Office of Parish Outreach Ministries/Health Care Ministry

MINISTERING TO PERSONS WHO ARE DYING

INTRODUCTION: Our Christian belief offers us an inspired lens through which to view the life event of dying. The death and resurrection of Jesus Christ and the promise of eternal life are strongholds we can grasp when navigating the waters of death. Faith helps us to encounter death with courage and hope, to surrender our self to dying with trust that we will be cared for by God.

Contemporary culture, however, can find it difficult to acknowledge the reality that death is a part of life. In the medical climate of today, people who are dying may be referred to as "having failed their course of treatment". Advances in medical technology have been successful in postponing death but, when the technology fails, it is often said, "nothing more can be done" for persons with a terminal illness. This image of death as the enemy has created a culture in which dying is frequently perceived as a totally negative life event, something which shouldn’t be happening. This view of death leaves many dying persons with a sense of failure, abandonment and loss of control. It strongly influences the growing interest in physician-assisted suicide as a means of gaining control of a process which we perceive as enveloping us.

In reality, death is not something which merely happens to us. It is an event into which one enters. Dying is a natural life passage, like being born, growing up, growing old. Each of these processes involves pain, questioning, challenges, deep struggle, a myriad of powerful feelings, growth and, ultimately, letting go. Living is, as Henri Nouwen has said, a chance to say "I love you" to God. Living also teaches us how to die.

CARE OF THE DYING

In ministering to persons who are approaching death, the call is to stand with them to review, assess, reconcile, and celebrate the "I love you" that they have been in this life. Dying is an experience of the whole person. As well as tending to spiritual needs, the pastoral caregiver must be mindful of how individuals are impacted in the physical, emotional and psychosocial dimensions of their lives. Invitations to dialogue can be used such as: Tell me how things are going for you. How are you feeling emotionally? How are you feeling spiritually?

Through this pastoral encounter one hears, and should acknowledge, spiritual pain: anger, guilt, hopelessness, abandonment, sorrow and loss of meaning. Positive spiritual experiences will be uncovered as well: gratitude, forgiveness, hope, communion, peace, consolation and sense of meaning. It is important to learn who God is for the person. What the pastoral minister comes to understand becomes part of the prayer offered to God for the one visited. It can be very meaningful to conclude a visit with a spontaneous prayer that includes the expressed needs of the person (for forgiveness, family concerns, a sense of God’s presence, courage, etc.), as well as thanksgiving for blessings received. Invite the patient and family to participate in the prayer by naming that for which they would like to pray, or by adding to the prayer with their own words.

The pastoral minister brings compassionate care, the skill of responsive listening and the gifts of the Church: Sacrament, prayer, Scripture, devotions and a theology of hope. The request of Jesus to his disciples in the Garden of Gethsemane to "watch and pray" provides the guide for ministry to dying persons. It is a ministry of prayerful presence.

THE EXPERIENCE OF PERSONS WHO ARE DYING

Often in the process of illness and dying, as one’s body and strength diminishes, one’s spiritual or religious life deepens and grows. All persons need spiritual care when confronted with their own dying. For Catholic pastoral caregivers, our mission is to enter into the spiritual life of the dying person and, with some knowledge of that life, to walk forward together in Christ. Many will find comfort and strength in their Catholic beliefs, practices and affiliation. For others, spirituality is expressed through their connection to family and the world around them and to their life work.

Through the pastoral conversation, a spiritual care provider should seek to discover how and where a person finds meaning in his or her life. What are this person’s values? Where is the spirit, the inner life of this person focused? How does s/he experience God? How is religious life a resource to that person? How does s/he understand or make sense of suffering? These are not questions to be asked in a probing manner, but rather information to be elicited as the sensitive minister engages persons who are ill in conversation about their life, their loved ones, their illness and prognosis and their relationship with God.

Howard Clinebell in Basic Types of Pastoral Counseling details a framework of religious/existential needs: the need for meaning and purpose, the need to give love, the need to receive love, and the need for hope and creativity. In ministering to dying persons, these four areas provide a road map to assess the challenges the dying person is facing.

Meaning and purpose:

* What personal values are important at this time?

* Are they able to draw on their religious faith?

* Do they continue to know themselves to be of worth even if they no longer can fulfill their previous life roles (as breadwinner, caregiver, professional, etc.)?

* Can they find purpose to life in the midst of their illness, or do they see their present life as meaningless?

* How do they answer the "why" questions?

