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JOURNAL OF PALLIATIVE MEDICINEVolume 9, Number 5, 2006© Mary Ann Liebert, Inc.

Maslow’s Hierarchy of Needs: A Frameworkfor Achieving Human Potential in Hospice

ROBERT J. ZALENSKI, M.D., M.A.1,2 and RICHARD RASPA, Ph.D.2,3

ABSTRACT

Although the widespread implementation of hospice in the United States has led to tremen-dous advances in the care of the dying, there has been no widely accepted psychological the-ory to drive needs assessment and intervention design for the patient and family. The hu-

manistic psychology of Abraham Maslow, especially his theory of motivation and thehierarchy of needs, has been widely applied in business and social science, but only sparselydiscussed in the palliative care literature. In this article we review Maslow’s original hierar-chy, adapt it to hospice and palliative care, apply the adaptation to a case example, and thendiscuss its implications for patient care, education, and research. The five levels of the hier-archy of needs as adapted to palliative care are: (1) distressing symptoms, such as pain or dys-pnea; (2) fears for physical safety, of dying or abandonment; (3) affection, love and acceptancein the face of devastating illness; (4) esteem, respect, and appreciation for the person; (5) self-actualization and transcendence. Maslow’s modified hierarchy of palliative care needs couldbe utilized to provide a comprehensive approach for the assessment of patients’ needs andthe design of interventions to achieve goals that start with comfort and potentially extend tothe experience of transcendence.

INTRODUCTION

HOSPICE IS A SYSTEM AND PHILOSOPHY of care de-signed to support the goals of patients and

families during the last phase of life. In the lastcentury, necessary steps were taken toward pro-viding an open comprehension of the burdens ofmortal illness, through lessening the tabooagainst talking about dying,1 and recognizing thedimensions—physical, social, emotional, and

spiritual—of “total pain.”2 Expansions of the pal-liative care/hospice concept subsequent to thesefoundations have included interdisciplinaryteamwork,3 initiating care earlier in the diseasetrajectory,4 and promoting opportunities for de-velopment at end of life.5 All of these advances

set the stage for reaching new possibilities, butthere has been no widely accepted theory-drivenpractical schema to guide interdisciplinary teamstoward realizing potential achievements of self-actualization and transcendence.

We believe that Maslow’s hierarchy of needscan be adapted to hospice and palliative care toprovide a theoretical and practical framework toachieve maximum human potential. Althoughwe find Maslow’s psychology to be compelling

and robust in application to palliative care, wehave found few citations in palliative care thatdescribe this use of Maslow’s hierarchy.6,7 In thispaper we review Maslow’s work, summarizingand illustrating his hierarchy of needs; adapt thehierarchy to hospice and palliative care; apply the

1Department of Emergency Medicine, 2Center to Advance Palliative-Care Excellence, 3Department of Interdisci-plinary Studies, Wayne State University, Detroit, Michigan.



adapted hierarchy to the care of a patient; anddiscuss its implications for patient care, educa-tion, and research.

MASLOW’S THEORY

Abraham Maslow is one of the foremost psy-chologists of the twentieth century. Thoughversed in Freud and Skinner, Maslow was re-pulsed by the negative implications of psycho-analysis and behaviorism for human potential,

because of their focus on psychopathology.8

Maslow responded by formulating a psychologythat encompasses higher levels of human func-tion. The result—his famous Third Force—is ahumanistic approach to psychology. In Motiva-tion and Personality, Maslow presents his theoryof hierarchical needs and human development.8

Maslow postulates that the individual is an in-tegrated and organic whole. A theory of motiva-tion must include the study of ultimate humanneeds and goals appropriate to humanity’s fullrange of being. Maslow asserts that the funda-mental desires of human beings are similar de-spite the multitude of conscious desires. His psy-chology is premised on a shared humanity thatcrosses geographic, racial, gender, social, ethnic,and religious boundaries. This premise is rootedin a main philosophical tradition of Westernthought, essentialism, that extends back to pre-Socratic philosophy and continues into thetwenty-first century.9 Maslow posits that human

beings have a higher nature that can be under-stood and summoned in everyday experience.

