One way to approach ACP is within the context of a holistic health assessment that includes a spiritual assessment (Chrash, Mulich, & Patton, 2011). As part of the spiritual assessment, the health care professional can explore
specific concerns about the distinction between prolonging life versus prolonging death, and sanctity versus quality of life. In addition, a spiritual assessment would address specific religious concerns about initiating and terminating life-support technologies and appropriate medication to relieve suffering, while maintaining awareness of hastening, or not hastening, death.

In many respects, ACP provides the space and time to address spiritual and existential aspects experienced during serious, life-threatening illness and death. When encouraged to talk about what the illness means to them, the sick individual and/or their loved ones may wonder why this is happening to them. These questions can lead to existential exploration of what gives the individual meaning and purpose in spite of the presence of disease. Providing space for existential discussions can help the health care professional support the patient and loved ones in discovering sources of hope, as well as identifying more supportive ways to journey with the patient and their significant persons during worsening illness and eventual death. The process of ACP can provide opportunities for the sick person to discuss more intimate matters with family and friends. It can be very helpful for professional caregivers to help patients and their loved ones to explore the value of their shared lives, feelings of love, exchanges of forgiveness for real or imagined events, and disclosing previously unspoken truths.

One aspect of the spiritual dimension is that of “always becoming,” and ACP can provide the opportunity to express desires for completing unfinished business or goals, doing or seeing particular events or places before dying, as well as desires for presence and rituals around dying. These discussions can provide the individual and his or her family a much-needed sense of control and possibility for continued growth and hope.

The ability to contemplate the reality of eventual death can also enable people to live life more fully in the present. Religious, spiritual, and philosophical teachings remind us that we cannot live life to its fullest unless we have confronted the possibility of our dying. Watson (2011) expresses this concept in observing, “The end (conclusion) of life leads us to think about the end (purpose) of life” (p. 45). This opportunity for growth can enhance the person's coping and resilience for facing the unknown as the illness worsens.


The dimensions of spirituality, religion, and culture may overlap within the individual, making culture, religion, and spiritual beliefs difficult to distinguish or separate. Culture may be described as the various ways of living and thinking that are developed and shared by a particular group of people
(Leininger, 1980). Spirituality can be shaped entirely by culture, determined by life experiences unrelated to culture, or influenced by both culture and personal experience (Martsolf, 1997). Indeed religion, spirituality, and culture can be deeply intertwined concepts.

The concept of cultural humility can be helpful in knowing how to approach other people about their beliefs, values, and personal preferences (Tervalon & Murray-Garcia, 1998). Cultural humility is in contrast to cultural competence, which suggests one can learn the patient's culture (or fully understand someone else's spirituality), as opposed to considering the effect of the health care provider's worldview and focusing on the particular beliefs and behaviors of certain groups of people. Rather, one can develop a greater self-awareness of one's own assumptions and beliefs that impact understanding and goal setting in working with individuals in health care encounters. Greater self-awareness on behalf of professional care providers facilitates the ability to develop a respectful partnership for person-centered interviewing, and exploring the patient's and their loved one's priorities, goals, and capacities, which are unique to each individual. Further, cultural humility enables the health care professional to negotiate each person's perspective to arrive at a consensus for goals of care and an agreeable plan of action, including developing an advance care plan.

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