Spi r i t u a l i t y
www.ej p c . e u . c o m
Implementing spiritual care
at the end of life: Estonia
In this occasional series, members of the Task Force on Spiritual Care in Palliative Care
of the European Association for Palliative Care report on recent developments and
current debates in their respective countries. Here, Liidia Meel takes a look at Estonia
stonia is a small Baltic country of
northern Europe which has 1,315,819
inhabitants. The 2011 census showed
that 29% of the population aged 15 and over
(all nationalities included) follow a particular
religion.1 This has not changed much since
2000, when the figure was 31.8%.2 At the same
time, the religious landscape has become
more diverse, as the number of religions or
churches has increased from 74 in 2000 to 90
in 2011.1,2 The two most common religious
affiliations are to the Orthodox Church (16%)
and the Lutheran Church (10%). The 2011
census further showed that 54% of the
population aged 15 and over does not follow
any particular religion; 14% of respondents
did not answer the question about religion.1
The population of Estonia is composed of
different nationalities, and religious affiliation
differs according to ethnic origin; 19% of
ethnic Estonians, but 50% of non-ethnic
Estonians, declare that they follow a particular
religion. Lutheranism is the most common
religion among ethnic Estonians (14%), while
the Orthodox Church rallies 47% of Russians.
Among the other nationalities, 27% of Finns,
15% of Germans and 14% of Latvians consider
themselves Lutherans; 51% of Belarusians,
50% of Ukrainians and 41% of Armenians are
affiliated to the Orthodox Church; and 47% of
Poles and 33% of Lithuanians are Catholics.
Islam is most prevalent among Tatars.1
In 2011, 29% of the Estonian population said they subscribed to a
particular religion. This figure has remained stable since 2000, but in
parallel the religious landscape has become more diverse.
It can be assumed that there is considerable demand for spiritual
care, both among the religious and non-religious population.
Spiritual care is becoming more acknowledged in hospitals, where
it is provided by chaplains and pastoral counsellors who have been
trained in delivering pastoral care and can train other staff.
According to earlier statistics, about 47% of
the Estonian population believe or tend to
believe in the existence of the human soul and
in an afterlife; about 45% believe that the
souls of their ancestors may visit them; about
37% consider reincarnation to be possible;
about 64% believe in some kind of higher
power that affects everything in the world;
and about 41% believe that certain magical
acts or rituals may affect the course of events.3
These figures lead us to assume that there is
potentially considerable demand for spiritual
care at the end of life, both among religious
and non-churchgoing populations.
Current service provision
In Estonia, palliative care is provided in three
hospital hospice departments (at the EastTallinn Central Hospital and Tallinn Diaconic
Hospital of the Estonian Evangelical Lutheran
Church, which have 24 beds between them,
and at Tartu University Hospital, which has
seven beds); and in patients’ homes by
palliative home care services launched in 1997
by the Estonian Cancer Society4 and used by
1,000 patients every year (15 home care teams
with one to five nurses and one or two
physicians each). The palliative care principles
of pain relief and psychosocial support are also
applied, to some degree, by healthcare
professionals delivering acute care in hospitals.
A multidisciplinary palliative care team, the
first of its kind, was created in 2011 at a tertiary
care hospital, the North Estonia Medical
Centre in Tallinn.5
Awareness of spiritual care needs is
increasing as palliative care is developing and
hospitals are hiring more chaplains
(ordination required) and pastoral counsellors
(no ordination required). Spiritual care in
hospital practice is becoming more
acknowledged as a concept. Both chaplains
and pastoral counsellors receive special
Copyright © Hayward Medical Communications 2015. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact [email protected]
Spir ituality
education in pastoral care, and both would
have the ability to train other staff. They are
expected to help train hospital staff to provide
spiritual support, recognise patients’ spiritual
needs, and respect patients’ individual
cultures and beliefs. At the same time, hospital
chaplains and pastoral counsellors are also
there to offer support to patients who belong
to a particular religion and their families, as
well as to anyone caring for the dying.