Fundamental to Maslow’s theory of motivationis that human needs are hierarchical—that un-fulfilled lower needs dominate one’s thinking, ac-tions, and being until they are satisfied. Once alower need is fulfilled, a next level surfaces to beaddressed or expressed in everyday life. Once allof the basic or deficiency needs—so called be-cause their absence is highly motivating—are sat-isfied, then human beings tend to pursue the

higher needs of self-actualization. Indeed, the ful-fillment of the basic needs is considered a pre-requisite to such pursuit.

In discussions of the application and limita-tions of his hierarchy, Maslow took pains to em-phasize that this theory is a schema. Needs can

be partially fulfilled at lower and higher levels.Inversions or reordering of needs for particularindividuals at particular turning points is also

MASLOW’S HIERARCHY ADAPTED TO HOSPICE 1121

FIG. 1. Maslow’s Hierarchy of Needs. The figure dia-grams the dependence of higher on lower needs; the apexof the pyramid suggests that higher needs are less fre-quently realized.

possible.8 So, Maslow’s theory is a framework forunderstanding and action rather than a rigid pre-scription governing all human activity.

THE HIERARCHY OF NEEDS

Briefly, the first level of needs is physiologic(e.g., the need for food, air, and water). The sec-ond level encompasses safety needs. These in-clude security, stability, protection; freedom fromfear, anxiety, and chaos. The third level of needis belonging and love. These needs involve the“. . . giving and receiving affection. When theyare unsatisfied, a person will feel keenly the ab-sence of friends, mate, or children.”8 The fourthlevel is the need for esteem, which is fulfilled bymastery of the environment and the prestige thatcomes from societal recognition. The fifth level,

the need for self-actualization, entails maximiz-ing one’s unique potential in life. Living at thislevel can lead to peak experiences and even tran-scendence—the experience of deep connectionwith others, nature, or God, and the perceptionof beauty, truth, goodness, and the sacred in theworld. Such experiences become highly motivat-ing and lead to feelings of being enlivened andenlightened (Fig. 1).

Events from the twentieth century provide il-lustrations of the hierarchy. Media have provided



stunning examples of the effect of deprivation atthe first level in images of dying children in thedeserts of Africa. They are exhibits of the desola-tion of hunger. Such wretchedness is a dramaticcontrast to most children in the West whose com-plex lives, nurtured by sufficient food, are filledwith opportunities for education, play, and

dreams of prosperity. Examples of unmet needsat the second level have been revealed by researchon human beings in extreme situations, such ashostage taking, concentration camps, prisons, andeven prostitution rings. It reveals the brutality oflife directed by a regimen of fear. Victor Frankl’swork, in particular, on concentration camp in-mates, demonstrates the unmaking of human be-ings in the face of intense fear for physical safety.11

Fears about physical safety dominate life.Lack of fulfillment at the third level has been

dramatized by expressive culture showing the

power wielded by yearning for belonging andlove. The repertoire of Tennessee Williams’ dra-matic works, Streetcar Named Desire, Glass Mena-

gerie, Cat on a Hot Tin Roof , and others reveal thesuffering of love-deprived people struggling tomake their way in life. American painter EdwardHooper illumines the isolation of people sittingin the glare of an all-night coffee shop as iftrapped in silent glass bowls. Maslow, like Amer-ican artists, sensed the Weltanschauung, or “timespirit,” of midtwentieth century America that fo-cused on the devastation of loneliness. Absenceof fulfillment at the fourth level shows the ne-cessity of the connection between the individualand community. Inclusion and respect from agroup that shares values can lead to higher self-esteem. Artists, scientists, educators, and so on,work in a tradition with established norms of per-formance and rituals of inclusion and exclusion.We develop as human beings by successfully par-ticipating in communal traditions in every do-main of life.

