'Limitless and without Horizon': Spirituality in EOL care

Early Exits: Spirituality, Mortality, and Meaning In An Age of Medical Assistance In Dying 
David Maginley
Tristan Press, 2025
Softcover, 480 p.
ISBN: 978-0995881136
MSRP: $27.30 USD
Also available: eBook (Kindle)

Reviewed by Frank Brennan, MD

Where does assisted dying (AD)—also called “medical assistance in dying” or “voluntary assisted dying”—leave the discipline of palliative care? More particularly, what is the place of spirituality and meaning where AD is legalized? The answers to these questions are by no means certain. Such is the seismic shift in perspective. What is certain are two facts: whenever people suffer with serious illnesses, there will always be a place for palliative care; and, equally, an emphasis on spirituality will forever be important given the sheer complexity of human beings, their varied needs, and their rich individuality. 

Canadian David Maginley has provided psychospiritual support to people with life-limiting illnesses and their families for 25 years. In Early Exits he has written a timely and wise reflection on spirituality and meaning in the age of assisted dying. This book is useful for all clinicians working in palliative care, whether or not their jurisdiction has legalized AD. 

Maginley steps back from the AD debate and does not attempt to recanvas it. Rather, his objective is to examine the period leading up to a natural death, a period that AD truncates and stops. The general population may see this period as purely a time of suffering with no redeeming moments. Maginley points out that clinicians working in palliative care know that this is not necessarily true.

A life-limiting illness is simultaneously a physical and spiritual process. For the author, focusing on the former but rarely the latter is a disservice to the complexity of human beings. It narrows the narrative. This book provides a broader view. A view that we who work in palliative care witness daily. 

Too often, spirituality is regarded only from a religious perspective and, in a secular era, is too easily dismissed. Maginley reinforces that the modern view of spirituality in end-of-life care includes, but is not confined to, religious faith: it addresses suffering, fears, relationships, vulnerability, meaning, and reflection. The breadth of spiritual care is limitless and without horizon. 

Maginley looks at this breadth in multiple ways, through medicine, psychology, philosophy, religion, the literature of spirituality, and his own personal experience. He reminds the reader of the remarkable richness of the insights of this most elemental experience. 

In contrasting assisted dying with a natural death, he finds the former “so kind and respectful on one level yet so impoverished and strange on another.” For Maginley, AD is “a medical solution being used to treat a spiritual condition.” Later, he states that AD “provides a solution to a situation that is asking not to be fixed but understood.” Suffering at the end of life may be physical but, in his experience, is more often existential distress. The author provides numerous examples of how he responds to that distress with a combination of patience, curiosity, and compassion, always while providing symptom management. AD provides a different path. For Maginley, it is “a spiritual bypass” that diverts “from deep engagement with the dying to efficient management of the dying.”

The book is an important addition to the growing literature on assisted dying. Maginley has witnessed the periods before and following the introduction of AD and, as such, writes with great experience and insight. By expertly concentrating on the spirituality of dying and the nature of suffering, he challenges the reader to consider these aspects amidst the technical, procedural mechanics of AD. Maginley reminds clinicians of the importance of these considerations, whichever path is chosen. 

Dr. Frank Brennan is a palliative care physician, past president of the Australian and New Zealand Society of Palliative Medicine, a senior lecturer in the Faculty of Medicine, University of New South Wales, and a lawyer.