Members of the clergy working in the
community may also visit patients in hospital
or at home; sometimes they can only visit
patients in hospital if they have been invited
to do so, either directly by the patient or by
staff. Spiritual care service provision is not
organised in all hospitals along the same lines,
and we lack studies to fully describe the
current situation, needs and potential for
implementing spiritual care at the end of life
in the hospital and the home environment.
Recent developments in palliative care
Palliative and hospice care conferences have
been held in Estonia every two years since
2006. In 2007–09, an Estonian cancer strategy
project was undertaken in collaboration with
the Estonian National Institute for Health
Development; as part of that project, palliative
care standards were elaborated at the oncology
centre of the North Estonia Medical Centre.
In 2010, a non-profit organisation, Pallium,
was founded with the aim of developing
palliative and hospice care in the country.6
Pallium’s founding members were hospices,
healthcare institutions and individuals
interested in improving access to, and quality
of, palliative and hospice care. Pallium also
aims to develop training programmes and
conduct research in the field. More research
would certainly be useful for implementing
spiritual care at the end of life in the home
care environment.
Pallium’s work is based on the WHO
definition of palliative care,7 according to
which spiritual support is an important part
of holistic care and the interdisciplinary team
addresses patients’ individual needs,
including their spiritual care needs. That said,
in practice, the care provided does not always
meet these requirements.
Higher education in pastoral care
Professional pastoral caregivers have been
trained since 1992 at the Tartu Academy of
Theology, founded the same year as a result of
a collaboration between representatives from
various Christian churches (the Evangelical
Lutheran Church, the Orthodox Church, the
Methodist Church and the Union of Free
Evangelical and Baptist Churches).8 The Tartu
Academy of Theology has had Lutheran,
Orthodox, Baptist, Methodist, Pentecostal,
Adventist, Catholic and Evangelical church
members attending the studies. In 2013, the
Tartu Academy of Theology joined forces with
the Institute of Theology of the Estonian
Evangelical Lutheran Church.
At the Institute of Theology of the Estonian
Evangelical Lutheran Church, founded in
1946, a range of subjects are taught in the
curriculum, including thanatology and
geriatric studies, and pastoral care features as a
minor specialty.9
Considering the statistics, we must
acknowledge that, in our multi-religious and
multicultural society, there is a need for
inter-faith and interdisciplinary training of
chaplains and pastoral counsellors, as well as a
need to train hospital staff and other
professional caregivers in spiritual care. These
needs have been partially addressed, on the
one hand by offering higher education in
pastoral care, and on the other by the general
development of palliative care. At the same
time, we must conduct further studies to
identify the needs and potential for
implementing spiritual care at the end of life,
both in institutions and at home.
Declaration of interest
The author declares that there is no conflict of interest.
This article is part of a series on spiritual care at the end of life. Previous
articles covered the Netherlands, Italy, the UK, Germany and Finland.
1. Statistics Estonia, Population and Housing Census 2011.
2. Statistics Estonia, Population and Housing Census 2000.
3. Elust, usust ja usuelust 2010 [Results of the sociological survey on ‘Life,
Religion and Religious Life’]. In: Jõks E (ed). Astu Alla Rahva Hulka [‘Step
Down among the People’]. Tallinn: Eesti Kirikute Nõukogu, 2012: 283–317.
4. Suija K, Suija K. Palliative home care for cancer patients in Estonia. J Pain
Symptom Manage 2012; 43: e4–e5.
5. Bambus M, Labe R, Sillaste P, Nazarenko S. The founding of a
multidisciplinary palliative care service in tertiary care hospital – First initiative
in Estonia. Poster presented at the 13th World Congress of the European
Association for Palliative Care, 30 May–2 June 2013, Prague, Czech Republic.
6. www.pallium.ee/en/about-us (last accessed 18/11/2014)
7. www.who.int/cancer/palliative/definition/en/ (last accessed 18/11/2014)
8. http://teoloogia.ee/wb/pages/en/home.php?lang=EN (last accessed
9. http://ui.eelk.ee/index.php/en/ (last accessed 18/11/2014)
Liidia Meel, PhD student, Faculty of Theology,
Tartu University and Pastoral Counsellor,
Haematology and Oncology Clinic, Tartu University
Hospital, Estonia
Copyright © Hayward Medical Communications 2015. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact [email protected]