Exploring the hidden before the end: A phenomenological analysis of forgiveness at the end of life among spiritual caregivers

Abstract

Background:

While forgiveness is linked to emotional and physical benefits at the end of life, little is known about how it is understood or addressed by palliative care professionals. Spiritual caregivers, especially in the Netherlands where formal training is growing, may be well-placed to support such conversations, yet their experiences remain underexplored.

Aim:

To explore how Dutch spiritual caregivers perceive and engage with forgiveness at the end of life, including their potential role in facilitating it.

Design:

This qualitative study used interpretative phenomenological analysis. In-person, semi-structured interviews were analyzed through reflexive thematic analysis.

Setting/Participants:

Eleven interviews were conducted with spiritual caregivers from various hospitals across the Netherlands. Interviews took place in hospitals (n = 6), caregivers’ homes (n = 2), via Zoom (n = 2), and by phone (n = 1). Due to conceptual differences related to religious and existential backgrounds, nine interviews were finally selected, focusing on the Christian (Catholic n = 4, Protestant n = 4) and non-affiliated (n = 1) ones.

Results:

Four main themes emerged: (1) concept of forgiveness according to spiritual caregivers; (2) forgiveness as a theme in the conversation between spiritual caregivers and patients, (3) barriers to talking about forgiveness, and (4) the role of spiritual caregivers in addressing forgiveness.

Conclusion:

Spiritual caregivers acknowledged forgiveness as beneficial but noted challenges—logistical, cultural, and personal—that make direct conversations difficult. As a result, they often adopt a subtle, indirect approach, using rituals and attentive listening to address forgiveness with patients nearing the end of life.

What is already known on this topic?

• Research has associated forgiveness with physical, emotional and spiritual benefits in people facing the end of life.

• Health professionals often feel unprepared to talk about forgiveness with their patients.

• The role that the spiritual caregiver plays with respect to forgiveness as a need of the patient is not clear.

What this paper adds?

• By offering in-depth, qualitative insights from experienced spiritual caregivers, this paper provides data of how spiritual caregivers perceive and address forgiveness as a theme at the end-of-life in the context of severe illness.

• The study identifies barriers experienced by spiritual caregivers to talking about forgiveness, and proposes resources to address them.

Implications for practice, theory or policy

• Forgiveness in palliative care should be explored and offered as a possible path toward peace within a person-centered and autonomy-respecting framework, acknowledging that not all patients wish or are ready to forgive.

• Spiritual caregivers need protected time and supportive conditions for spiritual conversations with patients, ensuring follow-up across care transitions when possible, and clear role boundaries distinguishing them from clergy when engaging in forgiveness conversations.

• Future research should include multi-faith perspectives, use diverse designs across different care settings (hospital, hospice, primary care), and integrate patients’ and families’ experiences to deepen understanding of forgiveness in palliative care.

Introduction

When people face serious illness, such as advanced cancer or heart disease, they are often confronted with deep questions about life’s meaning, identity, and purpose.^1,2 This search for meaning can uncover past conflicts and awaken a need for forgiveness. Forgiving others or oneself can provide peace and improve spiritual well-being at the end of life. ³ However, forgiveness is often misunderstood, confused with excusing, forgetting, or reconciling, which can limit its healing potential.^4–6 True forgiveness involves a voluntary choice to release resentment and respond with compassion. ⁴

Although forgiveness is frequently reported as a key concern for the dying, its role is not fully understood in palliative care. According to recent publications, the vast majority of seriously ill patients spoke about forgiveness or reconciliation when reflecting on their situation.^7,8 Forgiveness is also linked to greater peace, dignity, and quality of life.^9–13 Nevertheless, many health professionals report feeling unprepared to address forgiveness, ¹⁴ and conversations must be carefully adapted to each person’s cultural, religious, and existential context. ¹⁵

Spiritual caregivers often have privileged access to patients’ inner worlds. Their role is to guide spiritual reflection, validate emotions, and help patients find peace. ¹⁶ They typically hold advanced degrees in counseling, psychology, or theology and are trained to provide spiritual and emotional support across diverse healthcare settings.^17,18 Their role is distinct from that of priests, who are ordained representatives of specific faith traditions whose pastoral role may extend into healthcare when patients or families request religious rites or sacramental ministry. Depending on institutional policies, priests may function as chaplains, collaborate with spiritual caregivers, or provide support through their own faith communities. ¹⁹ Chaplains represent another figure in spiritual care: they are ordained clergy or certified spiritual caregivers who work in institutional contexts—such as hospitals or the military—offering pastoral care, religious services, and spiritual support, often after completing accredited Clinical Pastoral Education (CPE) programs. ¹⁹ In the Netherlands, spirituality is increasingly included in healthcare, with spiritual caregivers being recognized as professionals—either denominational (linked to a faith community) or non-denominational—trained to provide spiritual, existential, and ethical support to patients and families of any or no faith background, ²⁰ and working alongside medical teams.^20–23

Despite the growing integration of spiritual care in palliative care settings^14,24 and the formal recognition of spiritual caregivers as members of multidisciplinary teams, little is known about how spiritual caregivers experience and manage forgiveness conversations. This qualitative study therefore explores how nine Dutch spiritual caregivers working in palliative care with hospitalized patients understand forgiveness as an end-of-life issue, and how they perceive their role in addressing it.

Methods

Design

A qualitative study using a phenomenological approach with open coding a posteriori was used. ²⁵

Setting

Data for this study were collected from spiritual caregivers working with hospitalized patients receiving palliative care in the Netherlands—there were six hospitals involved.

Population

Inclusion criteria comprised: spiritual caregivers working in palliative care services in the Netherlands, being able to speak English and having at least a minimum of 5 years of experience in spiritual care in the context of end of life.

Sampling

Purposive sampling was used to recruit participants and to ensure deep understanding from experienced individuals. Participants were sampled by age and sex to ensure maximum variation.

Recruitment

There was no relationship established between the researcher conducting the interviews (CR) and participants before study commencement or recruitment. Eighteen spiritual caregivers were provided by one of the researchers (MSR) and first contacted by email (HvL) asking for their participation in the study. Three of them refused to participate; one of them was retired, another participant was finishing up her studies in spiritual counseling, and the third participant considered he had not had enough contact with patients to talk about this topic. Four spiritual caregivers didn’t respond to the first contact. Thirteen spiritual caregivers were interested and were contacted by the interviewer (CR). However, two of them preferred not to participate (one of them was retired and the other one thought his/her collaboration would be of no use), leaving 11 the total of the conducted interviews. All interested participants were provided with an information sheet and consent form (Supplemental File) detailing the purpose of the research—those who expressed an interest and gave their informed written consent were enrolled in the study.

Data collection

In-depth semi-structured interviews were held between June-August 2022 and conducted by the same researcher within the team (CR, female pre-doctoral researcher at that time and psychologist with experience in the research area of forgiveness). All of the interviews except three took place in-person, with all participants offered the choice of a preferred location (for instance, at home or in the hospital) and preferred format of interview (physically or online). The semi-structured interview topic guide (Supplemental File) was developed based on one pilot interview and covered key issues already identified in the existing literature. The themes of questions within the topic guide remained the same across all interviews. In order to address face validity, the interview was reviewed by the authors HvL, NvP, IC, experts in palliative care research and survey development. The consolidated criteria for reporting qualitative research checklist (COREQ) was followed for this work (Supplemental File). Interviews were undertaken across a range of settings, spanning: hospitals (n = 6), spiritual caregivers’ own homes (n = 2), by Zoom (n = 2) and by telephone (n = 1). The interviews varied between 30 and 40 min and were audio recorded and transcribed verbatim by the interviewer (CR) using Microsoft Word. All audio files were encrypted and uploaded to a secure data-storage platform provided by Amsterdam UMC, which complies with the General Data Protection Regulation (GDPR) and institutional data-protection policies. Interview data were coded at the point of transcription, and only the principal researcher had access to the encrypted files. Participants did not provide comments on the transcripts nor feedback on the results.