Ability to give love:

* Are they able to let their loved ones be with them in this time of illness, or are they keeping them at an emotional distance?

* Are they able to be somewhat other-centered, or do they place unfair demands on their loved ones and other caregivers?

* Are they able to pray?

Ability to receive love:

* Do they trust others?

* Do they trust God? Who is God for them?

* Can they express confidence in their caregivers?

* Are they forgiving of themselves? Of their loved ones? Of God?

* Do they see themselves as a burden or in the way?

* Are they expressing signs of feeling guilty, angry, fearful towards their loved ones or God? Do they feel abandoned by God?

* Are they so fearful of being dependent that it interferes with their care and quality of life?

Hope and creativity:

* Do they have realistic goals about their illness and their prognosis?

* Do they value their inner self more than their physical abilities?

* Where are they in the process of transforming the hope they had carried of being cured into a hope that more realistically reflects their present prognosis?

* Do they have a sense of God’s presence in their life? Of God’s steadfast love for them? If so, how are they experiencing that? If not, what might be blocking this awareness?

* Are there unhealthy religious beliefs that should be addressed?

* What are their beliefs about life after death, heaven and hell?

* How are these beliefs impacting their spiritual well-being?

THE SEVEN FEARS OF DYING

The concept of "The Seven Fears of Dying" is from the work of Thomas Leicht (1978) appearing in Hospice: A Caring Community, by Theodore H. Koff. Winthrop Publishers, Cambridge, MA 1980.

1. Fear of the PROCESS OF DYING

* Will death be painful?

* How will I get through this?

Encourage expression of fears. Find out if this person knows his/her prognosis. If life expectancy is brief, does s/he know that s/he is dying? (This is best determined by asking questions such as: What has your doctor told you about your illness? or What do you understand about your future? Also, What are you most worried will happen in the days ahead?)

2. Fear of LOSS OF CONTROL

* Must I give up independence?

* Can I cope with being dependent upon others?

We live in a culture that prizes autonomy, being independent and in control. Patients entering a hospital and, unquestionably, patients receiving a life-threatening diagnosis, are entering into uncharted waters. Their body, the pain it carries, life itself is clearly out of their control. There is a demand for constant adaption, a constant shift in the balance between being in charge - exerting control - and letting go - relinquishing control when appropriate. This is a dance, one that calls for fluidity and one that life may not have allowed time for practice. (Ministers might inquire: What is most difficult for you right now? or What is it like for you to receive care from others? )

3. Fear of LOSS OF LOVED ONES

* What is going to happen to them?

* How will they manage without me?

Often family members and patients are so invested in protecting one another that they risk compromising an opportunity to share this intimate experience as a family. It may be helpful to inform the family that when a person is dying, the body gives very clear clues that it is dying. The choice is truly whether the person who is dying and the family carry this information in isolation or share it together. Sharing allows a family precious time to reminisce together, to heal and reconcile, and to reassure their dying loved one that they will survive and support one another after his/her death. (Tell me about your family. What worries do you have about them? Facilitating story telling/life review with a patient and/or family can open up avenues of deep conversation and help them to remember the strengths they possess. )

4. Fear of OTHERS’ REACTIONS TO THEM:

* The fear in the eyes of others

* Their non-verbal communication/body language

It is at times difficult to disguise the shock that is experienced when one enters into the presence of someone whose physical appearance has been ravished by terminal illness. It is important to communicate acceptance of the person despite these changes. Touch is essential in communicating a willingness to connect. Do not be afraid to reach out, to hold a hand, to lay your hand in prayer on the forehead or shoulder of the one who is ill. (Ministers need to be very sensitive to the non-verbal response of patients to touch. In some situations, it may be appropriate to ask the patient’s permission. May I hold your hand? or to inform them, I’m going to lay my hand on your shoulder as we pray or as I bless your forehead with the sign of the cross. Touch should be suspended if the minister senses distress or tension in response from the patient.)

5. Fear of ISOLATION

* I’m experiencing decreased or shortened visits from health care professionals and friends

The role of spiritual caregivers is to model presence. The dying are still present until they have breathed their last breath and surrendered their spirit. As physical and emotional energy wanes, persons may withdraw emotionally and not have strength for visits from casual friends. In the final hours or, perhaps, days of life, a patient may not have the capacity to respond to those around them. It must always be assumed, however, that they hear and, to some measure, comprehend the conversations taking place around them. They are comforted by gentle, quiet presence, by storytelling about their lives, by love.

