Anthroposophy and Integrative Care at the End of Life

Abstract

The anthroposophic care model for patients with advanced and/or terminal illnesses offers instruments to care professionals to help allow the patients a gentler process of dying and death, while also aiming to ensure that this is a period of potential transformation and inner growth. The aim of this descriptive study is to present anthroposophic know-how in relation to end-of-life care and draw parallels between the anthroposophic paradigm and the good-death model of the modern hospice movement.

Anthroposophic therapies applied in end-of-life care, engaging care professionals in patient and family reception and the environment and integrative work between the various actors can contribute toward the quality of life of these patients, helping them in the process of dying and the bereavement phase. There are significant similarities between the good-death model of the hospice movement and anthroposophic end-of-life care. Care professionals who work with patients with progressive, advanced, and terminal illness may encounter substantial elements in the anthroposophic paradigm to help these patients and their families, while learning about new forms of care and approaches to the process of dying.

Introduction

Anthroposophy is a field of knowledge conceived by the philosopher, researcher, and educator Rudolf Steiner (1861–1925). Dr. Steiner maintained that through the development of the faculties of perceptive imagination, inspiration, and intuition, one can cultivate a form of thinking that enables cognitive experience of the spiritual world independent of sensory experience. Anthroposophy represents a vast field of knowledge dispersed throughout several areas, such as agriculture (biodynamic agriculture), pedagogy (Waldorf education and the Camphill movement), architecture (anthroposophic architecture), and economics (social pedagogy).^1,2

In the field of health, anthroposophy constitutes a supplementary medical practice that integrates biomedicine with the anthroposophic concept of the human being. In a comprehensive manner, in correlated areas such as nursing, physiotherapy, dentistry, psychology, nutrition, art therapy and music therapy, anthroposophy offers a broad conceptual spectrum and range of therapeutic choices.³ Specifically, in the field of care for patients with advanced and/or terminal illnesses, the anthroposophic premises and derivative therapies provide care professionals with instruments to help their patients experience a gentler process of dying and death and, whenever possible, with the patient being central to decisions made about his or her life.⁴

Anthroposophic medicine is practiced in roughly 80 countries. In Europe, it is practiced in several European Union nations, and in Norway and Switzerland, by more than 2700 fully qualified and licensed physicians and more than 15,000 physicians with some level of training. Anthroposophic medicine is provided in 24 hospitals—two of which are teaching hospitals—in five European Union member states and in Switzerland. In other regions of the world, there are approximately 500 physicians qualified in anthroposophic medicine and another 1000 with some level of training. There are more than 180 outpatient centers established around the world, and more than 7000 anthroposophic therapists in Europe and 700 in the rest of the world.⁵

Several studies have investigated the impact of the various forms of anthroposophic therapy on chronic disease. These therapies are known to provide long-term benefits with a low risk of side-effects, lower treatment cost, and improved patient quality of life (QoL).^6

–11 Nevertheless, there are very few reports about the applicability and benefits of such therapies in end-of-life care.^12

–15

The central purpose of this article is to present anthroposophic knowledge in relation to end-of-life care and the premise that the anthroposophic approach to death can be understood as a similar model to that of the modern hospice movement. Hence, parallels can be drawn between the anthroposophic paradigm applied to end-of-life care and the good-death paradigm of the hospice movement.

Anthroposophic Approach to Patients with Advanced and Terminal Illnesses

According to the anthroposophic approach, humans are on a path of spiritual evolution, wherein disease can play a central role in their terrestrial fates as part of a process of transformation and inner cures, with particular transformative power during the process of dying. In other words, disease is understood as a means of transformation and spiritual development.¹⁶ Therefore, disease, especially when it is incurable and advanced, carries the germ of something not always revealed, which is intimately bound to the ill person's life story (termed as biography). This paradigm involves the understanding that a human being in such conditions is in a seriously vulnerated existential state that demands knowledge beyond that which is essentially aimed at the relief of physical and emotional symptoms. This understanding is the root of a warm, compassionate reception that encourages a special way of viewing someone who is dying and aims to help and protect that patient on the threshold of death.

From this perspective, physical disease is viewed as an opportunity for transcendence for the patient, depending on the circumstances and the patient's openness to such transcendence.

