Spiritual Anger and Forgiveness in Hospice Family Care

Author: Case Western Reserve University
Published: 18 Feb 2013 - Updated: 20 Sep 2026
Publication Details: Peer-Reviewed | Research, Study, Analysis

Table of Contents:
Synopsis - Definition - Overview - FAQs - Insights, Updates - Related Content

Synopsis

This article explores the delicate interplay between faith, family dynamics, and end-of-life care, offering a thoughtful look at how spiritual beliefs can shape the experience of terminal illness. Drawing from research and real-world insights, it highlights the emotional struggles families face, such as anger toward a higher power or the need for forgiveness, while showing how palliative care can provide comfort beyond just physical symptoms. It's a valuable read for anyone navigating the challenges of serious illness - especially seniors or those with disabilities - since it sheds light on the often-overlooked spiritual and relational aspects of dying, making it a helpful guide for patients, caregivers, and loved ones seeking understanding and peace during tough times.*

At a Glance

• 1 - Prayer ranked as the most preferred coping strategy, while self-help resources and therapies drew the least interest.
• 2 - Resentment ran strongest among relatives of cancer patients and weakest among relatives of people with heart disease.
• 3 - Researchers surveyed 147 family members caring for a hospice patient at home through Hospice of the Western Reserve in Cleveland.
• 4 - Family members who reported being less religious or spiritual expressed more anger toward God, as did those who saw no deeper meaning in the suffering.

Topic Definition

Spiritual Distress in End-of-Life Care

Spiritual distress in end-of-life care describes the crisis of meaning, faith, and relationship that surfaces when a person is dying or when a family member is watching someone die. It can show up as anger toward God or a higher power, guilt over past mistakes, a sense of abandonment, or the urgent need to seek or grant forgiveness before time runs out. Unlike physical pain, it does not respond to medication, and it is often hardest on those who cannot find any deeper purpose in what their loved one is enduring. Clinicians treat it as a genuine dimension of suffering alongside pain, breathlessness, and fatigue, because unresolved spiritual struggle is associated with higher levels of depressive symptoms and complicated grief. Support usually comes through chaplaincy, prayer, sacred reading, honest conversation with family or the hospice team, and simply being given permission to voice feelings that many people believe they are not supposed to have.

Overview

Family Tensions and Spiritual Turmoil in End-of-Life Care

CWRU study examines family struggles with anger and forgiveness when relative is dying - Watching a loved one die tests some family members relationships with God or the higher being of one&'s faith. And the spiritual anger and resentment grow with the level of pain and suffering their family member endures, according to researchers at Case Western Reserve University.

Psychologist Julie Exline and palliative care advanced practice nurse Maryjo Prince-Paul surveyed 147 family members with a hospice patient under home care.

More than four of every 10 respondents reported at least some level of anger with God, a major source of which was watching a loved one suffering great pain. Resentment was strongest among family members of cancer patients and weakest among family members of heart disease patients.

A family member's level of spirituality was also a factor.

The less religious or spiritual family members said they were, the more anger they reported toward God. Family members also reported more anger toward God if they could not see any deeper meaning in the suffering that the patient and family were experiencing.

Exline, associate professor of psychological sciences in the College of Arts and Sciences, and Maryjo Prince-Paul, assistant professor at the Frances Payne Bolton School of Nursing at Case Western Reserve and research scientist at Hospice of the Western Reserve, published their findings in the current Journal of Palliative Medicine article, "The Spiritual Struggle of Anger Toward God: A Study with Family Members of Hospice Patients."

A related study by the researchers in a recent Journal of Palliative Medicine article (volume 15, issue 10, 2012), "Forgiveness, Depressive Symptoms, and Communication at the End of Life: A Study with Family Members of Hospice Patients," explored the importance of forgiveness-related communications between hospice patients and family members. Many family members reported that they saw seeking and granting forgiveness as very important in their relationships with loved ones who were dying.

The forgiveness study showed that if family members saw forgiveness issues as important but had not completed the process, these unresolved conflicts were linked with greater depressive symptoms. Building on these findings, the new study showed that anger toward God was also linked with higher levels of depressive symptoms among family members.

