Facilitating spiritual and cultural rituals as desired by patients and families is an important component of holistic palliative care.  The National Consensus Project for Quality Palliative Care makes this clear in their Clinical Practice Guidelines – Domain 5: Spiritual, Religious, and Existential Aspects of Care.

Ash Wednesday, which begins the Christian season of Lent 40 days before Easter, is marked with a ritual imposition of ashes – the sign of the cross with ashes on one’s forehead.  It is a time of prayer, reflection, and preparation. The traditional words shared are

remember that you are dust, and to dust you shall return

There is something particularly fitting about acknowledging one’s mortality within the hospital setting. Healthcare workers seem eager for this ritual, along with patients and families. As I was leading ritual on Ash Wednesday a couple of weeks ago, I recalled my first Ash Wednesday as a hospital chaplain, during which I was rotating with the palliative care team…

I began at 6:00 am, co-leading a chapel service with a fellow chaplain resident, which was a way to orient towards the day and appreciate the mutuality of our leadership.  I then carried ashes with me throughout the day and, because I had the mark on my own forehead, was stopped by numerous staff, patients, and families. These were generally brief encounters, but a reminder to me of the power and beauty in religious ritual.

A palliative care family meeting that day was turning long and difficult, as four adult children expressed their distress about whether they would be able to ensure a peaceful death for their mother. As we were concluding the meeting, the daughter who had been most resistant to our involvement asked me how she might receive ashes. We stepped aside to perform the ritual, since she explained that it would not be important to her mother or siblings, but was very important to her. Here was an organic entry point into empathic reflection about mortality, loss, and grief.

My final imposition of ashes for the day touched me most deeply. I was staying late to finish charting, and only a couple of palliative physicians were still around. One physician, who does not belong to a religious tradition, had asked thoughtful questions about the ashes earlier in the day. Now in the quieting evening, she expressed how much she was drawn to the symbolic recognition of mortality. Then, hesitantly, she asked for the imposition.  I gave them with sacred intention: you belong to the earth, and to the earth you shall return.


Domain 5: Spiritual, Religious, and Existential Aspects of Care (pp. 32-37) in National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, 4th edition. Richmond, VA: National Coalition for Hospice and Palliative Care; 2018. https://www.nationalcoalitionhpc.org/ncp.


Rachel Revelle, MDiv

Rev. Rachel Revelle is a chaplain at the University of Colorado Hospital and is a frequent contributor for the MSPC blog.



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