Data analysis

The transcripts were imported into MaxQDA 2020 ²⁵ software to facilitate data analysis. Following a reflexive thematic analysis approach, as defined by Braun and Clarke, ²⁶ CR conducted the primary coding. To enhance interpretative depth and cultural-linguistic accuracy, a second researcher (NvP), a native Dutch speaker and experienced qualitative and palliative care researcher, independently reviewed a subset of transcripts, coding notes, and emerging themes. Contextual understanding was also enhanced by a third researcher (MSR), also a native Dutch speaker focused on empirical studies of experiences of contingency in everyday life. Coding decisions and theme development were discussed in regular team meetings (CR, NvP, HvL, MSR), allowing reflexive engagement and refinement of the analytic framework. The process started with a closed and detailed reading of the transcripts and notes taken during the interviews, which enabled CR familiarization with the data. Initial descriptive codes were identified in a systematic manner across the data sets. The initial inductive coding generated 30 codes across the dataset. Through iterative comparison, refinement, and team discussion, these were organized into 19 sub-themes, which were then synthesized into four overarching themes that structure the Results section. The research team were in agreement that data sufficiency occurred after nine semi-structured interviews, having previously excluded two of the interviews due to their divergence in the concept of forgiveness (see Results). Throughout the reflexive thematic analysis, we actively attended to diversity within the data. Following Braun and Clarke’s guidance on reflexive thematic analysis, we examined not only shared patterns of meaning but also deviant or contradictory cases that diverged from the majority perspective. All interviews were coded inductively, and both prominent and less frequently occurring codes were compared across participants to identify nuances and tensions within the dataset. Diverse or minor codes were not excluded a priori; rather, they informed theme refinement by helping to define the boundaries and internal complexity of each theme. Some highly idiosyncratic cases—such as participants who held very conditional views of forgiveness or those who explicitly rejected forgiveness as a relevant end-of-life issue—were retained within themes when they deepened conceptual understanding, and described as variations within the findings. Cases that fell outside the scope of the research question (e.g. unrelated existential themes) were coded but not developed into themes. This approach ensured that the thematic structure reflected both dominant and divergent perspectives while remaining coherent and analytically meaningful.

Ethical approvals

As the Medical Research Involving Human Subjects Act was not applicable (reference number: W22_062 #22.094), the study was exempted from ethical approval by the Medical Ethics Review Committee of the Amsterdam University Academic Medical Centres.

Results

Participant characteristics

Of the 11 interviews, two of them generated results on the similarities and differences regarding the significance of forgiveness toward the end of life in reference to the interviewees’ backgrounds (Muslim and Humanistic) compared to the other spiritual caregivers with a Christian background. This deserves a follow-up, comparative study. Thus, for the present study it was decided to make the sample consistent with accounts of spiritual caregivers who have a Christian religious background and non-affiliated spiritual caregivers. That left a total sample of nine participants, whose characteristics are displayed in Table 1.

Table 1.

Baseline characteristics of the participating spiritual caregivers.

Variables	Interviewed participants
Gender and age, mean (± SD), n
Males	53.75 (± 12.42), n = 4
Females	60.8 (± 3.9), n = 5
Males and females	57.67(± 8.9), n = 9
Country of origin, n (%)
The Netherlands	8 (88.9%)
Belgium	1 (11.1%)
Civil status, n (%)
Married	6 (66.7%)
Partner	1 (11.1%)
Divorced	1 (11.1%)
Single	1 (11.1%)
Years of working experience, n (%)
1–5 years	1 (11.1%)
5–10 years	1 (11.1%)
10–15 years	4 (44.4%)
15–20 years	2 (22.2%)
20–25 years	-
25–30 years	1 (11.1%)
Christian faith, n (%)
Catholic	4 (44.4%)
Protestant	4 (44.4%)
Non-affiliated	1 (11.1%)

From the interview data, four overarching themes were developed (Table 2): (1) concept of forgiveness according to spiritual caregivers; (2) forgiveness as a theme in the conversation between spiritual caregivers and patients, (3) barriers to talking about forgiveness, and (4) the role of spiritual caregivers in addressing forgiveness. The concept of forgiveness relates to the definitions and views shared by the participants about forgiveness. The second theme gathers their opinion about forgiveness as a topic of conversation at the end of life. The third theme highlights the barriers and contextual factors that complicate discussing forgiveness with patients at the end of life. The fourth theme exposes how spiritual caregivers lead a conversation about forgiveness.

Table 2.

Results summarizing the four overarching themes.

No.	Themes	Subthemes
1	Concept of forgiveness according to spiritual caregivers	• Definitions of forgiveness: changing the perspective of someone or a situation; accepting and letting go of negative feelings, such as guilt; a gift which brings mercy. What forgiveness is not: exoneration, reconciliation. • Types and directions of forgiveness: self-forgiveness, forgiveness of others, spiritual forgiveness. To forgive or to ask for forgiveness. • Conditions: face-to-face encounter, expressed out loud genuinely, acts of contrition, reflection and consciousness of the wrong done, not minimizing negative feelings, not being lightly taken, time and space, severity and effect of the offense, it cannot be forced.
2	Forgiveness as a theme in the conversation between spiritual caregiver and patient	• Important and beneficial for patients’ well-being: peace, well-being, positive impact, relief, death acceptance • Hidden and indirect topic • Guilt and self-forgiveness • Rituals as a channel for forgiveness • Forgiveness and life review • A challenge for spiritual caregivers
3	Barriers to talking about forgiveness	• Logistic: ○ The hospital as a setting: few and short visits • Practical: ○ Patients’ health condition in hospital: crisis, pain, disease. . . • Sociocultural: ○ Dutch cultural aspects ○ The sensitivity of the subject of forgiveness and family conflicts ○ Influence of religious background • Personal: ○ Caution and scruples of spiritual caregivers
4	The role of spiritual caregivers in addressing forgiveness	Objectives: what spiritual caregivers aim to achieve when discussing forgiveness • Asking questions to make the patient reflect • Helping to change perspective: moving to a wider and more compassionate vision • Encouraging and giving hope Conditions: attitudes spiritual caregivers consider important when discussing forgiveness • Non-directive intervention • Listening with empathy: spiritual caregivers as space holders Media: ways spiritual caregivers use to facilitate forgiveness • Offering rituals, prayer and sacraments: • Spiritual caregivers’ role strengths and role constraints

Theme 1: Concept of forgiveness according to spiritual caregivers

Spiritual caregivers were asked to describe forgiveness. Each of them offered their own perspective of what forgiveness was and highlighted different aspects of the concept. Some defined forgiveness positively (defining what it is), and others defined it negatively (saying what it is not, or what it differs from, e.g. exoneration and reconciliation).

