When Death Becomes Us
In the spring of 2020 an elderly Jewish man from an ultra-Orthodox community was admitted to a North London hospital with a confirmed case of COVID-19 as well as mild dementia. His admission was in the early days of the pandemic and tight restrictions on hospital visitations had been put in place meaning that he was separated from his family and his community. This separation first provided a communication problem as the patient’s mother tongue was not English but Yiddish. However, what became more problematic for staff on the ward was dealing with the intense anxiety felt by his family about his separation from the rituals, observances and practices of his faith.
The patient himself was relatively compliant and did not resist treatment however the demands and anxieties of the family became ever more challenging. On a number of occasions a family member even managed to evade security and sneak into the ward by positioning themselves by the entrance to the electric door and 'tailgating' incoming staff. In an emotive phone conversation with the Consultant, the family stated they could not countenance their relative staying in the hospital and they felt it more important for him to be, perhaps to die, at home surrounded by his family with the traditional religious observances in place and the correct rituals performed. These were all keenly felt as it was coming up to Shabbat, the Jewish holy day of rest, and there was a real sense of urgency that he should be home before then.
Given this fraught situation the Consultant and the ward Sister made a difficult decision. They had concerns about releasing him for several reasons. Firstly there was a mobility issue; he was a rather large and frail man. Secondly they didn't know whether he was still COVID positive and could therefore pose a risk to family members. Weighing the strength of the family's needs against their safety and risk concerns they made their decision; they agreed to allow family members to take the patient home.
This story was told to me by a palliative care Doctor who had been the Consultant on the ward in question. I spoke to him during a series of interviews I conducted for the Woolf Institute's Diversity in End of Life Care research project. It was a story that stayed with me for a variety of reasons. Not least because of the gravity of the decision that was taken. However as a social psychologist who is interested in how religion influences behaviour, there were several things that struck me. First was the Consultant's understanding of the religious motivations underpinning the family's behaviour and his compassion towards their distress. For some, the desire to remove the patient from medical care because of religious preferences may seem baffling, if not downright dangerous. So this nuanced understanding was extremely refreshing to me given that I am often asked to explain why religion motivates 'irrational' or extreme behaviour. Yet the Consultant recognised why the removal of the patient from his religious community was so troubling for the family: he was extradited from his moral framework and therefore neither him nor his family were able to receive the comfort and security that is provided by communal religious rituals surrounding death (Jonas & Fischer, 2006).
Second was that this story seems to me to speak to a body of research that examines the role of religious belief and ritual on anxiety reduction, particularly in times of uncertainty (Hobson et al., 2018; Lang et al., 2015; Lang, Kratky & Xygalatas, 2020). Laboratory studies have found that individuals are more likely to exhibit ritualised behaviours when talking about anxiety-inducing scenarios (Keinan, 2002). And we see this play out in the real world. Episodes of war for example increase the prevalence of protective rituals (Keinan, 1994) as does religious observance (Henrich et al., 2019). Societies that live with the very real threat of earthquakes have higher religious attendance (Bentzen, 2019). And it is not just an individual who is the focus of a ritual that experiences emotional consequences simply observing a loved one perform an intense ritual causes emotional and physiological changes (Fischer et al, 2014).
In close-knit communities such as orthodox Jewish community that the patient belonged to, ritual is not only at the centre of life but of death. These are communities that know and embrace death collectively and over thousands of years have developed complex social observances surrounding the handling of the dead and dying. These are, in a way, communal activities so when recourse to these millennia old rituals is removed, it allows for intense feelings of anxiety and existential threat. This is because, as outlined above, ritual can mitigate anxiety surrounding death but also partly because of another proposed function of ritual, which is to act as a type of social glue (Fischer et al., 2013; Xygalatas et al., 2013). In the absence of this cohesive function I would suggest that not only do tight-knit communities feel heightened levels of anxiety surrounding death but also uncertainty surrounding their very existence. This is perhaps one reason why it matters to people so much, the entire identity of a community is forged and maintained by their rituals. With these gone, the community itself ceases to exist. Jonathan Boyd, Executive Director of the Institution for Jewish Policy Research, echoed this notion and described how preventing the activities and habits so important to Jewish life was 'shaking the Jewish community to its core' (Boyd, 2020, p.1).
Lastly the story also stayed with me because it highlights the ever growing interaction between end of life care and religious diversity. The rapid increase in religious and cultural diversity in the UK over recent decades has meant that palliative care now regularly encounters patients from an array of religious backgrounds with a variety of religious and spiritual needs. This rapid increase in diversity has posed several challenges to palliative care (Jansky, Owusu-Boakye & Nauck, 2019) and coping with these is one of the major challenges facing the field (Six, Bilsen & Deschepper, 2020). This story, I think, illustrates the way that during 2019 many of these challenges were brought into sharp focus. For thousands of religious patients and their families in the UK, the existential securities and psychological comfort that their religious traditions and practices afforded them surrounding end of life, were gone almost overnight. The story outlined in this article for example is by no means an isolated case.
