Initially the programme focused on the patient and provided academic challenge in the forms of the psychological concepts of the authentic person and the shadow persona, and theological exploration of the sanctity of life relating to the current euthanasia debate. Then it was the turn of our emotions to be exercised looking at dignity in death within daily clinical practice and the place of music therapy in relating to and easing suffering.

As the flow of the conference moved on we explored aspects of evidence, teamwork and overseas experience in order to ensure that we continue to extend ourselves as professionals. Gradually reaching its conclusion, gifted speakers then facilitated deep and powerful insights into using faith, healing and music in order to connect with troubled and distressed individuals. Our needs as professional carers were not forgotten and we were encouraged to find a way of meeting our own needs and creating balance in our own lives.

The sessions take place within the context of nurturing, affirmation and worship, which in itself is profoundly healing in so many ways. If you have not experienced a conference such as this please consider joining us in the near future. You will have opportunities for study, reflection and worship within a group of sustaining, like-minded people many of whom are likely to become friends. Be warned however, the catering is a delight and wearing an elasticated waistband is strongly recommended!
(Alison Morrison)

This was the first line of the beautiful Swahili Blessing that we all joined in at the end of a presentation by Music Therapist Ceridwen Rees, from Helen House Hospice. (Pauline Thompson, left, joyfully playing one of the 25 various African drums provided by Ceridwen!) Music was woven throughout the week, with Victoria Nevard also sharing sensitively chosen words enhanced by beautiful music to soothe and refresh both mind and soul. The week began with Dr Andrew Hoy, Consultant in Palliative Medicine, considering the history and future of palliative care. As it progressed we laughed and learnt from Jim Kuykendall, Bereavement Therapist & Clinical Supervisor; exercised our brains with Dr Rob George, Consultant in Palliative Medicine and expert advisor in Bioethics & Legislation; and Dr Martin Garsed, Hospice Physician, encouraged us to consider the practicalities of being part of a team. These, and other lectures, were interspersed with time to consider who we are, why we matter, and how much we matter to one another too. It was thought-provoking, encouraging, challenging and refreshing. (Marina O'Brien)

There has been nothing but welcome expressed by you for the proposed change to our strapline and the trustees have now formally adopted it. We believe it accurately reflects not only the call on The Fellowship today, but also the move of The Holy Spirit that inspired Peter Atkins and our late founder, Prue Dufour, to begin the work of The Fellowship in 1986.

When recording our history, Prue wrote: '…in 1986 the NHS formally recognised the need to provide enlightened care of the dying within palliative care and a commitment to support the voluntary hospice movement financially'.(!!!) She continues: 'It preferred a more secular expression of the principles and practice of what became known as palliative care and whilst the spiritual dimension of care was never denied, the ability of staff to recognise spiritual needs and competency to respond appropriately was never checked out.'

With a call and concern to make a contemporary contribution that would bring both inspiration and the resources of the Christian faith to those working in palliative care, St Columba's Fellowship was born.

Today, above all, we wish to sustain and refresh those working in palliative care, bringing spiritual resource and fellowship to those who are dry and weary - especially Christians who feel marginalised within their work environment. We also aim to resource those coming from a secular stance, who are well aware of the spiritual demands of their work and seek competence in this area, as well as those of other faiths who long to build bridges of understanding and co-operation.

She has recently endeavoured to balance this rather academic 'modus vivendi' by training as a Reflexologist and as a Traditional Chinese Medicine practitioner in Acupuncture. She runs a small practice - 'AcuCalm' - from home and regards this as the 'hands-on' aspect of her working life, from which she derives immense enjoyment and satisfaction.

Marianne is a committed Christian who describes herself as emotionally a Roman Catholic while theologically, being of the Reform tradition. Hardly any wonder that she feels muddled at times! She hails from a considerably ecumenical extended family which includes Anglicans, Presbyterians, Lutherans, Methodists and Christian Scientists. All grist to the mill for good debate once the core principle is understood as 'saving grace' and the journey of life as on-going relationship with the Lord! She greatly looks forward to being an active member of the Trustee group.

She greatly looks forward to being an active member of the Trustee group.

