatening illness (1). Palliative care provides instruments, methods, and approaches to relieve pain and other distress symptoms thus offering terminal patients the opportunity to live the last period of their life with dignity, serenity and peace (1). In order to achieve this, whoever provides palliative care affirms life in all its different manifestations, and regards dying as a natural process of life.

Affirming life has nothing to do with extraordinary treatments to prolong life at all costs, promising an extension of days without considering the quality of such days (1,2). Dying, the ultimate act, is considered in palliative care as a natural process of life. This gentle awareness is of outmost importance and can bring meaning to an entire life. Until our last breath, each of us can embrace the meaning of living and dying (3).

In our society, anguish is created as a result of having removed death from the range of thought and conscience, as if we wanted to nurture the illusion of human immortality (4). In units of palliative care, terminal patients come to see death as a natural phenomenon that belongs to all of us, with no exception: every animal, every flower or plant, every human being has its limit. Patients return to seeing the uniqueness of each life, not only that of humans but of each leaf, each butterfly, each mouse or each moose. Every man and woman is an unrepeatable being, a world heritage site, whose uniqueness is given by what she/he has created along his/her nonpareil path in life. As death approaches, we have no more time to lose in trivial things thus we focus attention on the few days, the few weeks, the few months (5,6).

When patients know they are dying, they need to express their feelings without being confronted with the denial of their loved ones, or burdened with blame because the others are not ready to accept their death and to be left alone (7,8). Patients would like to feel free to talk about their upcoming death: they need to know and share that naming of death will not provide their immediate demise: naming death does not mean calling it up immediately and causing the person to die at once. They know that those who talk about their feelings of coming death live as protagonists of their last period of life, taking full responsibility for life and death (9,10).

When such talk is denied or rejected, terminal patients may become anxious and feel responsible for the observed suffering of those they care most about. Furthermore, what their body feels can be disconnected from their thoughts because of the others denial of their declining state. The patient needs to restore his/her consistency between his/her mind and body, and thus restore harmony between himself/herself and others (11-13).

“We must carry the thought of death as lords carried a falcon on their shoulder.”—Montaigne.

During palliative care, priority is given to the impalpable quality of life rather than to the measurable length of time left to live (2,14,15). The palliative care system intends neither to hasten nor to postpone death but offers a variety of physical, medical, psychological and spiritual aids to help patients live the last days of their lives with dignity, serenity and equanimity (16,17).

Palliative care offers patients in pain not a measurable quantity of days, but quality of life, ready to accept the natural dying process characterized by the failing of the body, the despair of the soul and the sorrow of provoking pain to those who remain.

The palliative caretakers help the dying to forget his/her deteriorating body and to protect it with a light mantel of tenderness, loving kindness and compassion (18). In this way, the terminally ill patients regain his integrity, simply accepting the present moment for what it is (19).

Caretakers in palliative care soothe patients’ wounds in physical integrity, while accompanying the physical decline with gestures, looks and words (7,20). This approach recognizes and confirms the patient’s unique identity and not just the care for the remains of a deteriorated body. Caretakers give the terminal patients the gaze that confirms identity (Lacan); they offer day-by-day spiritual renewal (St. Paul) until the inevitable terminal stage.

Palliative caretakers share the position of Metastasio regarding death, that is, that “It is not true that death is the worst of all evils, it is a relief to mortals who are tired of suffering”. Caretakers do not offer euthanasia, the possibility to choose our own death. For this reason, palliative care is dedicated mainly to improving the situation of a suffering patient through pain therapy (17,21,22). Not only is physical pain connected with the sick body and its bones, flesh, skin, viscera…, but it is also emotional, and relational, experiencing shame, sorrow, regret, guilt, anger and fear, as well as spiritual suffering connected with the soul (7,11,13,23,24).

Palliative care offers not denial or the disguise of death, but a warm and soft mantle which brings tenderness to cover a sick body and protect a resilient soul (9,12,20,25,26). This holistic approach addresses not only the terminal patient but also supports their families and informal caregivers during the illness, death and bereavement (19).