Definitions of forgiveness and what forgiveness is not

In narrating their experiences, several participants portrayed forgiveness as an inner exercise that involves a fundamental change in perception toward the person or situation that caused harm, rather than as a single act or decision. For them, forgiving means broadening one’s view; as SC2 put it, “Forgiveness is the ability to let go of your own truth and to look at it from another side. . . to move in your views” (SC2). This process of shifting perspective was often associated with emotional release—particularly the liberation from guilt, resentment, or self-punishment—with two spiritual caregivers summarizing this dimension by saying, “Forgiveness, for me personally, is not being punished anymore for what you have done” (SC3), and, “You accept the wound, but no longer you lay (carry) the. . . charge? ( . . . ) That he’s (the offender) free from guilt” (SC8).

Forgiveness was also described as a form of grace, something that cannot always be achieved through human effort alone but may arrive unexpectedly as a gift that carries a sense of mercy and peace: “I think that, to forgive this person, was given to me. Was given to me that I could forgive him” (SC9). In such moments, forgiveness was experienced as a sacred event, what one caregiver movingly called “I would describe it as a really holy moment at the farewell situation” (SC7). At the same time, not all participants felt comfortable with the term “forgiveness,” given its religious connotations; a few preferred the term exoneration to emphasize a more neutral process of understanding and reframing, one that does not necessarily assign the roles of victim and offender. Others underlined that forgiveness and reconciliation are not synonymous and stressed that forgiveness may occur internally and precede reconciliation, which depends on mutual readiness: “It’s not about reconciliation, that’s not the issue—it is before the telling” (SC1); “reconciliation is also a step further, and you find a way to live in a new way with the other” (SC8).

Still, spiritual caregivers observed that patients nearing the end of life seldom asked explicitly for forgiveness; instead, they tended to seek reconciliation indirectly, for instance by saying, “Can we have some time for reconciliation?” or simply “Can we say to each other: it was ok?” (SC7). In these interactions, reconciliation often appeared more tangible and attainable than forgiveness itself, providing a concrete relational space in which patients and their loved ones could renegotiate meaning at the end of life.

Types and directions of forgiveness

In talking about forgiveness, participants did not refer to it as a single, uniform experience but rather described it as a multidimensional process. For instance, SC6 differentiated between “self-forgiveness: to forgive yourself, the things of how were things of life, how has been to you”, forgiveness directed toward others, described as “forgiveness in relationship to others, in your family, and maybe also in your work, neighbors. . .,” and a broader, more transcendent form of spiritual forgiveness, extending “to society, humanity, mankind, God'', “that goes further than the immediate relationship in which I’ve lived” (SC6). This threefold distinction illustrates how participants situated forgiveness simultaneously at the personal, interpersonal, and spiritual levels, weaving together everyday relationships and wider existential or spiritual concerns. SC8 highlighted the interconnection between transcendence and forgiveness in order to be able to truly forgive: “to come to forgiveness, and. . . to accept that transcendental power you have eh. . . you must have an openness, openness to it, and I think most people are very closed. . ..”

Others emphasized that the act of forgiving and the act of asking for forgiveness are not interchangeable. This distinction highlights the relational complexity and emotional asymmetry often present in end-of-life situations, “well it depends if you ask for it or if you, yeah. . . forgive”, “I think also asking forgiveness in this manner, is different from people asking one another forgiveness for something that they both did” (SC5).

Conditions of forgiveness

Spiritual caregivers identified several conditions that, in their experience, were necessary to facilitate authentic forgiveness. They emphasized that forgiveness is grounded in genuine, personal encounter, in which the other person’s remorse is perceived directly rather than at a distance: “( . . . ) to see the remorse. Not only the words or a letter, but, yeah, you need, I think you need to be able to see someone’s eyes.” (SC3). Saying it out loud and the presence of contrition and a concrete intention to repair harm was also seen as essential, as two spiritual caregivers explained: “I think expressing forgiveness makes it stronger. (SC8), and, “( . . . ) for me, forgiveness is hard to believe that I forgive someone who doesn’t, doesn’t. . . turn. Turn around to, to eh, to make his apologies.” (SC7)

Several participants further highlighted self-awareness and reflection as prerequisites for forgiveness; recognizing one’s own wrongdoing and accepting its impact were described as necessary steps before forgiveness could be offered or requested: “First of all there is the realization ( . . . ) that you hurt somebody, ( . . . ) and an acceptance it was something that is not just going away ( . . . ), that you’ve done something that you should not have, but you did!“ (SC5). Rather than bypassing or suppressing negative emotions, participants cautioned against minimizing pain, insisting that it must be acknowledged: “Not to push away bad feelings! ( . . . ) Not to make it smaller. I think ( . . . ) this is what’s hurting ( . . . )” (SC7). Concurrently, they stressed that forgiveness should not be treated lightly or assumed to be universally possible, as there may be situations that, in their view, cannot be forgiven: “I think you don’t always have to forgive, you cannot, you can’t, you can’t, sometimes things were too bad” (SC5). The timing and readiness of the individual were also described as crucial, since forgiveness was understood as a profound inner process that cannot be rushed or performed on demand: “You can’t forgive just because of forgiveness—it is a very strong inner process; you have to be ready for it.” (SC4). Participants noted that forgiveness often depends on the severity of the harm and the personal journey that follows, unfolding gradually as perspectives shift over time: “Sometimes it depends on how heavy it was, sometimes the years make the people look at it differently. . .” (SC5). Above all, spiritual caregivers converged on the view that forgiveness must remain voluntary and cannot be imposed, either from within or without: “You can’t force yourself to forgive someone” (SC9).

Theme 2: Forgiveness as a theme in the conversation between spiritual caregiver and patient

Important and beneficial for patients’ well-being

Across interviews, all participants agreed that forgiveness is an important and beneficial theme for patients approaching the end of life. Rather than being treated merely as a moral or spiritual ideal, forgiveness was described as a concrete process that can enhance patients’ well-being emotionally, spiritually, and even physically, with spiritual caregivers repeatedly observing that patients who were able to forgive—or to feel forgiven—experienced relief, inner peace, and greater acceptance. Several spiritual caregivers recalled vivid situations in which forgiveness brought about immediate and visible emotional change; one described a patient who, after reconciling with her mother, reported a striking sense of physical and emotional lightness, saying, “Oh, I feel air. . . that was what narrowed me” (SC1). Another caregiver noted that patients often begin to relax once they start to reflect on forgiveness, even if such transformations are difficult to quantify: “ ( . . . ) they tend to ease up, to let go of some of the tension of their lives” (SC2).

Forgiveness was also viewed as instrumental in helping patients come to terms with their mortality. SC5, for example, recalled that after conducting a ritual of asking forgiveness from a patient’s grandmother, “Finally she calmed down about it and eh, she could accept the situation of dying then.” (SC5). In other cases, the simple act of confessing guilt or articulating remorse appeared to reduce psychological and even physical suffering, promoting rest and emotional balance: “It affects their well-being, on all dimensions. . . this spiritual component was the most important to address.” (SC5). Conversely, caregivers observed that the absence of forgiveness could prolong distress, leaving patients restless and burdened by unresolved pain: “When people are not able to forgive themselves or others, it’s also a kind of suffering, of pain, that finds no relief.” (SC6). Some distinguished between feeling relieved and feeling forgiven, noting that while many patients experienced emotional release after expressing guilt, not all reached a sense of being fully forgiven: “ ( . . . ) if you ask them if they feel forgiven, I don’t know. Not really. Sometimes I do, but usually you don’t. Because eh, if someone is struggling for thirty year for this problem, yeah sometimes it is, right? Leaving their children or whatever they did, ehm, I’m not there to judge, I can’t make their problem go away. But! Are they relieved? Many times, yes, they are. Because there’s a place where they can set their guilt away, they can share their guilt, maybe not out spoken but I’m pretty sure it’s, it’s there, and that, that, that is a big relief for people.” (SC4). Nevertheless, even partial forgiveness was regarded as highly beneficial: “The impact is huge. . . when they are forgiven, or when they forgive—it gives enormous inner peace.” (SC7). Overall, spiritual caregivers converged on the view that forgiveness—or its absence—profoundly shapes the emotional and spiritual state of patients at the end of life, influencing their capacity for reconciliation, acceptance, and peace.