I am writing this having just returned from our Lee Abbey conference. As ever I was struck by the beauty of the surroundings and the rhythm of the day that balances times for input with times of refreshment. I was also aware of the sheer exhaustion of many of the delegates on arrival, and the huge stresses that face many who are working in Palliative care.

It is my strong belief that St Columba's Fellowship should be just that - a fellowship, there for each other and offering a support system, be it face-to-face or through emails and this Newsletter. The conferences, by providing education alongside spiritual refreshment, seem to me to be unique. I also believe we should fight the battle for conference time to be granted as study leave - they are always evaluated extremely highly which confirms the quality of speakers.

Have you booked for Scargill in November 2006? Details are elsewhere in this Newsletter - do come. And remember to hand on these details to your colleagues as well.

There seems to me to be the need to establish more local groups, who can meet together more regularly and establish friendships and support as well as having an educational content from time to time. In June we will be holding our first 'Spiritual Detox Day' for the Bedford, Herts, Bucks, and Northampton area. Other days will hopefully follow, perhaps looking at relevant topics such as suffering. If you would like to know more then contact me by email, or Lorraine Burt, who is one of our Regional Reps (chilloutsheep2003@yahoo.co.uk).

The Irish contingent continues to meet regularly and we will have the chance to catch up more with them at their Dublin conference (17 - 21 September 2007) - put it in your diary now! The education group continue to plan for future conferences at Lee Abbey (21 - 25 May 2007) and anticipate conferences at Lee Abbey in May 2008, and Scargill in November 2008.

Finally - I hope you enjoy the articles in this edition. There are two write-ups from the last Scargill conference to give you a flavour of what was said - although it can never be the same as actually sitting and listening, and interacting with each other. There are also a number of references to the euthanasia debate - if you have a view you might like to write a letter for the next edition? It would be lovely to hear more from our readers!

Jean Maxwell
jeanfmax@btinternet.com

The January meeting of St Columba's Trustees bade farewell to David & Barbara Price, and Janet Curmi.

David has been a source of spiritual support and wisdom since the Fellowship's inception and chaired the Trustees through some demanding times. David is an Anglican vicar (retired - not that you'd notice) and was Prue's friend and pastoral support as the seeds of St Columba's Fellowship took root and blossomed. As Trustees, we will miss his humour as well as his gentle challenge, and as a Conference attendee I will particularly miss his stimulating Bible studies and early-morning worship sessions. David is a man of prayer and a man of integrity whose counsel could always be relied upon to be Godly, compassionate and wise. David is always a delight to be with - particularly as he was usually accompanied by the ever-smiling Barbara who brought additional blessing to Trustee meetings in

the form of home-made cakes! It is always a special treat in life to find those people with whom one feels an immediate affinity and David and Barbara have a unique gift for making people feel as though they are family. We have been very blessed to have their company along the journey of St Columba's Fellowship so far and we are confident that their love and prayers will continue to uphold the Fellowship as, indeed, ours will continue to wish them a much-deserved, peaceful, healthy and joyful retirement.

We also, regretfully, lost the services of Janet Curmi who has been St Columba's International Co-ordinator. Janet is always recognisable at Conferences by her serene elegance and gentle smile. Even through the crisis of personal loss, Janet maintained her very genuine concern for others. It is this gift for hospitality and caring that has made her so very suited to the role of overseeing the visits of our international colleagues. Janet's warm welcome and calm organisation has been gratefully received by a succession of international guests. Hers will not be an easy position to fill - but if there are any members who feel drawn to offer hospitality to some of our international visitors and help co-ordinate their stay, then please contact Pauline Thompson, or one of the Trustees.

So, for Janet, David and Barbara we pray God's continued blessing and assure them that they will always be welcome faces at our conferences, in the hope that this is not goodbye, but au revoir. God bless, and thank you.
(Shirley Potts)

This article is based on a talk on Euthanasia, given by Susan Salt, Consultant in Palliative Medicine, to St Columba's Fellowship as part of the conference "Dying…to get it right" held in November 2005 at Scargill.

