*4.1. Ritualization of Care Practices*

Observations showed that ritualization took place during all types of care practices at the hospice. The repertoire of ritualized care practices in the hospice consists of (1) care practices in the morning,

<sup>2</sup> The research group consisted of four members. K.v.d.W. has a background in anthropology and is nurse, M.T. is spiritual caregiver in the hospice that functioned as site of research, M.H. is a ritual studies scholar and A.v.d.H. is professor in medical decision-making and care at the end of life.

such as washing, dressing and providing medicines; (2) meals; (3) care practices in the evening, such as undressing, putting on pajamas and putting to bed; (4) care practices in the dying phase, such as washing and putting on clean clothes; (5) a farewell ritual after a patient has died. This last ritual differs from the other ones because, instead of focusing on the patient, it focuses on both the bereaved and the care professionals who took care of the patient. The farewell ritual concludes the period of the stay in the hospice.

Analysis of the various ritualized care practices in the hospice context shows that ritualization takes place on a continuum. This means that ritualization takes place in various degrees and forms depending on changes in the dying process. We saw lower degrees of ritualization when the situation of the patient was relatively stable. This was the case with patients staying at the hospice for a longer period of time because their health situation stayed the same or deteriorated very slowly. In these situations, ritualization was directed at coping with the liminal situation of being in the hospice. This often happened by creating small moments of significance during bathing moments, meals (see Brumberg-Kraus 2020), bed time and during the night.

High degrees of ritualization were found on the other side of the continuum, when the situation of the patient was unstable because transition to death came near. This was the case with patients who entered the dying phase. In these situations, ritualization was directed to preparing for and assisting in a good transition to death. In the following, we will describe, analyze and evaluate two ritualized care practices, on both ends of the continuum.

## *4.2. Small Moments of Significance*

Mrs. Van Beek had been staying at the hospice for quite a number of weeks. She was an active woman until recently. Mrs. Van Beek is now immobile and spends her days in a wheelchair and in bed, sleeping most of the time. Her eyesight is bad so activities to occupy herself are difficult. Despite regular visits from family and friends, she often expresses that she feels lonely and that every day feels the same. During day-to-day practices at the hospice, nurses take this into account. They engage in contact with Mrs. Van Beek as often as possible, mostly through the senses of touch, smell and taste. Nurses pay specific attention to the bed bath Mrs. Van Beek gets in the mornings. She enjoys the proximity of the nurses in this situation and being pampered. The bed bath was given according to the existing nursing protocols and guidelines. The nurse, however, added her own elements to this situation. She brought in heated towels to cover Mrs. Van Beek during the process of washing and getting dressed. The nurse indicated that she found it important to give her patients a little bit of a wellness moment. Another essential element of the bed bath was to attentively massage Mrs. Van Beek using her personal marigold oil. The sensation and smell brought about positive associations and feelings, and every time, Mrs. Van Beek would remark on this. The nurse always ended the bathing moment by applying Mrs. Van Beek's favorite perfume, and again, she would comment how much she loved the smell.

The case of Mrs. Van Beek exemplifies how patients at the hospice can experience the state of liminality. She entered the hospice knowing that she was going to die but her health situation has remained the same for weeks now. Because she is too weak to do anything, her days are pretty much the same. In this relatively stable state of liminality, degrees of ritualization are low.

The routine bathing moment stands out from the ordinary through the stylized and deliberate use of warmth, massage and smell. The acts are symbolic because they served to connect to Mrs. Van Beek and to acknowledge her value as a person. This was both meaningful to the nurse and to Mrs. Van Beek. The marigold oil and perfume were symbolic objects because they represented positive associations with home and the life she used to live, which are meaningful to Mrs. Van Beek.

In this situation, ritualization had a recreational function by providing a small moment of significance that stands out in a day in which there was little to look forward to. These small moments of joy are her anchors during the day that provide structure and meaning. In that way, these practices could also be prophylactic, and in a small way, they might help Mrs. Van Beek cope with her situation. To the nurse, ritualization also had an expressive function as a way of expressing the value that she attributes to Mrs. Van Beek as a person.

As insignificant as these small, ritualized activities might appear, they create structure, meaning and value in the days of the patients and are a source of human connectedness, compassion and acknowledgment.