A hidden and indirect topic

Despite its profound significance, forgiveness seldom appeared as an explicit topic in spiritual care conversations. Several spiritual caregivers even described being struck by how rarely it was named directly, with SC9 commenting, “I’m surprised by the fact that I hardly ever meet this question, speaking with people” (SC9).

Early in the illness trajectory, patients were said to focus more on maintaining relationships, daily routines, and coping with treatment demands—concerns captured by SC2’s description of questions such as: “Like what’s going to happen to me? What will be left of my health, my body, what can I do, what can I, what is, what will my disability be, eh, dependence, things like that. . .” (SC2). As conversations deepened over time, however, forgiveness often emerged indirectly, embedded in other themes such as guilt, regret, or the desire to make amends: “It’s about making amends, it’s about. . . asking forgiveness but not really talking about it. It’s a little bit hidden ( . . . ). So yeah, I think forgiveness is a topic in many of our conversations, but, eh. . . usually not in the open, always as a side step ( . . . ).” (SC4). In this sense, forgiveness appeared to operate as a subtle undercurrent—present but often unspoken—surfacing through gestures, memories, or emotional tone rather than through explicit language.

The difficulty of addressing forgiveness

Participants acknowledged that engaging in forgiveness-related dialog can be emotionally demanding, both for patients and for spiritual caregivers. They described forgiveness as a process that calls for courage, empathy, and a willingness to adopt alternative perspectives, which can be difficult precisely because it exposes individuals to their own vulnerability and requires a sustained encounter with painful aspects of the self and of past relationships. As SC2 observed, “It is not always easy. It can be even more difficult to think about the perspective of someone else. ( . . . ) For a lot of people it’s very comfortable to stay in their own truth, stay at their own side of conflict ( . . . ).” (SC2). SC8 also expressed: “So there are often conflicts between people. . . but ( . . . ) it’s very eh. . . difficult for people to go, to come to the. . . attitude of forgiveness ( . . . ) It’s a very long way! To go there!.”

Guilt and self-forgiveness

Guilt frequently appeared as a central theme accompanying forgiveness, with many patients expressing remorse about perceived moral failings, life choices, or even the origins of their illness. One spiritual caregiver recalled a patient who struggled with long-term infidelity toward his spouse: “He said: Well, I’ve been cheating on my wife for more than thirty years! I need to talk about it, because I am depressed. So he needed someone to talk about this relationship with another woman. We talked about it, many times” (SC4). Another patient was tormented by the sense of having failed to connect emotionally with his children, a perceived shortcoming that continued to haunt him and contributed to suicidal ideation, as SC4 described: “he didn’t feel like he had really connected with his kids, and that was bothering him! Eh, he missed the connection with them now, ( . . . ) but of course, you can’t do anything about that anymore, because the relationship is, is, yeah, is business, is not warm! But the problem was he couldn’t forgive himself. We talked about it. He still struggled with that guilt, guilt, guilt, guilt, so then again in our hospital he tried again to end his life. . .” (SC4). Feelings of guilt also surfaced in connection with illness-related causes, as in the case of a patient with lung cancer whose self-reproach was captured in the words: “Mourning, guilt, many, many, guilt: I have lung cancer, oh men didn’t, why did I smoke twenty five years earlier, right?.” (SC4). In another example, a patient who had acquired a sexually transmitted infection in a single encounter and transmitted it to his wife experienced profound and enduring guilt as he faced the possibility of dying: “As far as he told me it was just once, and in this one sexual contact he was infected by HIV, which of course is very tragic and dramatic that this happened to him, and he also spread it to his wife. And this happened about eight years ago, ( . . . ) but it’s now that he has HIV since like a few weeks ago or maybe months ago, and he was facing - now he’s recovering again - but he was facing that, he was really thinking that he would die. His wife, of course, was very upset about all this, because he had never really told her that he had an affair and, eh, now he had to tell her that. And they are going, they will divorce, and of course he has feelings of guilt.” (SC9). In this way, guilt and forgiveness were often deeply intertwined, with self-forgiveness emerging as a crucial step toward inner peace for many patients.

Rituals as a channel for forgiveness

Rituals were described as key mediators of forgiveness, enabling patients to move on and let go without necessarily needing to verbalize the process explicitly. Through ritual practices—such as prayer, confession, or symbolic gestures—patients were seen to find structured and culturally meaningful ways to experience forgiveness. As SC4 explained, “Forgiveness ( . . . ) is there packed in rituals, like a prayer for Maria, or maybe, especially before death, eh, let’s say the Last Sacrament. So, forgiveness isn’t then really spoken out, but it is, it is in the ritual people really really really want.” (SC4).

Forgiveness and life review

Finally, spiritual caregivers noted that forgiveness often arose in the context of life review, when patients looked back over their past and sought affirmation of their moral and relational legacy. In these moments, forgiveness became closely intertwined with existential meaning-making, functioning as a pathway toward greater self-understanding, reconciliation, and spiritual readiness for death. As SC5 reflected, “Ah, well I think forgiveness is something which is—belongs to life, and I think that it is always good to be forgiven and I think many people who are about to die, and many people who ask people around: “Well, did I do good as a mother? Did I do good as a partner?” So, asking to forgive for a thing she did not do, maybe well, is something which ( . . . ) comes along with dying and surgery ( . . . ).” (SC5).

Challenge for caregivers themselves

A striking insight was that forgiveness is not only a difficult subject for patients but also for the caregivers themselves. Many admitted finding it challenging to introduce or sustain discussions on forgiveness because of its emotional and spiritual depth. The following theme explores in more detail the obstacles spiritual caregivers face in addressing forgiveness within end-of-life care.

Theme 3: Barriers to talking about forgiveness

Spiritual caregivers identified multiple barriers that limited how often and how deeply forgiveness could be addressed. These obstacles ranged from practical and environmental factors to cultural, relational, religious, and personal ones. The caregivers’ reflections reveal that while forgiveness holds great transformative potential, it also touches profound vulnerabilities—making it a delicate and often avoided subject within end-of-life care.

