The landmark report issued by the Institute of Medicine in 2014 regarding the process of dying in America, recommended the frequent assessment of the patient’s physical, emotional, social, and spiritual well-being as one of the core components for quality end-of-life care (1). Perhaps the most challenging aspect in the hospice setting is caring for the spiritual needs; i.e., caring for the human spirit of the individual.

Based on the premise that the human spirit has a compelling need to find meaning and purpose in life, addressing this need is a worthwhile goal when the end of life is imminent. Frankl (2), a psychiatrist, neurologist, and founder of logotherapy, believed that meaning can be found throughout life, including the final moments in life. Although logotherapy may be classified as a type of psychotherapy, it differs in various ways. Whereas psychotherapy focuses on problems, obstacles, and uncovering factors from the past, logotherapy focuses on solutions, goals, and discovering choices for the present and future. Rather than being reductionistic, logotherapy is holistic.

Patients and families in hospice care have the opportunity to reflect on the meaning of one’s life and to engage in the process of bringing closure. Hospice nurses and others trained in the practice of logotherapy have a unique opportunity to offer guidance and assistance. Training, both on-site and via distance education, is available through the Frankl Institute of Logotherapy (http://logotherapyinstitute.org).

Logotherapists practice from a theoretical basis that shapes their philosophy of life and gives them a unique ability to help patients, families, and loved ones actualize peace and fulfillment. Meaning-centered care can be especially beneficial in the hospice setting.

As described by Starck (3), the Theory of Meaning is the basis for the practice of logotherapy. The core premise is that the primary motivation of human beings is to seek for meaning and purpose in one’s life, and this motivation is stronger than the seeking of pleasure or power. “Why am I here? What is the purpose of my life?” For hospice patients, the questions to be confronted may include—” What has my life been about? What legacy will I leave behind? How will I respond to the challenges as I face death?”

In logotherapy, a person is viewed as an integration of body, mind, and spirit—soma, psyche, and noos. Body and mind are what we have; spirit is what we are. Although faith and religion may be important to one’s human spirit for some, the concept of spirit as used by Frankl (2), does not refer to religion, but rather refers to the essence of the person—the human spirit. Logotherapists recognize the dynamic power of the human spirit. This can be witnessed when a terminally ill person outlives a dire prognosis in order to see a child graduate from college. That powerful human spirit can be harnessed during suffering and endurance that may accompany the dying process. The human spirit can choose to adopt an attitude towards unavoidable suffering that shows courage and bravery. A useful topic of discussion that would facilitate a person harnessing that power is for the nurse to request, “Tell me about a time in your life when there was something you thought you couldn’t do, but you did.” The nurse is caring for the human spirit by promoting reflection from the patient.

Although logotherapists do not rely on a set of prescribed techniques, one of the most frequently used methods is Socratic dialogue. This method, involving asking provocative questions, often helps patients and family members view issues from a different perspective, and can affect one’s attitude. A case discussed by Frankl was that of an elderly general practitioner who was severely depressed after this wife died two years previously. Frankl reported:

Now how could I help him? What should I tell him? Well, I refrained from telling him anything but instead confronted him with the question, “What would have happened, Doctor, if you had died first, and your wife would have had to survive you?” “Oh, he said, “for her this would have been terrible; how she would have suffered.” Whereupon I replied, “You see, Doctor, such a suffering has been spared her, and it was you who have spared her this suffering—to be sure, at the price that now you have to survive and mourn her.” He said no word but shook my hand and calmly left my office. In some way, suffering ceases to be suffering at the moment it finds a meaning, such as the meaning of a sacrifice (2).

Asking the “What if?” question can evoke a change of perspective and can give one the freedom to choose an attitude toward a fate that cannot be changed. Another case that illustrates the effect of the Socratic dialogue involved a family in therapy for increasing dysfunction. The identified patient was a young adolescent with a progressive neurological disease who required almost total care. The parents were having marital difficulties thought to stem from arguments about whether to institutionalize their son. The older sister of the patient had gotten pregnant out of wedlock, and each parent blamed the other for not noticing what was going on in her life. The younger son had set fires to trash cans at school; thought to be another cry for attention. With all the family gathered, the logotherapist asked the patient the following question: “If you could, if it were possible to give your condition to someone else in the family and you would be free of it, which family member would you give it to?” The mother spoke up quickly, “I would take it.” But the therapist insisted the question was for the adolescent with the condition. Thoughtfully, the patient looked at each family member, moving from face to face around the circle. Finally, he spoke, “I would keep it myself, because I think I can handle it better than any other.” The family was quiet. No words were necessary for each family member to see the boy as heroic rather than a burden; willing to sacrifice for his family.

It is important to remember that meaning cannot be given, prescribed, or assigned to another. Each person determines his/her own sense of meaning. It is the role of the caregiver to lead and guide the patient in finding this unique meaning. In thinking about helping someone find meaning, there are three general categories through which meaning can be found, and Socratic dialogue may be useful in assisting patients and families focus on meaning:

1. Tasks- e.g., works or deeds one has accomplished, a career, raising children

“Tell me about the thing(s) you are most proud of accomplishing in your life”.

The nurse might ask the patient to make a list of his/her life values, i.e., what they most treasured. Such a list might be as follows:

My children

A reflection on the achievements in each of these values would focus on meaning from tasks that gave meaning to one’s life.