Ultimately, the human potential to fall ill is a spiritual problem. That which begins there (in the spirit) transforms over the course of time, until reaching the organic plane. The occurrence of disease in the organic plane is not, however, only the consequence of what has occurred in the higher planes; it is also a means of dissolving and defeating, in this lower plane, something that could not be created in a higher plane. From this aspect the disease takes on another dimension; it is not just a consequence of aberrations in the life of the spirit or soul, but becomes, at the same time, an aid in the development of the spirit.¹⁷

This understanding of disease as a possibility for inner transformation is captured in the everyday accounts of professionals involved with anthroposophic practices, in which one perceives a willingness to organize actions and interventions that aim to help patients in this end-of-life passage, thus helping them on their journeys. This leitmotiv personifies a specific mode of care, with constant observation, striving to soften therapeutic interventions, and, when conditions allow, centering on the patient's biography.⁴

The anthroposophic approach is therefore aligned to other models of end-of-life intervention, with the intention of constructing a journey for facing death, offering and organizing practices that seek compassionately to relieve symptoms and receive the patient on that path, characterized by potential processes of inner transformation, a kind of “sowing” for the afterlife. This arrangement, which according to our understanding is very close to the good-death model of the modern hospice movement, requires a kind of inner engagement of the care professional. The care professional's involvement extends to the phase of bereavement, which, in a certain way, is directed not only at the people who remain living, but also the deceased, in an insoluble bond, as expressed by Steiner in these verses: “No barrier can separate what remains connected in spirit: The eternal bond of the souls, Sparkling in light, Irradiant in love; As I am in your thoughts, As you are in mine.”¹⁸

Anthroposophic Therapies in End-of-Life Care

Anthroposophic therapies include several options for approaching the health–disease dichotomy, such as the threefold view of the human being, the fourfold view of the human being, and the processes related to the seven planetary archetypes. A deeper investigation into each of these models is not possible here. However, for example, the fourfold view of the human being as a reference, one could synthetically assert that each human has¹⁹:

(1) A physical, material dimension, known as the physical body (in common with the “mineral” world)

(2) A dimension where the substances are vitalized, which is responsible for the growth, for the vitality, for the secretory processes and for the regeneration of the physical body, the body of formative forces, called the etheric body (in common with the “vegetable” world)

(3) A dimension related to excretory processes, sensations, emotion and to consciousness, and therefore to the psyche or soul, referred to as the astral body (in common with the “animal” world)

(4) A dimension related to self-awareness, which is found free in thinking, and where we perceive ourselves as individuals, described as I organization

Health would be a state of dynamic equilibrium in the interrelations among these bodies, whereas disease would be “a consequence of isolated or disintegrated processes, functions or substances in the organism,”²⁰ an expression of disharmony in the interrelation between them.

The various anthroposophic therapies with and without medication engage these four dimensions and their interrelations in order to stimulate inner forces to help patients be more actively involved in the process of illness. The proposal of interventions in these different dimensions aims to achieve harmony among them. This multidimensional approach requires multiple players acting to benefit patients. Therefore, this joint action by different professionals aims to improve patients' day-to-day lives, helping each patient to find the inner strength to actively participate in treatment and decision-making processes. This therapy also helps patients—if possible and so desired—to give meaning to their illnesses.

Biographical counseling

The meaning of a patient's illness may be discovered by focusing on that patient's biography, always in a careful manner and never invasive, imposing, or damaging. Biographical counseling can take place in individual or group meetings and consists of building up—based on a study of the 7-year cycles of the biography—the patient's life story, wherein one can visualize his or her trajectory, as well as significant events and facts. This counseling process is intended to help the patient get in touch with any repressed feelings, have deepened undeveloped experiences, give meaning to everything he or she has lived to the extent possible, and gain deeper understanding. It may also help a patient find the questions that will place him or her on the path of facing unresolved experiences or situations, which could aid in the potential resolution of such pending matters. This process of biographical work may require pastoral reception of an anthroposophic orientation or of a patient's own religious orientation, as and when requested.²¹

Use of Medications

There are several anthroposophic medications, which are developed from the mineral, vegetable, and animal world and produced in accordance with homeopathic methods or specific anthroposophic pharmacy methods. These medications may be for oral or parenteral use, especially subcutaneous administration and in the form of creams or oils. The medications can be used to manage the most prevalent symptoms, such as fatigue, cancer pain, anorexia, diarrhea, constipation, nausea and vomiting, anxiety states, sleep disturbances, and depression.³

One commonly used anthroposophic medicine, especially for oncologic diseases, is Viscum album (mistletoe), which can help reduce the pain and side-effects caused by the cytotoxicity of chemotherapy and radiotherapy, and provide benefits in the patient's QoL.^22
–24