Logistic and practical barriers

Many spiritual caregivers emphasized that the hospital environment itself imposes significant constraints on meaningful conversations about forgiveness. They described how the short duration of patient stays, the lack of privacy, and poor continuity in patient interactions hinder the establishment of the trust required for such sensitive dialog: “They are in the hospital very shortly, maybe a couple of days, or they are so sick that they actually die in the hospital. Eh, in both instances there is not a lot of time to build up a relationship with patients and to talk about these, eh, these sensitive issue ( . . . )” (SC3). As SC9 noted, contacts are often brief and non-recurring: “Most of the time such contact is just one hour, ( . . . ) and I won’t see them anymore, because the person will die and they will leave the hospital ( . . . ) Maybe because eh I work in the hospital setting, and I think that’s different from, in a, in a hospice?” (SC9). Even when time is available, patients’ health conditions can make such conversations almost impossible, as acute pain, breathlessness, or physical exhaustion limit attention and emotional energy: “It’s hard for him to get him enough breath, so the conversations are not that looong and. . . and that I can feel that I can ask him but not too much, because it would bring up too many emotions for him?” (SC9). For some, the sheer intensity of becoming a patient left little capacity to engage with forgiveness-related themes: “What’s happening to me, my transformation into a patient. . . it’s so big I can bear it ( . . . )” (SC1). Reflecting on such crises, SC1 suggested that deeper work around forgiveness may need to occur outside the acute phase of hospitalization: “I think it will occur. . . but afterwards or before. But not in this crisis of 5 days of, of, in terrible circumstances, because when you can’t move your. . . your finger, you (incomprehensible) . . . (laughs ironically)” (SC1). Taken together, these reflections underline how the clinical rhythm of hospital care—brief interactions, intensive medical interventions, and constant monitoring—often leaves limited space for the deep emotional and existential exchanges that forgiveness requires.

Socio-cultural factors

Several spiritual caregivers attributed the rarity of explicit talk about forgiveness to broader cultural and generational characteristics, particularly among Dutch patients. They observed that many older Dutch individuals are not accustomed to discussing emotions openly and tend to value self-reliance and restraint, as SC4 and SC8 noted: “Dutch people are like, they’re like. . . they are a bit hard. . . Eh, not used to talk about their feeling at all because there wasn’t much room ( . . . )” (SC4), “( . . . ) they feel guilty but they do not know why. They feel guilty to their children, or to their exes-husbands or their exes-wives, and they do not know how to deal with it” (SC8). SC5 also described a complex relationship between culture and religion; while some patients maintain spiritual beliefs, these often coexist with a secular or highly private approach to faith: “There’s also this connection to this God ( . . . ), it still has a connection with taking confession, ( . . . ) I think The Netherlands is a very specialized country, ( . . . ) doesn’t happen very often and sometimes I’m surprised of how many people are still praying and thinking about a God or thinking about Heaven even though they never go to church or they would not define themselves as religious ( . . . )” (SC5). In addition, some patients appeared to avoid forgiveness-related conversations simply because they preferred not to revisit the past, steering away from painful memories or unresolved relationships: “Some people are not comfortable talking about what happened in the past, they don’t want to recall it all up ( . . . ) the relationship just water down, just. . . eh, stop existing, ( . . . ) they do know what happened and do want to talk about it but don’t feel the need to forgive or be forgiven.” (SC3).

The sensitivity of family conflicts

A particularly challenging area for spiritual caregivers involved forgiveness within parent–child relationships. These bonds, marked by deep emotions and long histories, were described as both the most frequent and the most difficult context in which forgiveness-related struggles emerged. Spiritual caregivers encountered situations in which neither party was able to offer forgiveness, even while longing to receive it: “Both are not capable of giving forgiveness to each other. ( . . . ) they wanted it from the other but are not capable of giving it.” (SC8). In other cases, adult children refused attempts at late reconciliation, questioning the authenticity of such efforts when there had been no prior contact: “In some situations, I’ve met that the children refuse to come, they said: ‘There was no contact in life, ( . . . ) it’s not authentic to come now and to eh, to play some kind of reconciliation.’” (SC6). These accounts highlight that forgiveness is not merely an individual act but an interpersonal and emotional negotiation, often constrained by relational history and by each person’s readiness—or reluctance—to engage.

Influence of religious background

Religious background was another factor that shaped how forgiveness was perceived and discussed. Spiritual caregivers observed that patients with Christian roots were generally more familiar with the language of forgiveness, but this familiarity could function both as a resource and as a burden. For some, Christian teaching on forgiveness heightened the sense of moral expectation, making it even more difficult to forgive when the perceived injury was profound: “( . . . ) when a patient religious is Christian, eh mostly, they say: ‘Oh no my son/daughter have done such things that no. . .,’ the wound is so big to come to that attitude of giving forgiveness, I think.” (SC8). At times, religion was said to complicate the process when doctrines or communal norms appeared to exert pressure to forgive prematurely, rather than allowing forgiveness to emerge organically from within the person: “It’s hard to force or to feel that you have to forgive someone, because it’s a process in a person to grow to forgiveness, and eh, if your religion eh, forces you or makes it like an ideal that, to forgive, that that – well, that’s maybe not good, to grow from the person.” (SC9).

Personal caution and scruples of caregivers

Finally, spiritual caregivers also described their own hesitations as a major barrier to addressing forgiveness explicitly. Many admitted feeling scrupulous about initiating such conversations, fearing that they might be intrusive, premature, or emotionally overwhelming for the patient. As SC3 explained, “( . . . ) what we can do is talk about, well, life in general, talk about some important issues, but something like forgiveness is, eh, is a very sensitive, eh, subject. . .” (SC3). For SC5, this translated into a strong reluctance to introduce forgiveness unless there was a clear sense of necessity: “And I just would never suggest that if I wouldn’t feel there’s is urgence.” (SC5). Similarly, SC9 emphasized the need for great caution, distinguishing between helping a patient to lessen the weight of guilt and explicitly declaring absolution: “So I. . . I don’t want to, eh, to speak about forgiveness, that’s too much, too far, I can’t do that, but I can maybe eh. . . help him to make it less, less massive? ( . . . ). But I’ll be careful with eh, well saying ‘you are forgiven.’” (SC9). This self-restraint reflects a deep ethical awareness among spiritual caregivers of the power and sensitivity of forgiveness; from their perspective, suggesting forgiveness prematurely risks imposing their own values or reopening wounds the patient is not yet ready to face.

Theme 4: The role of spiritual caregiver in addressing forgiveness

When asked about their role in the issue of forgiveness, spiritual caregivers described a practice grounded in presence, empathy, and non-directive guidance. They saw themselves as facilitators rather than instructors—companions who help patients reflect, gain perspective, and find hope within their own spiritual and emotional frameworks. Their insights can be organized into four interrelated dimensions: objectives, conditions, media, and role strengths and limitations.

Objectives: what spiritual caregivers aim to achieve when discussing forgiveness

Asking open questions to encourage reflection

Spiritual caregivers emphasized that their primary aim is to facilitate patient reflection without steering or imposing meaning, adopting a non-directive stance in which the patient’s own concerns and language take precedence. Through open-ended questions, they described creating a space in which patients can explore their inner struggles and gradually recognize, on their own terms, whether and how forgiveness needs to be addressed. As SC1 explained, “And I ask them: ‘What bothers you?,’ and that’s my standard question.” (SC1). Others similarly highlighted the importance of beginning with broad, person-focused inquiries—“The first thing I do is just ask: why are you here, how are you and who are you?” (SC2)—before gently inviting deeper reflection on life choices, regret, and guilt: “Is your life fulfilling? Did you live a wholesome life? Could you do something about it in the situation when you were there? Could you have done it differently? So then why are you feeling so guilty?” (SC4). SC8 directed her questions to a more relational-focused approach to help patients reflect about their bounds: “I think that the most important step is that you help people to reflect on their own attitude or way of life, or their own contribution to the interaction with the other person.”