As a consultant in palliative medicine and a Reader in the Anglican Church I have been challenged by the intensity and persistence there has been in the recent calls to legalise euthanasia. I have been asking myself the question why are those calls so strong and why are we hearing them now? What follows are my responses to those questions. These result not only from my professional role but also of my recent, personal experience of my mother in law's death, in the hospice where I work, and the subsequent discussions we had as a family.

Euthanasia is an emotionally laden term that arouses strong feelings in most of us. It challenges the very essence of what we understand about the meaning of life and the

acceptability or otherwise of prematurely ending another's life. There is a confusing array of terms which both sides of the argument sometimes manipulate for their own ends. This article will discuss only voluntary euthanasia - death requested by a competent adult. Such a request for the ending of life may be achieved by the patient's own hand (using drugs prescribed for the purpose - physician assisted suicide) or at the hands of a suitably trained individual (voluntary euthanasia).

Modern Society currently appears to place personal autonomy and self-determination higher in medical ethical terms than avoiding harm (non-maleficience), doing good (beneficence) or justice. Others, notably Bishop Cray (Bishop of Maidstone), have referred to the fact that as a result of the information technology revolution we live in a multiple-choice world (1). We have access to a staggering range of choices in life; frequently we can obtain instant gratification of our wishes and have relatively little need to consider the consequences on others. Society is becoming increasingly fragmented with fewer opportunities for people to meet together with subsequent loss of social capital in terms of trust of our fellows. We can work from home, shop from the comfort of our armchairs twenty-four hours a day and communicate via video link. There is little incentive to meet others just for the sake of friendship, fellowship or getting to know others. When was the last time you had a reasonably lengthy conversation with your neighbours?

Personal autonomy and choice have become the key arbiters of moral action. Politically, particularly with respect to public services such as health and education, choice has become the all-important driver for change. What I want I will have, regardless of the consequences for others. Such personal choice means that I as an individual have to take responsibility for the subsequent outcome of the choice, whether good or bad. This makes us more fearful of uncertainty and means we have less desire or capacity to simply wait and see. Thus the request to end to a life, when time is short and no one is too sure what the future will be, becomes far more acceptable than watching and waiting. The "slippery slope" argument, about protecting the more frail and vulnerable members of society, no longer appears so relevant.

In addition the economic arguments for euthanasia are strong. Society still measures an individual's worth by their ability to be productive. With an aging population which is going to develop increasingly complex healthcare needs, foreshortening life will reduce some of the economic burden of those needs. In addition healthcare today is already struggling to meet peoples' expectations and in some areas the needs of the population. With the relative success of modern healthcare people are surviving far longer than they ever did before, but often with some residual disability or at the very least a need for close surveillance. Both general and specialist palliative care are expensive in terms of human resources (although cheap in terms of drug costs) and are not always accessible. In such circumstances euthanasia could be a sound financial alternative.

Many of my concerns about euthanasia revolve around our lack of knowledge. We know so little about the physiological changes that happen as a person dies. We know that a person dying from a chronic disease process has very different needs to a person dying from an acute event, but we do not know how they are different (2,3). We understand very little about the psychological changes at the end of life or how that affects our spirituality (4,5). Death is full of uncertainty, from the accuracy of prognosis to how we define basic and extra-ordinary medical care. The reality is that death is a mystery, which we can only examine from one vantage point, that of the living.

As a Christian I have to examine the request for euthanasia using Christian ethical principles, as well as medical ethical principles. Christian principles include the presupposition that humanity is created by God, distinct from, but in relationship with other living things. That humanity is not perfect and can only be redeemed through Christ. As a consequence of these principles man cannot be viewed in isolation but in relationship with God and His creation. However if I accept these principles then, for me, God must be the final arbiter of the timing of an individual's death, and that we should not intervene to deliberately end a life, possibly weeks or months prematurely. Having said that, it still feels uncomfortable both as a professional and as a Christian to say no to such a request, in the face of genuine suffering. An additional and significant difficulty is that medical science's capabilities are outstripping theological thinking.

In addition I am concerned about how little we know about the spiritual processes that happen as we die. What opportunities for redemption, healing and restoration they may be missed by shortening a person's life artificially? What is the redemptive nature of suffering and how is it played out in the terminal phase of our lives?