Respondents in the new study were asked about which coping strategies they would prefer if they were feeling angry toward God.

The most popular strategy was prayer. Other common strategies included reading sacred texts, handling feelings on their own and discussions with friends, family, clergy or hospice team members. Self-help resources and therapies were less popular, respondents said.

Exline concludes that finding ways to overcome anger with God - and being able to seek and grant forgiveness in relationships with family members - can be important for both families and patients in the dying process.

"People have difficulties when they struggle to find meaning in their lives during stressful events," explains Exline. "If people feel guilty about mistakes they have made, or if they feel alienated from God or a family member, these issues can make it more difficult for them to cope." Such issues may loom especially large in end-of-life contexts, when repair of close relationships can take on great importance.

In the forgiveness study, family members wrote about the significance of expressing love and gratitude, but also felt that clearing up unresolved issues was important before the patient died.

These two articles continue Exline's research on the many anger-related issues that people can experience when they are facing stressful life events. The research also adds to understanding of the many emotional, social and spiritual strains faced by family members of dying patients.

About the Study

Staff of the Hospice of the Western Reserve in Cleveland were instrumental in conducting the study and also contributing to the article. The Fetzer Institute funded the research.

Frequently Asked Questions

NOTE: Researched FAQs by Disabled World (DW)

What is spiritual care in a hospice setting

Spiritual care is support for a patient or family member dealing with questions of meaning, faith, guilt, or reconciliation. It is usually offered by a chaplain or trained member of the hospice team and is available whether or not the person follows a religion.

Is it normal to feel angry at God when someone is dying

Yes. Anger toward God or a higher power is a common reaction to watching someone suffer, and clinicians regard it as an understandable response rather than a moral failing. Naming the feeling openly is generally more helpful than suppressing it.

Can a person receive hospice care without holding religious beliefs

Yes. Hospice services are offered regardless of belief, and spiritual support is optional. Nonreligious patients and families can accept practical and emotional care while declining any faith-based element.

How do I start a forgiveness conversation with a dying relative

Choose a quiet moment when the person is alert and not in heavy pain, keep the opening simple, and say what you feel rather than rehearsing old arguments. A hospice social worker or chaplain can sit in or help you prepare if the conversation feels too difficult to begin alone.

What is the difference between palliative care and hospice care

Palliative care focuses on comfort and quality of life and can be given at any stage of a serious illness, including alongside treatment aimed at a cure. Hospice is a form of palliative care for people expected to be in the final months of life, when curative treatment has stopped.

Does a hospice chaplain try to convert people

No. A hospice chaplain is trained to support the beliefs a person already holds, or their absence of belief, and to listen without pushing a religious position. Families can ask for a chaplain of a particular faith or decline chaplain visits entirely.

What support exists for family caregivers after the patient dies

Most hospice programs offer bereavement support for at least a year after a death, including counseling, support groups, and phone check-ins. This is typically included at no extra cost to the family.

How can a disabled person record their wishes for spiritual care in advance

Wishes about faith practices, chaplain visits, rituals, and who should be present can be written into an advance directive or a supplementary care plan and shared with the care team. Accessible formats and a named supporter can be requested so the document is understood and followed.

Insights, Analysis, and Developments

Editorial Note: Understanding the spiritual and emotional turmoil faced by families during a loved one's terminal illness is crucial. This research underscores the need for open dialogues about anger and forgiveness, enabling both patients and their families to find peace and closure during such challenging times. When someone's nearing the end, it's not just about managing pain or ticking medical boxes - it's about the messy, human stuff: faith wavering, old grudges surfacing, or a quiet hope holding things together. This piece reminds us that palliative care isn't only a science; it's an art that honors the whole person, spirit and all. For families, especially those supporting someone with a disability or in their later years, it's a nudge to lean into those tough conversations. Death doesn't wait for us to get comfortable, but a little clarity on the spiritual side might just ease the weight - for everyone involved.*

Attribution/Source(s): This peer reviewed publication was selected for publishing by the editors of Disabled World (DW) due to its relevance to the disability community. Originally authored by Case Western Reserve University and published on 18 Feb 2013, this content may have been edited for style, clarity, or brevity.

* Editorial additions by Ian C. Langtree.