Palliative care helps the patient to find an internal locus of control, to become able to manage fear and anguish as well as pain. This permits him/her to retrieve a resilient state during a terminal disease, and to achieve inner serenity enabling him/her to take leave of life in peace (10,13,19,22).

In the palliative care unit, irreversible time pushes patients to shape their lives into a meaningful story, and find their place in the world, before departing, transforming their death into destiny (7,8,18).

Even though death sometimes comes too soon, we are alive until the end. A death with dignity dignifies the life of a person. The time before death can be used to complete the life of a person, and leave those who remain with a sense of what really matters in life.

Death is a secret of nature that no one has yet unveiled (12,18,27). Even though the dying are close to unveiling this secret of being in deep connection with soul and spirit, they cannot share the secret because they are still alive. They recognize when they are about to die, when the last moment is arriving and would like to share this knowledge with their loved ones, hoping they will be given permission to go away forever (7,8,23).

Let’s see now how clinical hypnosis helps to ease anguish and make peace with life and death.

Clinical hypnosis in palliative care

One of the aims of clinical hypnotic palliative care is to offer a framework for healthcare professionals to connect with their patients’ emotions (10,25,26). The permission to express without denial allows the healthcare professionals to hear the patients’ fear, anxiety, and anger. Hypnosis offers the possibility to create a strong therapeutic alliance between the caregiver and the patient, an alliance characterized by motivation, trust, and collaboration (28,29). Motivation is based on the patient’s desire to reach a comfort zone, to find his/her resources needed to face death; trust is reached as soon as the patient experiences the benefits of hypnotic suggestions and self-hypnosis; the enhanced collaboration with the hypnotist is a natural answer of gratitude and recognition also occurring when the patient experiences the physical and psychological benefits of hypnosis (30-32).

According to Elkins et al., “hypnosis is a state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestions. Hypnotic induction is a procedure designed to elicit hypnotic trance. Hypnotherapy is the use of hypnosis in the treatment of a medical or psychological disorder or concern” (33).

The word “hypnosis” encompasses a wide spectrum of phenomena characterized by responses to suggestions for modulating sensations, images, behaviors, affects and meaning of the experience the patient is living in that moment (34-36).

The altered state of consciousness induced by suggestions made to focus attention on the patients’ inner world is reinforced by the expectation patients have regarding the benefits of hypnosis. The higher the expectation, the higher patients’ motivation and collaboration. When a person reaches such a state, she/he responds betters to suggestions. Suggestions are ideas the therapist sends that contain hidden directives for discovering inner resources and resilience (26,37-40). These suggestions may also contain implied possibilities for responding with efficacy to life’s challenges. Every suggestion invites patients to explore their inner resources, talents, and capabilities to help them face life’s difficulties.

Hypnosis treatments have demonstrated efficacy for a number of conditions (41-44) and is recognized for its potential to help to relax and calm the body, mind, heart and spirit of the suffering person. Literature reports different cases when those who are about to leave this earth, leaving behind every person and thing they loved, are able to cope with pain and stay alive until a fixed deadline: the graduation day of a daughter, the marriage of a son, the birth of a grandchild (7,9,25,38). They are able to wait until that particular day and die soon after, satiated by having accomplished their last wish. The person who knows she/he is about to die makes one last attempt to place himself/herself completely in the world before departure. Each one in his/her own time, after having completed the relationship with others, learns to surrender to the arms of death. The proximity of death gives us the strength to achieve, to complete and to fulfill our last wishes (7,11,13).

These episodes might support the hypothesis that people die when they are ready. Also, patients in coma may show when all things become intolerable but not all is settled for their departure, that they offer their loved ones the time to prepare for the final separation: they wait to receive their loved ones’ permission to stop living (7,9,25,26).

The holistic approach does not hold the belief that terminal patients cannot do anything but wait passively for death to come, and that the body is immobile, impotent, incapacitated. The holistic approach upholds the attitude that, since mind, heart, and soul are alive, patients can still play an active role in the life of the people around them, and keep up contact with beloved ones. Until their last breath they can give and receive love and in so doing embrace life (9,10,12,16).

Clinical hypnosis is patient centered care approach, which aims to help each single patient discover his/her inner resources and resilience at this critical moment of life. It focuses on terminal patients to help them live fully until the end, blocking any sensation of death while they are still alive.

