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Pastoral Care for the Dying, Part II

Gordon Cook

In my previous article we considered the signs of approaching death, the importance of facing death as a pastor, and several common spiritual tasks relating to dying: remembering, reassessing, and reconciliation. Now we turn to the fourth task, reunion, and a fifth, preparing for the journey.

Reunion

Many people report seeing loved ones coming to them prior to death. However this may or may not fit into your understanding of the world around you, it generally is very comforting to those who approach death. At the very least, it expresses a common human desire to be reunited with loved ones.

One man had struggled with his Christian faith for many years. At the root of the problem was the sudden infant death of his son. Some bear heavier burdens in this life than others. Yet he persevered in faith. As he approached his own death, the memories of his loss returned and made his days intolerable. Part of him was afraid to die. Another part wanted to take his own life. It was a nurse who raised the question of whether he thought he would see his son again in heaven. He raised the same question with me, and I responded by reading with him 2 Samuel 12, allowing him to draw his own conclusions. From that point on, his attitude completely changed. His interests turned to heaven, reaffirming his faith, preparing his soul to meet the Lord, and hoping that this would one day include a reunion with his son.

Preparing for the journey

In some literature, the metaphor of the journey is so misused that I am somewhat reluctant to use the language here. Nevertheless, many people as they approach death see themselves as preparing for a journey and speak of "going home." Jesus uses similar language in John 14, a passage which I sometimes share with these people.

Preparations include setting things in order, providing for loved ones, concluding business affairs, making funeral and burial arrangements, and the like. It can also include saying good-bye, expressing love for family and friends, asking for and granting forgiveness for past offenses, and saying thank-you to those who have supported them. In the final days of life this need to take a journey may be acted out physically as the person seeks to get out of bed (actions which place the person at significant risk for falling and incurring painful injury). The medical professionals often respond to this with medications. Simply affirming that the person is ready for this journey and that Christ will soon welcome his servant may be sufficient to inspire the patient endurance that is needed during these times of restlessness.

For many believers preparing for the journey also involves reaffirming their faith. This is not necessarily some formal reaffirmation, but rather a simple desire to share their spiritual journey and continued trust in the Savior with others. The faithful shepherd will listen to this reaffirming of faith, and offer reassurance.

Still others will use their last bit of energy to confess their sins, seeking God's forgiveness and reassurance of pardon.

This is not the time for profound theology, extensive teaching, or elaborate ritual. It is the time to listen with an open and loving heart and to provide that reassurance and comfort that comes from God's Word.

Some simply cannot wait for the glories which lie ahead. It becomes the focus of their final days. These have learned the secret of Paul's words "to die is gain" (Philippians 1:21). Sometimes they are so eager to move on to glory that they alienate themselves from family and friends who desire them to stay longer. Encouraging such a person to enjoy the days of life which God gives here in this world may provide a healthy balance to a preoccupation with glory, allowing the person to remain connected with family and loved ones. Gentle reminders of the Scripture's teaching on the intermediate state and the promises of a future bodily resurrection when we will be reunited with loved ones who have died in the Lord are appropriate here. I do not tend to challenge the many popular misconceptions which the person may hold, but only to reshape them in terms more consistent with the teachings of Scripture.

Some express fear of death, even though they profess their faith. One man's daughter approached me expressing confusion. "My father has always been a firm believer in Christ, a leader in the church, and a wonderful man. But now he seems afraid to die. What is wrong?" I talked with the man at some length. Sure enough, he made a very credible profession of faith in my presence, but shared his own concern that when he thought of dying, his whole body would tremble with fear. "Is there something wrong with my faith?" he asked. (One of those questions which often is a clear indicator that there is nothing wrong with a Christian's faith.) When we talked further about this and particularly about his past experience with those who are dying, I asked about the passing of his wife. He began to shake. Later he told me that his wife, also a strong Christian woman, had died of lung cancer. "She made me promise to stop smoking. But I couldn't keep my promise. When I get up there, she's going to kill me!" I assured him that those who die in the Lord are made perfect, therefore she will not be angry with him, and he will not have to die all over again. We then spent some time talking about grace and about how nothing can separate us from the love of God in Christ. He died peacefully several days later.

God's answer to anxiety is prayer. Pray with those who cannot pray for themselves. "Do not be anxious about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God. And the peace of God, which surpasses all understanding, will guard your hearts and your minds in Christ Jesus" (Phil. 4:6-7). I once thought that everyone can pray. I now know that sometimes the confusion and restlessness of approaching death can hinder even the most devout person in prayer. Don't rebuke them, pray with them!

Being present at the moment of death

One of the great privileges of the ministry and one of its burdens is that pastors are often welcomed into families as if they were full members. This means that when death is imminent or immediately after death has occurred, the pastor is expected to be present with the family. Unless the family tells you otherwise, if at all possible, be there with them, at least briefly.

In those final hours, no words may be necessary. Your silent presence will be appreciated, and your quiet prayers will be a comfort to all who are present. Some will desire quiet Christian music, others may appreciate readings from Scripture, many will prefer quiet.