At the fifth level, self-actualized people havepeak experiences. Cognitive psychologist M. Csik-szentmihalyi offers interesting research on the char-

acteristics of peak experience, including a mergingof self and action, a dropping away of all concernsother than the activity in the here and now, andself-forgetfulness. When people are at their best,they are in the peak or, in Csikszentmihalyi’s terms,the flow state.12 The great Boston Celtics’ basket-

ball center of the 1960s, Bill Russell, calls these statesof consciousness “magic moments.” When they oc-

curred, concentration was so intense that his playrose to new heights and he could almost predictwhere the next play would be.13

Recent scholarship in social science and hu-manities might question the usefulness ofMaslow’s hierarchy. For example, postmodern no-tions such as the politics of knowledge might sug-

gest that there are more accurate representationsof contemporary cultural forces and the dynamicsof motivation. The discourse of how knowledge islegitimated, for whom, and for what purposes,might challenge Maslow’s notion of a universallyshared human nature.10 Social constructivism, aswell, would argue that such knowledge of needsis local, context specific, and culturally configuredrather that total, universal, and natural. Other psy-chologists might consider Maslow’s model to besuperseded by newer theories.

Why, then, return to Maslow? Because we pos-

tulate that the theory of the hierarchy of needscan enable hospice teams to care more completelyfor patients at the end-of-life. Maslow’s approachcan encompass not only the relief of distressingsymptoms, but can also make explicit the oppor-tunities to address the psychological, social, andspiritual needs, taking one away from total painand toward human fulfillment. Maslow’s modelcan further open possibilities for transcendenceat the end-of-life, perhaps a unique opportunityassociated with this period.

Once modified for hospice and palliative care,Maslow’s hierarchy of needs is highly suitable forassessing needs and reaching human potential ofpatients with mortal illness. The resulting frame-work could be used and tested for its utility inthe assessment of need and the promotion ofhigher levels of self-actualization and transcen-dence.

ADAPTING MASLOW’S THEORY TOHOSPICE AND PALLIATIVE CARE

The etymology of “palliative” and “hospice”

indicate their purpose in fulfilling the hierarchyof human needs. Palliative comes from the Latin

palliolum, or cloak, a remedy for a condition thatcannot be changed or avoided, like winter, butwhose discomforting effect can be greatly less-ened. Likewise, ‘hospice” from the Latin hospitalismeaning host or guest, suggests a welcoming at-titude in the provision of both physiological and

ZALENSKI AND RASPA1122



safety needs, conveying a sense of warmth andappreciation for the traveler.

In applying the pyramid to hospice and pal-liative care, we are not arguing that the hierarchyis universal (applying to all) or rigid where nohigher level needs can be addressed until all ofthe lower ones are first satisfied. Our purpose is

to provide an improved approach to structuringcare to patients by using Maslow’s schema. Thehierarchy indicates the urgency of fulfilling more

basic needs first, and helps suggest a logic for ap-proaching a patient’s problems and needs. For ex-ample, it is inappropriate to talk about meaningor transcendence to a person in pain, fear, or so-cial dejection. At the same time, such conversa-tions might be necessary before all physical paincould be relieved.

We propose that the relief of physical pain is afirst-order need. The devastating and depriving

effects of chronic fatal illness call for an applica-tion of a modified hierarchy of needs. Dissemi-nated cancer, organ failure, or terminal frailty areconditions that threaten our most basic abilities—the expression of appetite and desire, the experi-ence of pain and energy, the power to functionas an embodied self in society. These threats canlead to a failure to meet basic biologic and safetyneeds. Untreated pain anywhere in the body cantyrannize consciousness and shatter any plan toextend the self into the world. Patients in severepain often yearn for death as the great relief. Inthose moments, throwing themselves out thewindow or being run over by a truck may notseem undesirable.