For me the arguments for euthanasia are strong and valid, but as a Christian are not acceptable. What is the reality if we curtail a person's journey to death through euthanasia? What is the nature of suffering in the process of dying and how does its redemptive qualities influence and affect the process of dying? For me it is important to battle against the medicalisation of what is a normal and natural process. For me the current strong call to legalise euthanasia comes from a false sense of certainty in the power of medicine in the face of a profound mystery - death itself.

References
1) Cray G - Mission Shaped Church. Church House Publishing 2004.
2) Ellershaw JE et al - Dehydration and the dying patient. 1995, Journal of pain and symptom management 10(3) 192-7.
3) Comfort care for the terminally ill patients - the appropriate use of nutrition and hydration. 1994, Journal of the American Medical Association (JAMA) 272(16) 1263-66.
4) Hinton J - Dying 2nd Edition 1972, London, Penguin books.
5) Cobb M - Dying Soul, 2001, Oxford University Press.

You will have seen that the latest attempt to introduce a form of legalised euthanasia into the United Kingdom - the Assisted Dying for the Terminally Ill Bill, Lord Joffe's bill - was voted against in the House of Lords. After a very full and thoughtful, emotive and sometimes passionate, debate, a motion was put to delay consideration of the bill for six months (i.e. until after the life of the present session of parliament, thus effectively killing the bill) and this was passed by 148 votes to 100 - a substantial majority, not comprised solely of the bishops! The debate is well worth reading in Hansard for 12th May.

So now what? Lord Joffe ended the debate saying that if it was voted out this time he would bring it back again and again until the matter had had proper consideration. Whether he does so or not, there will undoubtedly continue to be discussion about euthanasia in the country. There will also continue to be strong opposition from medical, nursing, religious and disabled groups, and there will be confusing public opinion polls! However, we cannot assume that the decision will always be the same.

So those of us who oppose euthanasia must:

• continue to work in our hospices and palliative care units for relief of pain and suffering, since this is still the strongest secular argument against the introduction of euthanasia;
• continue to research for more effective ways of caring for people whose pain is not yet fully relieved;
• work and teach to improve the quality of care in residential and nursing homes, hospitals and the community (at Lee Abbey some of us heard a very strong plea from carers in a rural community where people were still dying with severe pain and misery. And we can be sure that this is true also in other areas - and not only rural ones);
• use every opportunity to gently and courteously argue our case for the effective care of people with advanced illness.

Thank you for the work you all do in the care of such people. May the Lord strengthen our efforts!
(Anthony Smith)

The place of ritual in death and dying
This talk, by Stuart Milligan, Education Facilitator, Ardgowan Hospice, Greenock and Lecturer in Palliative Care, University of Paisley, was first presented at the Scargill Conference in November 2005

According to Wikipedia, a ritual is "a formalised, predetermined set of symbolic actions, generally performed in a particular environment and/or on particular occasions". Expressed more poetically, ritual is "a language of demonstration where actions of the body say more than words" (Stanworth 2004).

Ritual is particularly used to mark significant events or at times of transition. Every culture in the world has seasonal rituals, many of which have been assimilated into religious calendars (the many practices associated with Christmas and harvest being examples from the Christian tradition). These are symbolic actions which bring communities together, re-stating shared beliefs and re-establishing links between the past, the present and the future.

The different cultures also have a range of rituals associated with the major life events of birth, coming of age, courtship/marriage and death. In such cases, rituals become the signposts, and in some ways the vehicles, which help us navigate important points along life's journey.

Few of us stop to think about the function of rituals, and many of their origins are long forgotten. However, when we start to examine how we continue to use rituals, it becomes apparent that they have real purpose and value in modern society. Rituals can help us express fundamental truths or meanings, find security in times of change, and subvert "strangeness" by recalling the familiar (Stanworth 2004). Rituals can be used to explain the inexplicable and express the fundamental. They can help us to discover the sacred in the mundane, and express the profound nature (and true meaning) of events, even when they take place in ordinary surroundings.