One day I came into the hospice unit at a VA Hospital. The nurses were furious. The day before, a hospice patient had died, while his family members sat in the next room watching a football game and cheering for their favorite team. The nurses thought this was hopelessly inappropriate. I reassured them that only weeks earlier, the patient had shared with his family in this tradition, undoubtedly with some liquid refreshment in his hand. Each family is different in how they approach these last moments, which often feel very awkward for all of those present.

If I can give you one piece of advice, memorize the Twenty-third Psalm. We cannot begin to count the number of times that Psalm has brought comfort to the dying, and to the family after a death has occurred. Memorizing it allows you to use it before, during, or after prayer without having to find it in your pocket Bible or your iPhone Bible app. (One word of caution about this, many associate the Twenty-third Psalm strongly with death and grief. Because of this, if you use this Psalm with someone who is not actively dying, they may misinterpret the situation, which in turn may produce an unintended personal crisis for them.)

Becoming Part of the Team

Two terms which you should be familiar with are hospice and palliative care. Both provide comfort care for persons in crisis. Hospice is an organized program of healthcare professionals and well-trained volunteers who provide care for people in the final months of life. It supports those who desire to die at their home or at their residence in an extended care facility. Hospice can also provide care within a specialized hospice facility or hospital if a patient's symptoms get out of control. For those who have a prognosis of less than six months of life, the hospice benefit found in most insurance plans, including Medicare, provides significant healthcare and financial assistance. Palliative care is a mode of healthcare which focuses on the alleviation of pain and suffering, rather than aggressive treatments focused on a cure. Palliative care concerns itself with quality of life, rather than prolonging life. Most hospitals have a palliative care team which works with patients who are actively dying and with their families.

Both share a commitment to provide spiritual and religious support for the people they serve. They will be interested to know that you serve as the person's pastor and will encourage your visits with the patient and the family. Within the bounds of confidentiality, the team can help to keep you informed of the needs of the patient and family, and will be both interested in and responsive to your perceptions of spiritual needs. I would encourage pastors to make themselves known to the hospice chaplain or other members of the hospice or palliative care team. This team can help you better understand what your church member and his or her family are experiencing. The team can also notify you of times when it may be important for you to be present with the family.

The Assessment of Pain

One concern that many people have regarding approaching death is pain. The desire of many people as they approach death is to just go to sleep and not wake up. Some people actually die this way with very little discomfort. For others, approaching death is accompanied by a great deal of pain and discomfort. Hospice and palliative care professionals have a wide variety of medications and interventions that can help to keep people as comfortable as possible. These medications, when used appropriately, do not hasten death, but bring much needed comfort to those who are dying.

The challenge for the healthcare professional is that their patients who are approaching death are not always able to speak for themselves to give verbal indications of discomfort and thus of a need for medical interventions. They need the help of family members, friends, and pastors to identify people who need additional pain relief. Some people will share their experience of pain far more readily with the pastor who they know and trust than with a doctor or nurse. Sometimes such a person will identify his or her level of pain as a prayer request. If a dying person tells you that he or she is having pain, I hope that you will report this to the family or to the nurse who is providing care. Don't just pray about it and walk away. God can and often does use medications and other very simple interventions to alleviate pain in his children. Something as simple as the provision of a hospital bed in the person's home may make a huge difference in his or her comfort at the end of earthly life.

Others are unable to speak about their pain, but show signs of pain that you may recognize. Behavioral indicators of pain include:

  • facial expressions such as grimacing, wincing and the like
  • vocalizations such as outcries, groans, or moaning
  • bodily movements - continual restlessness, rubbing an area of the body, and the like
  • changes in interpersonal interactions—withdrawal from social situations, irritability, combativeness, declining a pastoral visit when these visits have been common
  • mental status changes—increased confusion, inability to concentrate

Your observations of change in any of these behaviors are of particular importance. If you have never seen this person doing this behavior before, please pass this information on to a healthcare professional, either directly or indirectly through the family.

My sister was on the respirator for three days. She had asked never to be placed on such a machine. When they finally turned the machine down, the expectation was that she might die. But God had other purposes for Joyce. She awoke from her coma, weak but alive. She continued for almost a year. During that time, she and I enjoyed a most precious fellowship in the Lord, writing to each other almost daily, reflecting together on the Psalms and on the gospel of our Savior. It was hard for both of us, but a true gift from God.

Then came the call. Joyce was actively dying and the family was gathering. My wife and I travelled over to Vermont to be with her during her final day. When we arrived, she was unresponsive and actively dying. Once again I sat with her, reading what had now become familiar passages of Scripture, and offering prayer on her behalf (and on mine). I am grateful for the wise counsel of an older pastor to thoroughly memorize the Shepherd Psalm (Twenty-third). It is helpful when you can no longer read the pages before you, and it is as comforting to my soul as it is to the others present in that moment.

Joyce's passing into the arms of a loving Savior was quite peaceful. However, I was surprised how very difficult it was to watch the funeral director remove her body from her home. The pastor's task does not end when the person dies. Now there is a family to comfort. But I will reserve this for another article.

As for my sister, her soul rests securely in the Lord, awaiting that day which we all await.

Gordon Cook is the pastor of Merrymeeting Bay Orthodox Presbyterian Church in Brunswick, Maine. He also serves as the pastoral care coordinator for Mid Coast Hospitalin that community, and as a hospice chaplain. Ordained Servant, February 2010.

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