Helping to change perspective: Moving toward a more compassionate vision

Spiritual caregivers also described helping patients to reflect on their experiences from a broader and more compassionate standpoint, gently guiding them toward greater self-understanding and encouraging a kinder view of themselves and others. SC2 summarized this role as “my task” of “To relieve stress, and to open new perspectives. ( . . . ) trying ( . . . ) to look to the other side, of the vulnerability of life ( . . . ) You don’t have everything at your hands.” (SC2). In a similar vein, SC9 portrayed spiritual care as an invitation to adopt a more merciful self-view: “It’s to help this man to look a bit more mild to himself ( . . . ). So it’s another perspective I’ll show them in this question: Look at yourself in God’s eyes, and what do you see, yeah. And I feel it makes people more open.” (SC9).

Encouraging and giving hope

Spiritual caregivers emphasized their role in encouraging patients to draw on their own strengths and spiritual resources, rather than introducing something entirely new. Their approach was described as gentle and non-directive, focused on expressing hope and belief rather than prescribing moral or religious obligations. As SC5 explained, “( . . . ) you just help people to use the sources they already have, they already used in their lives. You just help them to recall ( . . . )” (SC5). Similarly, SC6 understood spiritual care as an expression of personal hope and spirituality—“(. . .) at the end I think it’s kind of expressing my own hope and my own. . . my own belief, my own spirituality ( . . . ) So hoping, sometimes praying, sometimes giving a blessing, that’s eh that’s also a kind of action of a spiritual caregiver.” (SC6)—while SC9 described formulating invitations as wishes rather than demands: “I say it as a wish, I hope you can become more mild to yourself, look at yourself with another eye, or yeah. . . See if you can understand why you did things the way you did it, or. . . yeah, yeah, something like that.”(SC9).

Conditions: Attitudes spiritual caregivers consider important when discussing forgiveness

Spiritual caregivers consistently framed their interventions as fundamentally non-directive. All participants agreed that discussions of forgiveness must remain patient-led: they avoid raising the topic unless the patient explicitly expresses a need for it, allowing the process to unfold naturally rather than as a predefined therapeutic objective. As SC3 put it, “So, the patient is in the lead always, I can bring it up, but I cannot convince people. I don’t, I don’t think that’s my, my role.” (SC3). Similarly, SC5 emphasized that they would only introduce forgiveness when there is a clear sense of necessity, explaining, “And I just would never suggest that (forgiveness) if I wouldn’t feel there’s urgency. People just do and I can facilitate and help with what I told you, a ritual or just by counseling ( . . . ).” (SC5).

Within this non-directive stance, listening with empathy emerged as a core attitude of spiritual caregiving. Caregivers described themselves as “space holders,” striving to create a safe environment in which patients can express guilt, anger, regret, or sadness without judgment or premature reassurance. Their attentive presence was seen as enabling both emotional release and meaning-making: “Especially when people are at the end of their lives, making room for their story and letting them tell and let the sadness, let the anger and let it all come out and then see what would help. . .” (SC5). SC6 similarly highlighted the importance of an open, empathic stance: “I think being present, listen to them very openly, and also express my eh, my eh, my empathy, also my kind of eh, eh, eh, sympathy for their willing to, to come further in the process ( . . . )” (SC6).

Media: Ways spiritual caregivers use to facilitate forgiveness

Rituals, prayer, sacraments and sacred texts were commonly described as spiritual pathways for facilitating forgiveness, providing patients with concrete forms through which reconciliation and peace could be sought. Most participants, being active members of the Christian church, drew on familiar religious frameworks and especially on sacraments of healing such as Reconciliation (Confession) and Anointing of the Sick, alongside practices like prayer, blessings, and symbolic acts (e.g. asking forgiveness from deceased loved ones). As SC6 put it, “Sometimes praying, sometimes giving a blessing; that’s also a kind of action of a spiritual caregiver ( . . . )” (SC6), while SC4 noted that “Forgiveness, for one, is there packed in rituals, like a prayer for Maria, or maybe, especially before death, eh, let’s say the Last Sacrament ( . . . )” (SC4). One caregiver recounted how a young woman’s struggle with guilt toward her grandmother “needed a ritual,” leading them to use a photograph as a focus for prayer and a spoken request for forgiveness: “But this needed a ritual, so we did, we had a picture of her grandmother and, eh, she asked her for forgiveness and she was praying and eh, finally she calmed down about it and, eh, she could accept the situation of dying then.” (SC5). Similarly, SC9 described how sacramental encounters themselves become spaces for narrative and meaning-making: “Then, people tell me about their life, eh, during the ritual, the anointment I, well, I do a reading from the Gospel and I try to, eh, to connect the things that happen in life with the words in the Gospel.” (SC9). Several spiritual caregivers also described using biblical stories and other religious or spiritual texts to help patients gain distance and a new perspective on their guilt and worth, for example, SC7 describes: “( . . . ) a story from the Bible or spiritual or religious text sometimes is helpful because it ( . . . ) can give them (the patients) back the relationship between themselves and for instance God, (so) that they feel: “I am a small one,” ( . . . ) “I am of worth and I can always, I can always trust upon the Creator, or the Almighty One, or Father, or the Mother, or which metaphor you need. This is, I think, very important ( . . . ) but this is more from a religious perspective.” SC5, who is a chaplain, also expressed: “to tell as a chaplain is to show that there are stories in the Bible, for example, which say “Hey it happens, listen, the Bible spoke of people, and people do make mistakes ( . . . ). SC7 evoked the parable of the prodigal son when sharing the story of a woman who forgave her daughter for being rough with her: “Eh, when you were talking about ( . . . ) the story from the Bible, (it) was coming up (to me) [eh from] the father of the son who was lost.” Some spiritual caregivers were inspired by witness figures such as Desmond Tutu (SC2, SC7), Edith Eva Eger (SC9), and Simone Weil (SC9), as well as by their own life stories (SC9).

Strengths and constraints

Spiritual caregivers highlighted their unique contribution within palliative care teams, emphasizing that they address existential and spiritual dimensions often overlooked in the biomedical model. Their presence was described as enabling a more holistic understanding of the patient’s experience and as supporting healthcare colleagues in recognizing spiritual needs within their own practice. As SC2 observed, “So. . . that part of the story, the doctor doesn’t know that ( . . . ). Or doesn’t address it. He just, he or she, wants to get the tube in the right place. ( . . . ) And what’s, the problem of the medical profession is that it is always about pain, or about. . . is physical pain, about medicine, about operations, and not about what is important. Not about values, not about spirituality, so our role is to address that, and to try to make doctors aware of the fact that not every treatment is a good idea.” (SC2). In some cases, spiritual caregivers were not only directly involved in patient care but also played an important consultative role for the team, particularly when emotional or existential suffering was not readily recognized as such: “But for the nurses and the doctors it was a very difficult situation, they didn’t even know what was happening, they only saw somebody very depressed ( . . . ). ( . . . ) spiritual counselors are necessary in a direct manner, but to train them to do so and to help them and to have these conversations and specially to listen to somebody who has to tell something and you don’t have to do something, they have to tell you something, yeah.” (SC5).