External Treatments

Medications of anthroposophic origin may be also be used externally. These external treatments correspond to a very important part of end-of-life care. Conducted by nurses specialized in different methods developed for this purpose, external treatments include medicinal baths such as bathing in essential oils; hot or warm compresses; vegetable or mineral rubs or patches applied to specific regions (such as the hypochondria, precordium, lower back) at certain times of the day (after meals, first thing in the morning, before sleeping); foot baths; and entirely or partially wrapping the body in heated, oil-imbued strips.^25,26

It is important to point out that the role of anthroposophic nursing is central to end-of-life care. These professionals are constantly and intensively engaged in the process and are responsible for the daily care and everyday reception of the patient and near and dear people.³

Rhythmical Massage Therapy

Another external treatment is rhythmical massage therapy. This technique consists of delicate movements applied to the skin, following a pattern of suction, rather than pressure, alternated in a rhythm of contraction and expansion. The method involves gliding movements, kneading, and malaxation (a kind of gentle kneading with strong suction), as well as forming double circles and lemniscates on the skin. The intent is to improve cutaneous circulation, acting on the hydric organism (etheric body), oxygenating, and warming.²⁷

Dietary Advice

Anthroposophic dietary advice also has specific aspects in end-of-life care. The aim of these dietary recommendations is to maintain the quality of a patient's diet. This falls within an understanding that food from the mineral, vegetable, animal, and nonindustrialized spheres of life are a way of connecting the patient with the curative and regenerative forces of nature. However, the suggestions made, especially in relation to the use of whole-meal food and restrictions on food already part of the patient's everyday diet, may not always be accepted and incorporated. An individualized approach should be considered.

Art Therapy

Art therapy is another valuable and frequently used tool. Some of the most commonly used kinds of art therapy used include drawing (dynamic drawing, geometric drawing, drawing shapes, chalk or charcoal drawings, working with light and shadow); clay modeling (making platonic bodies, human figures in motion, human body parts, still life, and others); and watercolor painting. The use of each of them depends on the patient's clinical symptoms and performance status of the patient.

Even when a patient is bedridden, it might still be possible to invite the patient to paint a watercolor in soft colors, suggesting that he or she experience the rhythms of nature through the colors. Another possible use of art therapy involves the observation of certain works of art, for example, various Madonnas (Raphael's, Donatello's, Michelangelo's), Raphael's Transfiguration of Christ, or Grünewald's Isenheim Altarpiece.

Eurhythmy

Eurhythmy can be used as a therapeutic instrument in end-of-life care. Eurhythmy can be defined as the art of movement, which has as its essence the sensory and esthetic experience of phonemes through bodily representation, reproducing primordial sounds through gestures. The foundations of this, according to Steiner, are:

…that vowels express more that which lives inwardly in man as feelings, emotions and so on. Consonants describe more that which is outwardly objective. When we remain within the realm of speech, these two statements are valid: vowels, more expression, revelation of the inwardness of feeling.…And so basically all consonants are more reproductions of the outward form-nature of things.²⁸

The proposed exercises will depend on the kind of disease that the patient presents with and may be performed daily, sometimes more than once. Even when a patient is bedridden or unconscious, the eurythmic therapist can perform the exercises in front of and for that patient. Eurhythmy aims to create an atmosphere of respect, of human warmth and love, to inspire courage and hope in the patient, who often gains a semblance of serenity by the end of the exercises.

Approach in the Bereavement Phase

As well as support to bereaved people, a special aspect of the approach to bereavement in the anthroposophic framework is that the deceased patient can also be helped. One of the ways of doing this is by proposing that bereaved people bring to mind their warmest memories of the deceased, provided these people manifest interest and are open to doing. The understanding, according to Steiner, is that:

…the bridge that unites us with those who have departed cannot be built with abstract thoughts.…If we want to send the deceased pale, abstract thoughts, they will not be able to be united with us; rather we must have vivid inner thoughts of our relationships, of our conversations.…if we develop a subtle sensitivity to recall what their voice was like, their special way and feelings or how they controlled their temperament in relation to us; if we feel a vivid and warm relationship with their desires, in short, if we imagine everything very real, in such a way that it becomes an image, that is, we see ourselves with them, we recall how we sat together, or ate together, or lived together in the world.…These vivid images surpass the threshold of death.²⁹

It is also possible, in the spiritual support given to bereaved people, to offer certain prayers/meditations, which, in some way, may be useful for exploring the loss of the dear one, if and when there is an open attitude toward this. In the current author's experience, the bereaved and/or other members of the family reading one of the two verses provided below tends to be well-received, bringing an inner calmness, an experience of acceptance, despite the suffering in this phase:

Verses I

Our love accompanies you

Oh soul, that now weaves in the Spirit!