The terminal patient living in a hospice or in a palliative care unit can still experience new things in another way, at a more interior level, within the realm of his/her relationship to the world. When they cannot do anything because their body is immobilized by pain, or incapacitated by amputations, they can still love and be loved. Thus, they leave a message to the people around them: “live your life until the final end, give and receive love until the last moment of life”. The idea that the end of life cannot be deferred leads us to fulfill ourselves. “Death gives us a chance to give completeness to our life”, Hans Jonas says.

The hypnotist accepts the suffering and the anguish of the patient, and gives back compassion, participation and peace of mind. The message the hypnotist sends is “while you enter the mystery of death, I am with you, you are not alone”. When the patient feels his/her fear and anguish welcomed by caring arms, he/she can remit himself/herself with confidence into the arms of sister death (7,8,13,25).

Benefits of hypnosis

Hypnosis treatments have demonstrated efficacy for managing a number of symptoms and conditions (16,21,22,41,45). Hypnosis offers the opportunity to gain better body perception, elicit personal resources and improve mood. After suggestions, patients report feeling the body as a whole not only as a source of pain, but also to live pleasurable sensations (19,41,45). Hypnosis generates relaxation that can encourage deeper elaboration during this phase of life.

People working with palliative care learn how to help those who are in pain to recognize the messages of their body without denying it, and to recognize the wisdom coming from the physical body that is about to complete its natural life cycle.

In this sense, hypnotic induction can elicit wisdom contained within this kind of suggestions.

Feeling your whole body

Now you can be aware of your breathing, and you can imagine that when you breathe in, you bring relaxation into your whole body, and when you breath out, you expand relaxation all around you. Now you can feel that when you breath in, you bring calm into your whole body, and when you breath out, you expand calm all around you. Now you can feel that when your breath in, you bring peace into your whole body, and when you breath out, you expand peace all around you. Now you can feel that when you breath in, you bring serenity into your whole body, and when you breath out, you expand serenity all around you. Now that your body and your surroundings are full with relaxation, calm, peace and serenity you feel a deep connection with the love you have given and received. Stay with these sensations for all the time you need.

Clinical hypnosis and spirituality

Clinical hypnosis suggests considering the universal need for a caring relationship essential to each human being. The hypnotist approaches suffering patient as a whole, not just reduced to the symptoms. She/he offers an approach, which has a calming, reassuring, and comforting effect (23,24). Hypnosis increases the person’s ability to cope with pain and other treatments (21,28,32,44).

The hypnotist offers through suggestions a therapeutic contribution within an ethical dimension that accompanies patients in the last period of life. The therapeutic relationship and alliance between the patient in the palliative care unit and the hypnotist creates the premises for recovering and using hidden resources, while increasing awareness and sensitivity about spiritual needs (29,38) Acknowledging the spiritual needs of patients and their families helps the hypnotist to understand when to offer special rituals, prayers, chants, mantras or other spiritual supports (7).

“When we pray, we meet those in heaven who are praying at the same time and whom we could not meet except in prayer.”—Kahil Gibran.

Providing spiritual care to the terminal patients offers time and space to assess their beliefs regarding dying as a vital stage of their life. In all religions, when we die, death transcends the body but the soul survives. Death is not an end, we leave behind traces of our individual passage on earth (4,7,12,13,18).

When professional caretakers realize that spirituality improves connection and collaboration with their patients, they can access it to help the patient to enhance his/her awareness of inner wisdom. Professional caretakers can address patients’ attention to a deep sense of aliveness, interconnectedness with something bigger than themselves, and searching for meaning in life. Spirituality in this broader sense is not necessarily associated with a specific religion or church, temple, mosque, or synagogue. Spirituality is a way to seek of a comforting presence of someone or something bigger than us and to feel connection to nature, to beauty, to art and to transcendence (20,46-49).

Hypnotic inductions to elicit spirituality can utilize the following suggestion inspired by Pierre Hadot (27).