At the same time, caregivers acknowledged important limits to their authority, especially in relation to sacramental acts. Patients sometimes expected them to perform the functions of a priest—for instance, by offering absolution—yet participants were clear that such roles fell outside their professional scope. As SC5 explained, “I am not a priest or I am. . . it’s not up to me, if he goes up to forgiveness, it’s people who forgive one another and aam so it’s not up to me.” (SC5). Similarly, SC7 underlined the distinction between their role and that of ordained clergy: “So that’s different from a priest, because a Catholic priest can say ‘Yeah, you are forgiven’, I, I, can’t say this, I won’t!” (SC7). SC9 likewise described being “careful in what could be said: “Because, when I should be a priest, then I maybe would say it in a different way, but I’m not a priest so I’m careful in. . . in what I say, and, yeah.” (SC9). These reflections reveal the ethical and professional boundaries spiritual caregivers seek to maintain: while they can accompany and guide the process of forgiveness, they cannot declare or grant it. Their power lies not in absolution, but in presence, empathy, and the capacity to open a space in which forgiveness can emerge authentically.

Discussion

This study provides original insights into how spiritual caregivers perceive and address forgiveness as a theme at the end-of-life in the context of severe illness. It identifies (1) the concept of forgiveness according to spiritual caregivers; (2) forgiveness as a theme in the conversation between spiritual caregivers and patients, (3) barriers to talking about forgiveness, and (4) the role of spiritual caregivers in addressing forgiveness. Across interviews, participants associated forgiveness (or feeling forgiven) with relief, inner peace, and acceptance. At the same time, spiritual caregivers described the topic as delicate, frequently “hidden,” and difficult to broach amid clinical time pressures, symptom burden, family conflict, and cultural or religious ambivalence. The study introduces possible responses to the identified barriers.

What this study adds

While previous literature has highlighted the importance of forgiveness in end-of-life care, particularly its impact on physical, psychological and spiritual well-being, ²⁷ there has been limited research exploring how spiritual caregivers themselves experience and address this in practice. This study fills that gap by offering in-depth, qualitative insights from experienced spiritual caregivers, most of whom had over a decade of clinical work.

The findings show that spiritual caregivers described forgiveness in ways that align with the literature, identifying its cognitive, emotional, and behavioral dimensions.^28–30 Participants also distinguished between types of forgiveness—self, interpersonal, and spiritual—echoing common categorizations in forgiveness research.^31,32 Additionally, spiritual caregivers highlighted the directionality of forgiveness (to forgive or to be forgiven), a distinction supported by previous studies. ²⁹ While most elements reflected established frameworks, some spiritual caregivers emphasized conditional forgiveness—requiring remorse or a face-to-face encounter—which contrasts with the concept of unconditional forgiveness central to forgiveness theory.^4,33 This conditional view may limit a patient’s healing when reconciliation is not possible. However, spiritual caregivers in the study found alternative pathways, such as rituals and prayers, to support patients in achieving peace, even in the absence of interpersonal resolution.

In interpreting these findings, it is also important to consider the person-centered approach that shaped how spiritual caregivers engaged with forgiveness in practice. This approach reflects core principles of person-centered care, in which patient autonomy, readiness, and meaning-making are prioritized. ³⁴ Within palliative care, spiritual caregivers are explicitly called to avoid prescriptive or coercive practices and instead respond to patients’ expressed concerns and openness. ³⁵ Rather than presenting forgiveness as something patients “should” achieve, spiritual caregivers in the present study respected each individual’s autonomy in determining their own position toward forgiveness, including the choice not to forgive. At the same time, person-centered practice does not preclude gently opening space for exploration.^36,37 Spiritual caregivers described creating supportive environments in which patients could reflect on forgiveness if they wished, offering spiritual or symbolic resources—such as rituals, blessings, or reframing—when patients showed openness. This balanced approach ensured that patients were neither pressured into forgiving nor denied the opportunity to consider forgiveness as a potential pathway toward peace. In this way, spiritual caregivers translated theological and psychological understandings of forgiveness into clinically sensitive, patient-led practices that acknowledge the complexity of end-of-life experiences.

Data also confirmed existing barriers to spiritual care, and, therefore, to talk about forgiveness, such as limited time, lack of intimacy, and poor continuity in patient interactions, as also noted in previous studies.^38,39 This aspect highlights the importance of a holistic and multidisciplinary approach to spiritual care, emphasizing that the integration of forgiveness should not fall solely on spiritual caregivers but be supported by the entire palliative care team. Echoing prior findings,^14,40 spiritual training should be provided across disciplines, enhancing recognition and support for spiritual needs like forgiveness. In the Netherlands, a national consensus-based guideline on multidisciplinary palliative care (further: the Spiritual Care guideline) exists. ⁴¹ As a result, primary health care professionals are expected to recognize the spiritual needs of the patients and those closest to them, screen for their needs, follow up the process, refer, and assess (take the spiritual history). ⁴¹ In order to train healthcare professionals in forgiveness, an existing multidisciplinary intervention which aims to facilitate forgiveness in palliative care ⁴² could be used. The Nursing Interventions Classification (NIC) outlines this intervention as a tool to support individuals in replacing anger or resentment with empathy and humility. ⁴³ Many of the NIC-recommended activities align with what the spiritual caregivers in this study already practice, such as empathetic listening, encouraging rituals, and involving spiritual resources. These practices could be integrated into multidisciplinary or even transdisciplinary training sessions for the entire palliative care team. ⁴³

Training in forgiveness should consider sociocultural aspects. Spiritual caregivers in the study reported that Dutch cultural norms, resistance to emotional expression, and lack of religious affiliation often hinder forgiveness conversations. Yet paradoxically, although the Netherlands is one of the most increasingly secular countries in Europe—where church membership dropped from 67% in 1966 to 27% in 2024 ⁴⁴ —spiritual caregivers of the study were surprised that even patients who had stopped practicing their religion often asked for religious support, especially related to forgiveness, while nearing death. Most spiritual caregivers worked within a Christian frame, and their descriptions often echoed biblical motifs—repentance, confession, mercy, and reconciliation. Several spiritual caregivers valued the use of biblical narratives, helping patients to recognize their own stories in flawed biblical figures who receive mercy from God and are invited to forgive others, such as the parable of the prodigal son.

From a Christian theological perspective, forgiveness is grounded in the conviction that God offers forgiveness through Christ and calls believers to extend that forgiveness to others. This is reflected, for example, in New Testament passages that speak of Jesus’ blood “poured out for the forgiveness of our sins” (Mt 26:28), the proclamation that everyone who believes receives forgiveness through Him (Acts 10:43), and the understanding of redemption and forgiveness “through His blood” as a gift of grace (Eph 1:7; Col 1:14). The call to “forgive as the Lord forgave you” (Col 3:13) further underlines the link between being forgiven and becoming able to forgive others. Although the spiritual caregivers in this study did not cite specific biblical verses verbatim in their descriptions of practice, their references to themes of guilt, mercy, reconciliation, and a trustworthy God suggest that such theological motifs implicitly shape their understanding of forgiveness. A plausible explanation for the absence of literal biblical quotations, being Christian mostly all of the interviewed spiritual caregivers, is that they described working with both Christian and religiously unaffiliated patients; thus, they seemed to prefer to translate Christian forgiveness theology into more existential or relational language that can be meaningful across a range of belief positions, rather than explicitly framing forgiveness only in confessional or doctrinal terms. In fact, they distinguished forgiveness from reconciliation and rejected coercive or premature forgiveness, which sometimes is wrongly promoted in strict Christian religious backgrounds. This divergence aligns with a person-centered ethic, respecting patient autonomy and readiness while still drawing on Christian values of compassion and grace.