One of the most inexplicable and unfathomable of all life events, and one which frequently takes place in ordinary and uninspiring surroundings is death itself. For many people in our modern society, death is unfamiliar and frightening. The pain of death means that we avoid taking about it, so that it becomes "a game of pretend, where the sacred rite of passage is not honoured as it could be because the players just cannot face it" (Sebastian 2004). We are unprepared for this strange, inexplicable experience, and we can find ourselves treating death as a failure of medicine rather than the profound and sacred event that it should be. Ritual offers us, and those we care for, the opportunity to see and deal with death in a different, more appropriate and ultimately more meaningful way.

Each of the major world religions (and indeed every culture and belief system) has developed rituals to explain, express and navigate death. Taking the example of Christianity, we have a range of helpful practices to draw upon: The anointing or blessing (I have heard it referred to as "the issuing of the celestial boarding pass") acknowledges the sacred journey which has already begun; the poetry of worship that we call liturgy, comfortingly familiar as we recite, perhaps for the thousandth time, words heavy with personal meaning. The simple symbols of faith - the holding cross, the votive candle - linking us with generations of others who have meditated on these same symbols, and found profound comfort, impossible to achieve with words alone. And after the death, the symbolism of the funeral, providing a familiar certainty in often never-travelled territory.

Clearly Christianity and the other religions have much to offer their adherents, in terms of comforting and meaningful death rituals. However, the reality today is that many people have weak or non-existent connections with faith communities (or, indeed, with any community at all), most deaths occur in institutional settings (detached from their community) and families are often disenfranchised with respect to the care of the dying and the remains. As a result, death and dying have become more unfamiliar and unconnected than perhaps ever before. Death is seen as a medical failure, bodies are regarded as frightening and objectionable, "rules" for what to do at the bedside and following the death are unclear, funerals are devoid of personal significance and rituals that mean anything to those involved have virtually disappeared.

In response to this vacuum, those on the professional side of caring for the dying have developed a whole range of professional rituals intended to smooth the passage, but seldom adding any significance or meaning to the journey from life into death. There is the "setting apart" when people are "sent away" to hospital or a side room when they are dying. There is the medical jargon which we use (terminal, critical, end-of-life, SUPAC, DNR etc) - a modern liturgy, heavy with meaning for the professional but alien to the dying and those being left behind. There is the chaplain's visit, with so much potential for healing and understanding, but all too often reduced to a tick on the care plan. We promise not to let the person die alone, but then fidget and fret because there is so much work we could be getting on with. We sombrely note the time of death, but do this more to ensure the death certificate is complete than to acknowledge the diminishment that we all should feel. Our last offices are carried out not to symbolically prepare the body for its last journey but to meet the health and safety standards. And our funerals, even with the best will in the world, are so "cookie-cutter", that mourners come out wondering if they have attended the right one.

Given such a set of circumstances, there seems to be a real need to rediscover meaningful ritual to help restore personal significance, meaning and explanation to many modern deaths. As already discussed, we have a strong heritage of religious rituals and one way forward might be to improve access to and participation in these rituals, particularly for people with only a tenuous connection to a faith community. Encouraging the "personalisation" of funerals is one way in which this is already being done. It might also be possible to learn from the more traditional practices which still persist in our society. In the Western Isles of Scotland for instance, community members keep watch over the dying before and after the death, the body is brought home and "visited" by neighbours and friends, and "wakes" are held to encourage rememberings and support those left behind.

In health care too, some meaningful practices still persist (although their origins have been virtually forgotten). We close the eyelids of the deceased to signify the place of rest and peace that the person has moved to; we place flowers on the pillow or locker to symbolise the transience of life and the natural cycle of birth, death and new life; we open windows to "free the spirit" - an acknowledgement that something has departed or gone to a new and better place; and we close curtains as a signal to each other, and to the community, that we are poorer for the loss of this one person.