Suggestions on natural wisdom

Now you can be aware that your universal wisdom frees you from regrets of the past and fears of the future. Imagine that you are now leaving your body here while your mind and soul walk in nature and you feel a deep connection with an animal you love, a natural element that gives you wellbeing, a deep intimacy with earth, wind, water, sky, clouds, sun, every tree and every flower. Feel the connection with the mysterious beauty of nature that engenders awe, admire the harmonious beauty of a rose, of an orchid, of a waterlily. Feel free to feel the deep sense of connection with the entire universe that gives you the sense of immensity and vastness. Now you are deeply connected with nature and its beauty where everything changes and passes. With this deep sense of connection with nature, its beauty and its universal wisdom, feel the wisdom of your body, the beauty of your soul and realize that you are living according to human nature, loving changes, differences and mysteries, like the one that you are now facing.

Spirituality helps to manage human dilemmas such as: why is there life? Why does the universe exist? Why do human beings exist? How important are human beings in the universe? How important are we in relation to others and to the universe? Spirituality helps to reconcile experiences, beliefs, reason and emotions. It helps to find true values and unique identity. It overcomes difficult problems, conflicts, losses, offering the necessary calm to experience well-being through awareness of life’s limitations, challenges and mysteries.

Spirituality invites the terminal patients to stop asking questions that do not have answers, to stop wondering why something happened and something else rather it did not happen, to let go of any desire of driving ambition and supremacy, and recognize that there is nothing to understand (10,12,13). Patients in a palliative unit acknowledging spiritual aids, recognize that their terminal illness have illuminated the essential. This has made irrelevant what is superfluous, and highlighted the precariousness of life, as well as the transience of all things. The only thing that becomes important, in this moment of their life, is to seek the protection of another human being, with whom they can feel again the sense of belonging, being loved and being in a safe place.

To help patients to create their own safe place here are some suggestions inspired by Tara Brach (46).

Being in a safe place

Now you can allow yourself to go deeper into your unconscious mind and find your safe place, which is also your true refuge. Go to your safe place where you find all your resources that you have deposited during your lifetime. These resources are made of good memories you have protected from oblivion. There you find happy memories regarding your childhood, your adolescence, your adulthood, memories of joy and happiness as well as of exploration and discovery. You know that in this safe place you find true refuge from pain and suffering, because it belongs to your wisdom coming from knowing the laws of nature regarding differences, changes and mysteries. In your safe place, you recognize your uniqueness and your being different from other human beings and you also become aware of all the changes you have made during your lifetime. In your true refugee, you also nurture the curiosity regarding the mysteries of life and death. While you are thinking about your entire life with its ups and downs, with its good and evil, you now know that you are facing the last part of your life, where you give a sense of completion to your true self. You may remember every time you asked yourself why you were born, not finding a proper answer. You may remember every time you asked yourself why you were born in that family, in that place, on that day, not finding a proper answer. Now you might ask yourself why you are finishing your life in this way, not finding a proper answer. The only answer you can give yourself is that you lived your life as it was meant to be lived. And now with your natural wisdom you prepare for this last part of your life, ready to bring with you the same curiosity you had every time you were facing something new.

“Life is a great surprise. I do not see why death should not be even a bigger surprise.”—Nabokov.

Spirituality ensures that a human being becomes what it was called to become, and that when the body welcomes the spirit, the anguish is replaced by the belief that death is the crowning accomplishments of our lives, the climax that gives meaning and value to what we have done during our lifetime. In this way, time preceding death can be useful to the fulfillment of a person. The dying are alive until the last moment, until their last breath. The experience of life beyond is given by experiencing life itself and its mysteries (46-49).

Suggestions on spirituality

Now you can feel a sense of peace in your body, mind and soul. While your body is resting quietly, your mind can go around the world to visit places you loved the most and your soul can enjoy this peaceful experience. You can go to the top of a mountain and feel the stability and the solidity of the mountain while you also feel the warmth of a spring sun, and a soft wind caressing your face.

At a certain point, you see a spring and its crystal-clear water. You fell like to follow the journey of transformation in a source stream and then in a river. Stop in the riverside and appreciate the flexibility of the river which creates its own way during its journey from its spring to its ends at the mouth in a lake. Stay in front of the lake for a while, just to feel its calm, its deepness and vastness on a day with a clear sky. Now you can go downhill and realize that the day is coming to its end and you stop to see the most astonishing sunset you have ever seen. Stay there until the sun disappears and you start admiring twilight and the sky preparing a night full of stars.