The second order needs are for safety in a per-sonal and social sense. When safety needs are notmet, fears can dominate living, ranging from day-time worry to nighttime anxiety and insomnia.Fears might be about falling or physical safety.Fears can be about the way one might die, suchas choking, suffocating, drowning, or they mayconcern the fear of death and the end of existenceitself. At the extreme, fear can be completely iso-lating and paralyzing, rendering minute-to-

minute existence unbearable. Maslow’s hierarchyreminds us that until such fears are addressedand relieved, no progress can be made towardimproved quality of life or ascending into the up-per levels of the pyramid.

At the third level, devastating illness can testone’s ability to give and receive affection, even ifthese needs were previously met, and, especially,

if they were not. For example, after any disfigur-ing disease or therapy, like a mastectomy or am-putation, people naturally wonder if they are stillloved or even lovable. It is evident that specialsupport systems, which can be mobilized by thehospice team, may be vital to address this worry.

The need for belonging is especially important

at the end of life. Dying alone can be a brutal ex-perience. Paradoxically, the end of life is the finalspace for intimacy. It is in this space that a per-son can feel secure revealing thoughts, feelings,and action that might otherwise be assessed aswrong or negative. Intimacy is the experience of

being oneself, and of being recognized and ap-preciated for that self by others. Ideally, at theend of life the summoning of intimacy can be-come the space for healing.

At the fourth level, the inability to accompanyfamily or friends in usual activities can lead to

doubts about one’s ability to enjoy life with oth-ers. Disability and resulting unemployment candevastate the person’s sense of self-esteem andworth. Such dislocations can lead to intense suf-fering.14 The hospice and palliative care team canmake special efforts to appreciate the patient forall that his or her life is and has been. Inviting thepatient and family to share with the team the pre-vious activities, accomplishments, and values canmarkedly affect the attitudes of caregivers andpatients alike. Recognizing the patient’s contri-

butions to a profession as a craftsman, technician,lawyer, as well as to a friend or family as son,daughter, father, mother, relative, or friend, mayrestore a sense of value and esteem.

According to Maslow, fulfilling the first fourlevels of the pyramid gives patients the bestchance to achieve the fifth level—self-actualiza-tion and transcendence. Maslow’s definition ofself-actualization is, “the tendency to actualizeone’s potency, to become more and more whatone idiosyncratically is.”8 This fits well with Cic-ely Saunder’s description of the goal of a patient’s“being himself” at end of life.15 Transcendence isconnection to others, the universe, or divinity

leading to an intensification of life, a feeling oflimitless possibilities, and a sense of wonder andawe.8

Maslow’s hierarchy suggests that addressingthe first four needs—symptom control, safety, be-longingness, and esteem—is valuable in itself aswell as for the potential to achieve self-actualiza-tion and transcendence. As the illness progresses,




lower needs, such as hunger, might literally betranscended. The patient may no longer be ableto eat, and, thus, nonmaterial needs might be theonly domains that can still be satisfied.

Measurements of quality at end of life, such asthe McGill Quality of Life Questionnaire scale16 fo-cuses on emotional and spiritual concerns and con-

firms that intimacy, esteem, and actualization areindeed the prized domains in the final phase of life.Moreover, each step up the hierarchy, such as free-dom from pain, is itself a kind of transcendence, aleap that releases energy for future tasks of devel-opment. Figure 2 outlines specific elements of thepatient’s experience within the hierarchy.

APPLICATION TO PATIENT CARE

We will use the adapted hierarchy to analyze

the care given to Frank, a patient seen by the pal-liative care consult team at Veterans Hospital. Hisfirst name and his story are used with written per-mission of his family. Frank was diagnosed withan abdominal mesothelioma in 2003, and his in-patient doctors gave him 2 months to live. How-ever, he then went on to live for 1 full year in hos-pice care. His major health care problem prior tocancer was a severe affliction with posttraumaticstress disorder (PTSD). Episodes of flashbacksand bouts of depression were disabling for him

ever since his return from Vietnam. His family re-called twice-yearly hospitalizations aroundpainful trigger times, such as Memorial Day,when they would have to literally drag him to thehospital. Prior to his diagnosis of cancer, Frank’squality of life was severely jeopardized by theseepisodes.