On the other hand, some spiritual caregivers preferred the concept of exoneration (from Contextual Therapy) as a non-doctrinal entry point—focusing on understanding rather than moral adjudication.^45,46 Exoneration involves shifting from blame, to understanding a person’s past limitations and choices. While some view exoneration as distinct from forgiveness, others see it as a foundational step toward it. ⁴⁷ This approach may be particularly useful in secular contexts or when patients resist religious framing. In such cases, spiritual caregivers put aside their own beliefs and focused on the individual’s personal story, background, and values. This flexibility is increasingly necessary, as the Netherlands sees growing demand for secular and multi-faith spiritual care ⁴⁷ , and also ensures person-centered ethics. In fact, since 2015, spiritual caregivers can also be certified as non-affiliated chaplains by the Council for Non-Denominational Chaplaincy (RING). ⁴⁷

Another issue identified by participants was that some patients confused the role of spiritual caregivers with that of priests, often requesting absolution of sins or the Sacrament of Reconciliation. However, unlike priests, spiritual caregivers and chaplains do not exercise sacramental power. In Catholic theology, forgiveness of sins is sacramentally mediated through Confession, where absolution is granted by the priest in persona Christi. ⁴⁸ By contrast, Protestant traditions emphasize a more direct relationship between the believer and God, where forgiveness is received through faith, repentance, and divine grace, without priestly mediation. ⁴⁸ These theological differences influence both patients’ expectations and the ways spiritual caregivers engage with them in clinical practice. In this study, each participant, aware of their professional role and delimitations, clarified this when patients demanded of them something that fell beyond the scope of their role, and redirected them appropriately (e.g. intervention of a priest to receive the Sacrament of Reconciliation).

Finally, most of the end-of-life scenarios described by the participants of the study showed unforgiven intra-familiar relationships and conflicts – more specifically, parent-child conflicts. In the majority of these cases, family members of the dying patient showed no or little involvement in his or her journey to end of life. On some occasions, even when the parent was dying, no encounter or reconciliation with children occurred. Consistent with literature on unfinished family business at end of life,^49,50 these cases revealed that unaddressed family dynamics can cause distress for both patients and bereaved families. Although family involvement may sometimes open opportunities for dialog and potential reconciliation, recent studies also report that such involvement can increase emotional burden or intensify existing conflict in certain cases.^51,52 For this reason, spiritual caregivers in our study adapted their intervention depending on whether involving family members would likely be beneficial or harmful. When patients expressed a desire to pursue reconciliation and the relational context appeared supportive, spiritual caregivers were predisposed to act as intermediaries, ⁵³ always respecting the patient’s autonomy and readiness. Conversely, when direct contact was not desired or was expected to increase distress, spiritual caregivers supported patients in finding alternative or symbolic forms of closure, such as reflective conversations, letters, or ritual practices.

Practical implications and future research

This study has several implications for clinical practice. First, it underscores the need for forgiveness to be approached within a person-centered framework, recognizing that not all patients wish—or are ready—to forgive. Respecting autonomy and allowing patients to define what forgiveness means to them preserves dignity and emotional safety. Rather than being framed as a moral duty, forgiveness should be offered as a possible path toward peace, explored only when the patient expresses readiness. Second, it underscores the need for structured time and supportive environments to allow spiritual caregivers to engage meaningfully with patients, which are often limited in hospital settings. Providing protected moments for spiritual conversations and ensuring follow-up across care transitions can help patients reflect on forgiveness more deeply. Third, it supports integrating forgiveness-focused interventions—as defined in the Nursing Interventions Classification (NIC) ³⁸ —into broader palliative care protocols to equip healthcare professionals to recognize and address forgiveness needs through empathic listening and sensitivity to individual beliefs. Fourth, the study also points to the need for careful and selective family involvement. Family participation should occur only when desired by the patient and when the emotional context is safe. When direct reconciliation is impossible, spiritual caregivers can facilitate symbolic gestures, such as unsent letters or prayers of closure. Finally, it highlights the importance of clarifying professional roles. Some patients mistake spiritual caregivers for priests and seek sacramental absolution. Spiritual caregivers should communicate their supportive but non-sacramental role clearly and refer patients to clergy when Confession or formal reconciliation is requested.

Future research should also be conducted with spiritual caregivers from non-Christian and multi-faith backgrounds to explore how forgiveness is conceptualized and practiced within diverse traditions. Adopting mixed-methods and longitudinal designs could further illuminate forgiveness processes in palliative care. Moreover, future research should compare forgiveness processes across hospital, hospice, and primary-care settings, where longer-term relationships may foster trust and openness. Including patients’ and families’ perspectives would complement professional insights and deepen understanding of lived experiences. Also, further exploration of approaches such as Contextual Therapy may broaden the applicability of forgiveness work in secular and pluralistic societies.

Strengths and limitations of the study

A key strength of this study is its qualitative design, which enabled an in-depth exploration of spiritual caregivers’ perspectives on forgiveness at the end of life. Semi-structured interviews allowed participants to share personal, nuanced reflections often missed by quantitative methods. The purposive sampling of experienced spiritual caregivers added credibility, and the approach was well-suited to the sensitive nature of forgiveness. All participants worked in the Netherlands, where formal training in spiritual care is available, and most had Christian backgrounds, offering a meaningful context for their insights.

However, the study has limitations. First, the sample was limited to a Dutch context, which may not entirely reflect the experiences of spiritual caregivers in other religious societies or within different healthcare systems. Second, findings reflect the perspectives of spiritual caregivers only; future work should integrate patient and family voices to provide a more complete view. Third, all interviews were conducted in English, which was not the native language of either the interviewer or the participants. This most likely affected the fluency and syntactic clarity of some quotations, as well as the level of concreteness in some examples. To preserve authenticity, quotations were kept verbatim even when the grammar was imperfect; however, we reviewed them carefully to ensure that their meaning remained clear to readers. The fact that English was also not the interviewer’s first language raises the possibility that nuances could have been missed during data collection or early interpretation. We therefore approached the reflexive thematic analysis with explicit attention to researcher positionality. A second researcher (NvP), a native Dutch speaker familiar with the healthcare and cultural context of the participants, reviewed transcripts, coding notes, and theme development. This collaborative process helped ensure that linguistic subtleties, cultural idioms, and contextual meanings were correctly understood and contributed to the credibility and depth of the final themes. Together, these procedures aimed to balance the limitations introduced by multilingual data collection with a rigorous and transparent analytic approach.

Conclusions

This study highlights how spiritual caregivers perceive and address forgiveness in end-of-life care. Spiritual caregivers recognized forgiveness as a complex process involving emotional, cognitive, and spiritual dimensions, aligning with existing theories. They encountered challenges such as time limitations, lack of intimacy, cultural resistance to emotional expression and personal scruples, which often hindered meaningful forgiveness conversations. Despite these barriers, spiritual caregivers found different ways—such as rituals, empathetic listening, and existential reframing—to support patients, especially when reconciliation wasn’t possible. The study emphasizes that forgiveness should be patient-led and multidisciplinary, embedded in person-centered care and supported by appropriate training, institutional guidelines, and collaboration with clergy when sacramental ministry is sought. Family involvement should be selective and patient-directed to avoid harm. Future studies should include patients and families, explore diverse cultural contexts, and examine how forgiveness conversations can be supported across the continuum of care, including by primary care physicians and hospices.