Can We Be at Peace With Unsolvable Suffering?

A Qualitative Study Exploring the Effectiveness of Supportive Communication and Resilience Building

Hiroaki Nagano, MD; Keiko Chida, BA; Taketoshi Ozawa, PhD


Journal of Hospice and Palliative Nursing. 2022;24(3):E76-E82. 

In This Article

Abstract and Introduction


The authors provided six 180-minute interpersonal assistance workshops using teaching materials from the End-of-Life Care Association: 90 minutes each on supportive communication and role-playing. The content included the following:

• Suffering people are "at peace" with someone who understands their suffering, which starts with building a relationship through empathetic listening. The goal is not to "understand them" but for them to "feel understood."

• Realizing the suffering of others and recognizing the internal moral and emotional strength of those who live with suffering.

• Resilience building: helping caregivers face difficulties even when helpless; remembering one's support networks and valuing oneself.

Participants (n = 114) wrote reflective journals after each session. Two domains and 10 key themes were identified through thematic analysis. The domains comprised topics on the importance of using listening techniques, such as repetition, waiting in silence, and asking questions (not to understand but for dialogue). The 3-month postinterviews revealed that participants could ease their sense of weakness by helping suffering people, which is relevant to work, grief care, and daily life. Changes in relationships between participants and patients were also identified. Role-playing can teach supportive communication, such as listening attentively and accepting others, which may help supporters engage with people experiencing incurable suffering.


One problem facing Japan in the 21st century includes a declining birth rate and an aging society. Whereas population aging is underway in many countries, the aging rate in Japan is unprecedented. Japan is forecasted to reach the super-aged status (defined as more than 20% of the population being 65 years or older) by 2025.[1] The national government has promoted policies including community medical care plans and advanced care planning to support terminally ill patients within the community rather than in the hospital.[2] However, even if such a system is established, people face a shortage of trained personnel to assist those who experience unsolvable, incurable suffering at the end of life.[2–4] Furthermore, there have been few opportunities to learn from a multidisciplinary perspective about the structure of suffering and resilience building. Although many workshops regarding palliative and self-mental care are occasionally held, their effects remain unclear.

The End-of-Life Care (ELC) Association was established in 2015.[5,6] The association has held many study sessions for interpersonal assistance across Japan, presenting information in a way that is easily understood by everyone, regardless of age or occupation. People in all professions, including those in health care, should learn the basics of interpersonal assistance and continually learn in real-world work environments. Furthermore, each person should continue his/her learning based on the basic principle that people who are suffering are "at peace" when they have someone who understands their suffering, it all starts with building a relationship through empathetic listening, and the goal of the communication is not for caregivers to understand patients but for patients to feel understood.[5,6] "Being at peace" encompasses positive emotions such as being happy, not suffering, smiling, and feeling well. The features of supportive communication—repetition, being silent (waiting), and asking—were based on previous research by Murata[7] and Morita et al and a practical guide for refractory suffering and palliative sedation therapy in advanced cancer patients.

This qualitative study was conducted by the ELC's Okinawa team to demonstrate participants' learnings through their ELC experiences. The purpose of this study was to examine whether the study sessions are successful in "strengthening of minds" or cultivating "resilience" in participants, and providing them the tools and strength to carry on, even during the COVID-19 pandemic that has exacerbated suffering when people have experienced increased difficulties and suffering.