Maslow’s hierarchy of needs enables us to con-ceptualize and elucidate the care he was given.The palliative care team treated each type of needas it was discovered. When Frank was initially re-ferred to palliative care, he had several first-leveldeficiency needs. On the physiologic level, he wasexperiencing nausea, pain, and a high degree ofdiscomfort from a malignant peritoneal effusion,which recurred despite serial abdominal taps. In-termittent opiates, reglan, and an indwelling“pigtail” abdominal catheter were successful innearly completely relieving these symptoms.

Once these were addressed, we were able toexplore the level of safety needs: Frank was afraidof dying a slow painful death and of lingering inagony. This concern was specifically addressed

by his palliative physician as often as was needed by reassuring him, that if such symptoms devel-oped, he would be given the opiates and othermedication needed to relieve his symptoms. Ashe strongly desired, such pain would be relievedeven if it was accompanied by the side effect ofsedation. The team assured him that medicationseffective in treating such pain would not bespared. When Frank was fearful of further nau-sea and vomiting, the hospice team explainedwhich drugs and interventions would addressthese symptoms. This commitment to pain andsymptom relief settled his fears.

On the third level—belonging and affection—Frank was fortunate to still have living and lov-ing parents, as well as a brother and sister whowere very committed and active caregivers. Hehad lost his wife to cancer 10 years prior. Frankwas pleased to have a hospice nurse whom hefound quite physically attractive, as he consid-ered himself still an eligible bachelor. He had

coworkers, former businessmen, and friends. Inparticular, he had a Marine Corps friend—his bestfriend from high school—who stayed with himthrough the end of his life. In addition, hospicestaff liked Frank, with whom they laughed and

joked, even when performing the most routinetasks and procedures. His health care team, in-cluding his doctors, celebrated his birthday, andeven remembered him with long-distance calls


FIG. 2. Maslow’s hierarchy adapted to hospice and pal-liative care. The figure diagrams the dependence on lowerneeds; the apex of the pyramid suggests that higher needsare less frequently realized.



when they were away on trips. The team physi-cian brought a small wooden carving of a dragonfrom a trip to China, which helped persuadeFrank that he was cared for even when the doc-tor could not be with him. Frank and his familytreasured these calls and tokens of affection.

On the fourth level, the VA hospice staff re-

spected Frank for his service to his country. Theylistened to his stories about war in the jungle, theyoung men he left behind, the Marine base that heran, and the way he cared for those under his com-mand. He recounted how he floated for days inthe South China Sea but escaped capture. The teamalso listened to his narratives of his work life, talesof his life as a builder of fabulous homes worthmillions of dollars in Orlando, Florida. The pallia-tive care team knew that such interested listeningwas a generative act that could lead to healing.

Did Frank reach the fifth level of self-actual-

ization on Maslow’s hierarchy? The authors be-lieve that by meeting these deficiency-needs,Frank reached toward Maslow’s highest level.This achievement occurred in stages, and not inclear, unbroken movements. What follows is achart of his progress that maps the geography ofhis healing.

Frank comprehended his prognosis. He knewhe was dying, yet that awareness somehow pro-vided a deep, existential relief. The pain of hisPTSD, from which he suffered for more than 30years, was ending. His severe PTSD, requiring atleast two hospitalizations per year, vanishedwhen he was given the terminal diagnosis. Heseemed to be able to shed the guilt of having sur-vived the deaths of younger men in Vietnam forwhom he had felt a total responsibility.