Clinical hypnosis offered in a palliative care unit can help patients to reach spiritual strength and open the way to their deep human development while freeing them from false conceptions and restrictive assumptions. This permits the patient to make the best of every event, accepting what cannot be changed and reconciling with their own past and with others.

When terminal patients are ready to recognize that their life is about to end, like a sunset that does not prepare another dawn, they can also be open to recognizing the resources they still have. They become aware of the meaning of what is happening to their body, mind and soul. In that moment, they are ready to understand that it takes all life to learn to live and, even more wonderfully, it takes a lifetime to learn to die (11,12,18).

Learning to die is learning not to regret what we could have done and we did not, nor to feel guilt for what we should have done and did not do, but accepting that we did the best we could. In this phase of the life cycle, it is important to make peace with ourselves and with others, forgiving ourselves and others and letting go of what cannot be kept and brought with us to the other world.

Clinical hypnosis helps patients to cope with major regrets which usually are related to not having lived a full life, to not having had the courage to live according to desires and wishes, too busy trying to satisfy others’ implicit expectations or explicit requests. Other regrets usually are related to having devoted too much time to working instead of loving oneself and others, and for having neglected the search for serenity and wellbeing.

Hypnosis and mindfulness in a palliative care unit

Mindfulness is a practice of Buddhist positive psychology which provides an approach to helping people to care for themselves, accepting experiences as they are, achieving happiness and reducing suffering by focusing conscious attention on what is happening at the moment (18,27,46-49). Hypnosis helps to focus, and to integrate sensations, imagination, affects, meaning, and behaviors, thus giving validity to feelings and emotions as they are felt, using logic to acquire and maintain acceptance, gratitude, and compassion. Mindfulness means being alert to what the mind is thinking, moment by moment, to what the senses are feeling in the here and now. It requires being present to what is as it is, without wanting to change what cannot be changed, nor the sense of what it is being experienced. Mindfulness helps to discover that the authentic life lies in every instant. We possess only the moment, the real-life moment, that certainty of living in the moment.

According to mindfulness (as well as to Stoics), an authentic life is free from the burdens of the past and from the worries of the future (9,10,25,49). Thus, it requires objectivity and self-control, pays attention to the internal and external world, gives up unnecessary desires and is grateful to the infinite value of each and every moment. When patients in the palliative care unit are helped to pay attention to their internal and external world, they can also govern vulnerability, shame, anger, fear, disappointment, despair through reasoning, imagination and intuition.

Clinical hypnosis and mindfulness help patients to accept that, during the ultimate phase of life, it is not worthwhile to pay attention to the past with its mistakes and learning, nor to the future with its hopes and illusions, but to be present in the present moment. Feeling and fully living the moment by moment experience can give wellbeing, fullness, gratitude and meaning to the fact that we are still alive until the last breath (50). When terminal patients realize the speed at which life vanishes and fades, they give value to time, do what has merit and give meaning to life, learning to want what is happening as it happens (3,5,6,18,26,47,49), knowing that the only way to fight against time that flies is to use it intensively (Epictetus).

“Death is nothing both for the living and the dead. When we live, death is not there, and when death is there, we are not.”—Epicurus.

“For birth and death there is no remedy except to enjoy the interval.”—G. Santayana.

When the dying accepts that death is the inevitable ultimate stage of life, it becomes easier to recognize its arrival and prepare to go elsewhere, to another place and to another time, in a spaceless, timeless dimension. They better accept being taken away from earth, from their loved ones, from everything they have created, built and loved.

Suggestions on detachment

Now feel the sensation of your entire body, and be calm and restful. Appreciate this sense of calm inside and outside yourself and enhance it by detaching yourself from your own thoughts and emotions. Be fully aware that you are not your thoughts, and that you are not your emotions. Thoughts are only thoughts, emotions are only emotions and you can recognize them, accept them and let them go. In this way you exercise your openness, your loving kindness, your non-judgmental and non-defensive attitude. Now be aware of what you are thinking, be aware of what kind of thought you are thinking, welcome it, accept it and let it go. Now be aware of what you are feeling, be aware of what kind of feeling you are feeling, welcome it, accept it and let it go.