These retained practices hint at the possible part ritual could play in our modern management of death. What is needed, and what seems to be already starting to happen, is the development of new rituals with personal meaning for and by those involved. These new rituals may have no religious basis, but will often be "fused" with traditional Christian (or other) practices to reflect the experience of life in our modern society. These include a rediscovery of the ritual of waiting with the dying, a resurgence in the use of symbols and the development of contemporary ways of remembering. Waiting with the dying is a tradition common to Christianity, Judaism, Hinduism and many other faiths, but one which had appeared to be in decline. Now, with openness and choice having replaced previously rigid hospital regimes, the public have the opportunity to reclaim the bedside of the dying as a place of connection, healing and contemplation. That contemplation might involve the use of candles and other traditionally religious symbols (angels, holding crosses etc), even in the absence of any formally recognised faith. The use of symbolism derived from nature (crystals, flowers etc) also appears to be increasing, reflecting post-modern ideas about man's relationship with the natural world, but perhaps also echoing the values of the ancient Celtic Christians. The rituals we use when disposing of the remains of the dead are being reclaimed with growing numbers of personalised funerals characterised by secular music and football or other symbolic regalia. The desire to express a symbolic connection with the natural world is also present here, with more people than ever before opting for "green" funerals. The increasing use of "roadside shrines" to mark road traffic accident and other deaths, and the development of new memorial rituals (such as "Light up a life") demonstrate that remembering the dead is also being helped by the rediscovery of ritual.

For this process of rediscovering meaningful ritual to continue, the desire of the public must be matched by a willingness on the part of professionals to engage in the process. One of the most important ways that this can be achieved is by supporting the practice of waiting with the dying. Every instinct tells the accompanying relative to escape from what is frequently an unfamiliar and painful duty. There is also the tendency to focus on the death and forget about the important time leading up to it. Professionals can support patients' families to take time to explore and experience this unfamiliar but potentially profound territory. Although not a substitute for just being, having practical duties to perform, such as mouth care and hand massage may help the accompanying person learn the waiting role. Professionals may have to be willing to let go of some of these duties (the same might apply to last offices) so that families can be more involved.

Remembering the past can help people find connections and meanings in the present, so it may be useful to encourage the accompanying person to spend some of the time talking, both with and about the dying person, perhaps using old photographs to rekindle memories. However time should also be left just to be - to share a part of that most profound of journeys in that most profound of ways - without words. Such practices allow both professional and family to connect in an intimate and profound way with the dying person. Dying is not all about us (the watchers and waiters). Our priorities will tend to be our feelings, our fears, our tasks that have to be carried out. But simply waiting with the dying can help us understand and appreciate the mysterious and sacred event of which we are privileged to be part.

Publisher Kingsway Communications Ltd. Cost £6.99
Available from May onwards in Christian bookshops,
or from www.equippingthechurch.co.uk

Anthony is the doctor who introduced me to Palliative
Medicine, and whose insights into holistic care
I value enormously.

His Christian faith shines through in all he does, and, in this book, with no compromise he demonstrates his medical expertise alongside a clear understanding of ethics. When I was sent a copy of 'Euthanasia' to review for this news letter I was going to pass it on to someone else - but then I read the first chapter, and then the next - and within an afternoon I had finished it in one sitting.

Books on ethical issues are, I find, often difficult to digest and need to be taken in small doses - hence removing the continuity and flow. Not so this book. It is written in an almost conversational style, using lots of case histories to put a scenario in the readers mind. Out of these he so easily provides the definitions we need to understand about euthanasia and assisted suicide. He leads on through a whole range or moral and ethical issues and throughout he clearly explains the dilemmas as seen by the patient, carer and professional.

One could ask who this book is written for. I suspect it is aimed at the lay person (the expression 'tummy' is used more than once - but then that is part of the conversational style.) Having said that, I believe all health professionals, clergy (and MPs!) ought to be compelled to read at least the first five chapters, whatever their level of training, just to ensure they really do understand the issues and can express them to others. If they read that far they would be certain to continue!

The book is also clearly written for Christians, and Biblical viewpoints follow. But space is given to explain the point of view of other religions, which I found most helpful.

It is an up-to-date book, although the legal points may not remain so. Reference is made to the Assisted Dying Bill which is to be debated again in the House of Lords at the same time as this book is published. One can only hope Their Lordships will quickly buy a copy and understand the implications of any change in the law, for it is clearly spelt out.

Do buy it - it is inexpensive, extremely readable, on a subject that we need to understand,
for the sake of our patients, now and in years to come.
(book review by Jean Maxwell)