Another instance of Frank’s movement towardself-actualization came from doing things he mis-takenly believed he could no longer do. The pal-liative care team encouraged Frank to say how hewould like to spend his final months. The teamgave him permission to dream. Frank responded.He spoke of a longing to go to Florida, to rewalkthe steps of his first date in St. Augustine with

his late wife. He wanted to feel the salt spray onhis face and the sand between his toes, and re-visit the mansions and his former business part-ners who now owned them.

These plans may also have served to meet ahigher need as well as address a fear. One of hisspiritual fears was that after death, he might losethe treasured memories of his wife and friends.His father had inadvertently suggested that possi-

bility, perhaps hoping to provide a release. Frankwanted explicit reassurance from the hospice doc-tor and asked, “That cannot be true, can it?” Whileno one could guarantee an afterlife, strengtheninghis connection to his past was a concrete way ofavoiding his father’s prediction. His doctor sug-gested he could deepen his memories by traveling

to Florida. Revisiting the significant people andplaces would simultaneously be a leap into the fu-ture and a journey into the past. Frank could reachfor new adventures and, at the same time, com-plete his fond memories of the past.

His “pilgrimages” to Florida were a way ofstrengthening those memories. As soon as his in-dwelling abdominal catheter was placed anddraining, Frank purchased airline tickets toFlorida, and asked his palliative care doctor forpermission to go. After assuring adequate sup-port, provided by his best friend, his doctor gave

him “permission”—a resounding yes. So suc-cessful was the trip that Frank repeated the jour-ney two more times. By embracing connectionsto the memory of his beloved wife and his past,he was achieving closure.

In his final months, Frank’s focus turned towardhis family. Being with them was the most impor-tant part of his life. He sold his house and movedin with his parents. His family, particularly his

brother and sister, cared for him. His parents spentprecious time with him. Frank and his father, aWorld War II veteran, exchanged war stories thatthey had never previously shared. At each stageof his illness, Frank began to express gratitude forthe life and time that he had, in contrast to so manythat he knew. His swollen abdomen, he said, wassmall burden in comparison to those who had lostlimbs, or were in the ground at age 18.

Frank’s extended family felt that 30 years afterVietnam, they had mysteriously gotten the old“Frankie” back. Frank was cheerful, kind, andeven a comic with his nephews. The usual fearsof his “going off” at Christmas parties, a troublingprior pattern, were assuaged. This was clearly adifferent year. During a palliative care visit in Jan-

uary 2004, Frank declared that he had had the“best Christmas ever.”

Three members of the palliative team visitedFrank the day before he died. A new spiritual dis-tress became apparent. When asked why he ap-peared fearful, Frank explained that he was notsure that he had lived a good enough life. Having

been raised in the Catholic faith but having givenit up, he felt that it was too late to ask for forgive-




ness, and too hypocritical to turn to God, in the lastdays of his life. Reassurances and offers to have asympathetic chaplain visit appeared only mildly toallay these fears. About 30 hours after these con-versations, Frank died in his brother’s arms withhis family at the bedside, the community hospicenurse present to alleviate symptoms and to pro-

vide guidance to his family of caregivers.Frank’s dying in hospice was a journey of heal-

ing toward self-actualization. He lived his lastyear of life with exuberance, and his family’smemories of that time are an enduring gift. Hisfuneral was a celebration, and the hospice teammembers who attended were treated as the fam-ily members they had somehow become.

IMPLICATIONS OFMASLOW’S HIERARCHY

This case example shows an application ofMaslow’s hierarchy. It illustrates how the deliber-ate addressing of the more basic deficiency needsstabilized the patient and allowed him to actual-ize his important end of life dreams. Earlier atten-tion to spiritual care may have led to addressingforgiveness and spiritual worth that arose at thevery end of life. Such work might have left Frankmore prepared to face his final days.

Maslow’s framework provides a comprehen-sive approach not only for achieving comfort atend of life—through the relief of symptoms andaddressing of fears and safety issues—but for aself-actualization that can be achieved in the lastparts of the journey. We believe that Frankreached the final hierarchical level by fulfilling at-tachment and esteem needs in his community offamily and caregivers.