In 2019, the Woolf Institute published 'Diversity in End of Life Care: A handbook for caring for Jewish, Christian and Muslim patients' to help facilitate this type of interaction between end of life care and religious diversity. Dealing with patients' existential threat is hugely complex at the best of times particularly when the patient and their families have a set of beliefs surrounding death that are rooted in a religious framework that might not be familiar to the care giver. Our hope is that the Diversity in End of Care handbook provides a starting point for end of life staff and volunteers who wish to provide better support to patients and families of Jewish, Christian and Muslim backgrounds in the period leading up to and surrounding death.
Dr Katherine O'Lone is Research Fellow at the Woolf Institute.
Thanks to the support of the James Tudor Foundation, we are currently offering an online training session to explore how the spiritual and religious aspects of end of life care have been affected by the pandemic. Contact firstname.lastname@example.org if you and your team would like further information.
 The North London hospital in question is located in an extremely diverse borough and is the home to a large (and heterogeneous) Jewish population, with a concentration of Orthodox and ultra-Orthodox communities.
 For example they were extremely concerned about him not receiving kosher food and being touched by female members of staff.
 At that stage COVID testing wasn't as frequent and was not available freely outside in the community
 'Irrational' from a secular viewpoint where religion is often seen as something rather curious, or for more extreme secularists, something damaging (Dawkins, 2006; Hitchens, 2007).
 Shmira for example is the Jewish custom of remaining with and guarding the body from the moment of death until burial. During this time a family member, or member of the Jewish sacred burial society (Chevra Kaddisha), remains with the corpse and recites psalms.
Bentzen, J. S. (2019). Acts of God? Religiosity and natural disasters across subnational world districts. The Economic Journal, 129, 2295-2321.
Boyd, J. (2020). The Importance of Community in the Coronavirus Epidemic. Institute for Jewish Policy Research. Available at: https://jpr.org.uk/documents/JB.Community.March_2020.pdf
Dawkins, R. (2016). The god delusion. Black Swan.
Fischer, R., Callander, R., Reddish, P., & Bulbulia, J. (2013). How do rituals affect cooperation? Human Nature, 24, 115–125.
Fischer, R., Xygalatas, D., Mitkidis, P., Reddish, P., Tok, P., Konvalinka, I., & Bulbulia, J. (2014). The Fire-Walker's High: Affect and Physiological Responses in an Extreme Collective Ritual. Plos ONE, 9(2), e88355.
Henrich, J., Bauer, M., Cassar, A., Chytilová, J., & Purzycki, B. (2019). War increases religiosity. Nature Human Behavior, 3, 129-135.
Hitchens, C. (2007). God is not great: How religion poisons everything. Toronto: McClelland & Stewart.
Jansky, M., Owusu-Boakye, S., & Nauck, F. (2019). "An odyssey without receiving proper care" - experts' views on palliative care provision for patients with migration background in Germany. BMC Palliative Care 18(8).
Jonas, E., & Fischer, P. (2006). Terror management and religion: evidence that intrinsic religiousness mitigates worldview defense following mortality salience. Journal of Personality and Social Psychology 91(3), 553-67.
Hobson, N., Risen, J., & Inzlicht, M. (2017). The Psychology of Rituals: An Integrative Review and Process-Based Framework. SSRN Electronic Journal. doi: 10.2139/ssrn.2944235.
Keinan, G. (1994) Effects of stress and tolerance of ambiguity on magical thinking. Journal of Personalist and Social Psychology, 67(1), 48-55.
Keinan, G. (2002). The effects of stress and desire for control on superstitious behavior. Personality and Social Psychology Bulletin, 28(1), 102-108.
Lang, M., Krátký, J., & Xygalatas, D. (2020). The role of ritual behaviour in anxiety reduction: an investigation of Marathi religious practices in Mauritius. Philosophical Transactions Of The Royal Society B: Biological Sciences, 375(1805), 20190431.
Lang, M., Krátký, J., Shaver, J., Jerotijević, D., & Xygalatas, D. (2015). Effects of Anxiety on Spontaneous Ritualized Behavior. Current Biology, 25(14), 1892-1897.
Six. S., Bilsen, J., & Deschepper, R. (2020). Dealing with cultural diversity in palliative care. BMJ Supportive & Palliative Care, bmjspcare-2020-002511.
Xygalatas, D., Mitkidis, P., Fischer, R., Reddish, P., Skewes, J., et al. (2013) Extreme rituals promote prosociality. Psychological Science, 24, 1602–1605.
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