In this way, you can go to your favorite place, listen to your favorite music and recall experiences of peace. In this way and with these peaceful sensations you feel welcomed and embraced by people who love you and whom you love.

“In life, there is a lot of suffering and perhaps the only suffering that can be avoided is the pain of trying to avoid suffering.”—R. Laing.

Eliciting gratitude

Terminal patients are aware when the breath of death is close to them and recognize that they are still an entire person with personality and values (50). They do not want to be remembered as a disfigured body to be ashamed of (7).

Additional knowledge coming from studies on people facing death in palliative care units regards eliciting gratitude to what life has given to that person (50). Sometimes patients feel the need to also thank their ancestors. Great grandfathers and great grandmothers, grandfathers and grandmothers, fathers and mothers: all the ancestors can be thanked for the heritage of courage, resilience and hope. If they had not existed, we would not have existed either.

For the following suggestions, a magic thought is needed, inspired by Victor Hugo sentence: “the dead are invisible, not absent.”

Meeting the ancestors

Now you can allow yourself to travel in time and space to another time and another space, all over the ages, all over the universe. You can start this journey going back in time and space to meet your ancestors, not only the persons you met in your lifetime, your mother, father, grandfathers, grandmothers, but also all your ancestors you could not meet because they had already left life on this earth. You come from all your ancestors, and some of their experience was passed to you, some genes, some way of thinking or feeling, and you are grateful for what you have inherited from their wisdom, from their experience.

And when your body sends you the message that you are ready to die, you can feel the warmth and the closeness of all the persons in the world that love you and you can imagine they are sending you their messages of love and their permission to die.

And when you receive their permission to die, you are ready to meet all the persons all over the world who are dying at the same moment. You may know that every minute around 150,000 people are dying with you: people of different ages, genders, nationalities, social statuses, religions. People from all over the world are welcomed to live with their ancestors. You and all the people around the world who are dying with you at the same time are living this moment of completion of life with equanimity, peace and serenity, feeling the universal embrace of all the people that have experienced the same fate before you.

We will know true joy only by accepting the sorrows and deprivations that afflict us; we will know true peace only by embracing the bodies destroyed by wounds and torments; we will know true life only by accepting death which amplifies and enrich life.

Conclusions

When death is preceded by an incurable disease, people might search help in a palliative care unit where to find support for their physical pain as well as for their psychological and spiritual suffering. This article has presented some suggestions inspired by universal wisdom of the Stoics, by positive psychology of mindfulness, and by laws of nature (3,5,6,18,46-49).

Entering a palliative care unit means entering into an ultimate reality, knowing that bodies are fighting but souls are inspiring. Although terminal patients feel and see their body decline, although weakened they also feel that their soul has become stronger. They are not there to fight against the disease but to remit and to accept the last part of life with the wisdom. This wisdom springs from the knowledge of impending death, aware that if life did not exist, there would be no death. They know that they cannot imagine life without death. Death is not only the last moment of life: it crosses all existence, following the sadness of every separation. It remains a mysterious enigma full of solemnity.

Patients in a palliative care unit with the help of caretakers know to make sense of the time left to live. With the help of clinical hypnotists, they find their strength of their vulnerability (51) and they feel their profound identity has remained intact and restored so that they continue to live until real death arrives.

Palliative care encourages the best life possible until the last moment and the last breath: long life depends on fate, good living depends on the soul, as Seneca says. Life is long when it is full, when it is satiated by days, hours, minutes; It is full when the mind is able to recognize that, even if life is ephemeral, the fact of having lived is registered in time. Jankelevitch says (12): “Everyone who has lived is an eternal fact, no matter what the length of his/her time. Our death is not our end. We live on in the memories of those we love and leave behind, in our actions and deeds, and in the persons who we helped to generate, the successors and heirs of our genes”. Gabriel Marcel adds: “To love someone is to say: you will not die” (4).

Acknowledgements

None.

Footnote

Conflicts of Interest: The author has no conflicts of interest to declare.

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