Healing and coping with suffering

In the third edition of Motivation and Personal-ity, Maslow himself suggests a way of conceptu-alizing healing in the face of serious illness. A per-son who is able to meet the range of human needs

described in the pyramid could be consideredhealed despite the absence of a cure for terminalillness. This distinction between healing and cur-ing is a key to growth and, even, renewal in theface of chronic fatal illness. Experiencing loss andthen restoration at differing levels of the hierar-chy can move a patient to express gratefulness forthose things which have been taken for granted.Frank communicated appreciation for the feel-

ings of comfort, rest, and the presence of peoplewho provided love and esteem despite the diffi-culties of terrible illness. Gratitude is an amazingsign of the highest level of self-actualization.

Maslow’s hierarchy also has the power to in-form caregivers about the suffering of those whohave never had the basic needs of safety, love, or

esteem fulfilled. For those who are already suf-fering from “deficiency” needs, one effect of fa-tal chronic illness may be to reopen the originalwounds and produce additional suffering. Whenthe wounds are reopened, there also may be apossibility of healing these wounds in a deeperway.

The conscious implementation of Maslow’s ap-proach may increase motivation and enhancesuccess for patient and caregiving team. Thevalue of applying Maslow’s hierarchy to chronicillness is beginning to be recognized.6,7,17,18 Ex-

tending that application in the domain of pallia-tive care can deepen the understanding thatMaslow’s work fosters, namely that unmet needsprevent further progress in caring and healing forthe terminally ill. The use of Maslow’s hierarchyis compatible with other interventions, such asVictor Frankl’s logotherapy.19 We believe thatMaslow’s emphasis on an experience of life com-plements Frankl’s emphasis on an experience ofmeaning.11

SUMMARY AND FUTURE PLANSThe explicit use of Maslow’s hierarchy in the

care of hospice patients can be the difference be-tween tragedy and transcendence at the end oflife.18 Addressing symptom control and the reliefof fears are not only important in themselves, butalso the basis for further development in the do-mains of love, esteem, and actualization duringlife’s final phase. As the case of Frank illustrates,the sensitive attention the hospice team gives tothe patient in providing pain relief, alleviatingfears, delighting in stories and verbal exchanges,

eliciting and encouraging dreams—these acts caninspire patients to transcend the disease. Thus, inthe face of death patients can experience an in-tensification of life and a profound connection tothe people and the world around them. Maslow’sapproach could serve as the theoretical frame-work for the design of interventions that mighthelp many develop greater potential at end of life.We intend to develop and test these interventions




that are derived from this adaptation of Maslow’shierarchy of needs to palliative care. The most im-portant benefit, in our view, that the hierarchymay provide is its comprehensive reach. Symp-tom control, relief of fear, expression of love andesteem can have the power to inspire a patientand family to experience self-actualization and

transcendence.

ACKNOWLEDGMENTS

The authors wish to acknowledge the expertreview and generous contributions of the mem-

bers of the The Illness and Human PotentialStudy Group: Linda Emanuel M.D., Ph.D.; Sara J.Knight, Ph.D.; Terri Kovach, Ph.D., A.M.L.S.; San-dra Moody-Ayers, M.D.; Lance Rintamaki, Ph.D.;Whitney Perkins Witt, Ph.D.; M.P.H. We also

thank Renata Korabiewski for invaluable assis-tance in the creation of Figures 1 and 2. Materialsupport for this work was provided by a sabbat-ical leave from Wayne State University.

The authors acknowledge and thank everyclinician who cared for Frank on his journey ofhealing.

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2004;49:366–72.

Address reprint requests to:Robert J. Zalenski, M.D.

Department of Emergency MedicineWayne State University

4201 Saint Antoine6G UHC

Detroit, MI 48201

E-mail: [email protected]


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