You contemplate the life of the soul

and contemplating you recognize yourself with Spirit.

And that which, in the world of souls,

through the force of thought,

is presented to you as your own being,

take it together with our love,

so that we feel in you,

and you find in our soul,

what lives with you in fidelity. ³⁰

Verses II

My love is interwoven in sacrifice

To the enclosures that now surround you

Cooling your warmth,

Warming your cool.

Taken by love

Caressed by light

Live upwards.

To spiritual fields I want to send

The loyal love we find

In order for soul to unite with soul.

You will find my thoughts loving

When the luminous fields of the Spirit

To me you will look to perceive

That which you seek in me. ³¹

Comparing Anthroposophic End-of-Life Care with the Modern Hospice Movement

End-of-life care can be categorized into three main fields of care in Western, secular society: (1) the movement that defends euthanasia and assisted suicide; (2) medical futility; (3) and the modern hospice movement. The end-of-life care model formed by the anthroposophic way of caring and dying can be understood as very close to that of the modern hospice movement. Anthroposophic end-of-life care involves the everyday practice of that which is prescribed as good care practices and both models, based on a unique esthetic and ethical experience of facing death, striving not to fight against or toward death, but rather to fight beyond death.³²

One element common to anthroposophy and the modern hospice movement is the importance of Christianity in the structuring of the ethos in which they are embedded.

The modern hospice movement relates to a Christianity that originally had a strong Anglican connotation, which, in its subsequent development, became aligned to an ecumenical Christianity, in a spirit of accepting anyone regardless of their creeds or religions.³³ For anthroposophy, it is a question of conferring to Christ and to the mystery of Golgotha a central event for the development of humankind, pervaded by curative forces to be offered to the patient with the intention of receiving patients with hospitality regardless of their beliefs and values.³⁴

Acknowledging that, in this phase of life, the patient should be treated in a comprehensive manner, in different dimensions, both the anthroposophic and the modern hospice models advocate treatments involving professionals who contribute diverse fields of knowledge and work in an integrative, harmonious fashion.

Other similarities between these two care models exist, including:

• The principle of respecting the patient's autonomy

• The understanding that there is always something that can be done to care for the patient, that is, the principle of nonabandonment

• The understanding that this daily, uninterrupted care, given in a technically competent and loving manner is fundamental to relieving symptoms and helping the patient in the process of dying

• The fact that both models can be applied in different settings, which may include, in addition to hospices and anthroposophic clinics, the possibility of being applied at home and in general hospitals

• The central role played by the nursing professional in everyday care

• The aim to achieve a process of dying with potential opportunities for inner development for all people involved

• The preparation for after death

• Reception of the bereavement phase and the belief in transcendence

To Contact Dr. Ciro Augusto Floriani

Ciro Augusto Floriani, MD, PhD

Instituto Paliar, São Paulo, Brasil

Avenida Francisco Matarazzo, 1752

Conjunto 1712, Água Branca

CEP 05001-200

São Paulo, Brasil

Phone: +55 11 5051 0555

E-mail: ciroafloriani@gmail.com

Website: www.paliar.com.br

Another shared element is that both the modern hospice movement and the anthroposophic movement neither intend to represent an alternative to the biomedical care model, nor to be fringe movements, disincarnated from the care reality. These movements are intended, rather, to bring substantial gains in the care of the patients, who are inserted into a biotechnoscientific paradigm, in a scenario identified with continuous and persistent interventions.

Anthroposophic end-of-life care practices combine and converge with those developed and perfected by the modern hospice movement. Bringing these two care models together could result in a rich experience and potential benefits to patients and their families.

Conclusion

Anthroposophic end-of-life care, through the use of its several treatments, is intended to ensure a warm, comforting reception for patients on the threshold of death, within a comprehensive, multidisciplinary model that aims to soften the process of dying and death. At the same time, this care also supports the experience of this period as one of potential transformation and inner growth.

Care professionals who work with patients with progressive, advanced, and terminal illnesses may encounter substantial elements in the anthroposophic paradigm to help these patients and their families, by learning about the anthroposophic form of care and the anthroposophic way of dying. The intention of this would be to disseminate this rich field of therapeutic elements, introducing them into everyday care and making them available to those who assist patients in this phase of their life. ■

Footnotes

Disclosure Statement

The author declares that there is no conflict of interest.

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