2. Experiences- e.g., loving another human being, appreciating a beautiful sunset

“What was the happiest experience you remember?” “What is the most memorable birthday you ever had?” “Tell me about a time you experienced goodness from someone.”

3. Attitude- e.g., choosing an attitude toward circumstances that cannot be changed

“What has been your motto in life?” “What principle do you live by?”

Some patients may ask for a list of mottos from which to choose. A list can be constructed according to the culture, but some suggestions are:

The service we give to others, is the rent we pay for being on this earth.

The concept of self-transcendence refers to getting outside the self to serve a cause greater than oneself. Terminally ill patients who agree to participate in a research study that will not benefit them, but can perhaps benefit others who come after them are being self-transcendent. This itself is meaningful. Those who make choices that benefit others, such as family members, have transcended their own needs. Like planting a tree that one won’t live to see grow big and provide shade for others, a deed that is done for the good of others without direct benefit to oneself is self-transcendent.

Dealing with suffering is one of the most challenging aspects for hospice caregivers. Human suffering, like pain, is a subjective experience unique to the individual. Whether is it simple and transitory or extreme, causing anguish and despair, suffering consumes the whole person. No one can escape life on earth without some type of suffering; it is a universal experience. However, in hospice care, preventing or mitigating unnecessary suffering is of vital importance, e.g., giving pain medication to keep one comfortable. One should not look for any meaning in suffering; rather one should look for meaning in spite of suffering. There is no meaning in having cancer; but the challenge is finding meaning in spite of having cancer and its devastating effects. In order to stimulate reflection on suffering experiences, the nurse might have the following discussion:

“You have suffered a lot. What has helped you get through it? What have your learned about human suffering? Has any good come out of this suffering?”

Frankl (2) described the worst of suffering and despair as an existential vacuum. This is a feeling that all is hopeless and all is meaningless. A lesser, but equally concerning state, is existential frustration when one is searching for meaning, but continually thwarted. The need to discover meaning is profoundly important.

Kang et al. (4) developed an applied logotherapy internet learning program, called “Finding Treasures in my Life.” The program was designed for testing with a group of adolescents with terminal cancer. The program consisted of five sessions, each called a “Treasure”. The sessions focused on the concept of the three natures of the mind, creative values, experiential values, and attitudinal values, and becoming the master of one’s own life.

To evaluate the effects of the logotherapy education program, Kang et al. (5) compared results from a control group with an experimental group who received five daily sessions for one week. Results showed significant reduction of suffering and improved meaning in life perception for adolescents with terminal cancer.

Choi and Kim (6) detailed a process for nurses that can lead patients to a more meaningful experience in hospice care. The first phase of acceptance and awareness of self and life focuses on the acceptance of the limits of human existence and the coming of death. The second phase concerning the actualization of creative value involves doing a deed for the last time before death. In the third phase, focused on experiential value, the concentration is on love, whether of an individual, nature, or a religious deity. The fourth phase consists of fostering the choosing of a meaningful attitude, such as bravery and acceptance in facing suffering.

Breitbart et al. (7) conducted a randomized control trial to determine the effect of an 8-week Meaning-Centered Group Psychotherapy (MCGP) protocol for patients in advanced stage III or IV solid tumor cancers. Patients were assessed before and after the intervention, as well as after two months. The MCGP consisted of specific weekly topics related to meaning. The sessions were facilitated by trained professionals, and topics were focused on the concepts and sources of meaning, with discussions of attitudinal, creative, and experiential forces of meaning. The last session focused on goodbyes and hopes for the future. Results demonstrated significant improvements in spiritual well-being and a sense of meaning. These treatment gains were even more substantial at the two-months follow-up assessment. The battery of assessment tools consisted of five instruments widely used and validated in terminally ill patients.

Professionals who work in hospice care need to be aware of their own needs concerning meaning and purpose. Their work requires personal sacrifice for the benefit of others, but rich meaning through one’s career may be the result.

The general public often expresses wonder at how hospice care professionals can endure working with patients whom they know will shortly die. Indeed, empathic caregivers develop close feelings to patients and families, often over an extended period of time, amidst the shadow of impending loss. It is important that hospice caregivers find meaning in their work.

Socratic dialogue and reflection may help to maintain a healthy sense of professional self. Feelings of a job well done can be meaningful. To be able to work in the field of hospice care is an achievement in which not everyone can be successful. To walk with families through the dying process of a loved one requires depth of feeling, special communication skills, and concurrently, enough detachment to be therapeutic. Professionals must be strong when patients and families are at the nadir of their despair.

Mason and Warnke (8) presented strategies that help professionals find meaning after a patient’s death, called the “Pause.” Those who cared for the patient, including the family, are invited to gather together. A serene picture, such as a sunset is placed in a visible spot as the focal point. The group is led in a reflection. Time is taken to reflect on the care given to the deceased patient as being honorable. The “Pause” ends with a period of silence. This practice is intended to foster healing and a sense of purpose of the team members involved in the care of the deceased person.

In conclusion, nurses who practice logotherapy can help a patient in hospice care as well as family and loved ones of the patient. Guiding patients to reflect on meaning and purpose in their lives and what they have contributed and experienced can be an important part of spiritual care. Future research should focus on outcomes that demonstrate quality end-of-life care.