A primary requirement in providing good spiritual care to the dying is a willingness to hear the truth of the dying person, especially their fears and concerns. Having entered into this reality, the ministering person is better able to bring the individual's needs to God.

6. Fear of THE UNKNOWN

* What can I expect?

* Will there be life with God after death?

Even the strongest faith can be challenged in the face of the reality of death. Be open to exploring the beliefs and questions of a person facing death. Remember, for all our education and training as pastoral care providers, none of us has yet to experience death. This is a moment of profound humility. While it may be helpful for ministers to share their beliefs and their faith, they should always leave room for the questions of the one who stands at the threshold. (When you think about your death, what do you imagine lies ahead? What do you need most from God now? Are there faith or family issues that need reconciliation?)

7. Fear that LIFE WILL HAVE BEEN MEANINGLESS

* Review of life history

* Need to identify positive aspects in one’s life

Listen to the stories! They are a wealth of information about all aspects of the life of this person. Look beneath the stories for the common themes discussed above: meaning and purpose, giving and receiving love, hope and creativity. Where is their heart, their spirit focused? How can we help them reach more deeply into the recesses of their soul and lift up the meaning of their lives in celebration! (As you look back on your life, what do you feel good about? For what are you most thankful?)

PASTORAL RESPONSES

The following are suggestions for pastoral caregivers:

DO’S

Do set aside your agenda when you walk into the presence of a dying person. Even if you have been called in for a specific purpose, e.g., to anoint the patient, allow yourself to focus on the person, not the task.

Do take the risk to move beyond social conversation and ask questions about what is going on within the heart of the dying person. Respectful questions will not be experienced as intrusive.

Do keep your heart open to the experience of this particular person. You may have been present at the bedside of many dying persons, but this is the only time that this person will die.

Do allow yourself to be with the feelings of the person who is ill, dying or bereaved. Be comfortable with silence. This may be difficult as feelings of sorrow or suffering can stimulate the minister’s personal life experiences of loss and struggle.

Do avoid euphemisms (God doesn’t send more than we can bear) or providing simplistic answers to the deepest questions (Why did this happen to me?).

Do assume that the dying person can hear you. Speak directly but quietly to the person who is dying, acknowledging that you are aware that s/he can hear you, but is not able to respond.

Do include the family in your caregiving, in rituals or in anointing the dying person. If the patient is conscious, priests can offer the possibility for the sacrament of Reconciliation. Request that the family allow you a few moments of privacy. Re-invite the family back into the room to continue with the rite of anointing and the offering of Viaticum.

Do take time to grieve the losses you experience in your personal and ministerial life. If reflected upon and processed, these experiences become great ministerial gifts and an opportunity for a deeper understanding of God’s loving presence in suffering. If these experiences are denied or ignored, they may become a great liability.

DON’TS

Don’t name their experience, e.g., I know how you feel. Ask the person how s/he is feeling. The pastoral care provider can’t assume to know.

Don’t let your fears of your own mortality, helplessness, discomfort keep you from visiting or from hearing fears and other concerns. Embracing within yourself the fears you experience when in the presence of illness and death will allow you to be more open to inviting dying persons to share their fears with you.

Don’t tell the dying person or their loved ones how to feel - be brave - or how to behave - there is no need to cry. Our desire to direct these feelings and expressions of grief usually comes from our personal anxiety or sense of helplessness in the midst of such strong emotions.

Don’t feel that you must eliminate or take away the sad reality. Some ministers can mistakenly feel that they should cast a positive light on painful situations and try to make a person feel better.

CONCLUSION

In the face of terminal illness, it is often said that "nothing more can be done". The truth is that there is a great deal that can be done to assist a person who is facing the end of his/her life on earth.

In caring for dying persons and their loved ones, spiritual caregivers help them to look at the past, cherish what has meaning, and set right what is unfinished or in need of reconciliation. In listening to the questions, concerns and life stories voiced, spiritual caregivers assist in the clarification of values and beliefs, the claiming of joys and pains, successes and failures, hopes and dreams. By non-judgmental presence in the search for meaning, spiritual caregivers foster inner spiritual growth, enabling patients and family members to find within themselves strength and integrity.

In listening well and communicating care, the pastoral visitor is an implicit experience of God’s compassionate presence. Explicitly, one can assist the dying person with their spiritual preparation for death by offering prayer, providing sacraments and bringing and sharing a sense of trust, hope and peace.

Prepared by Jean Marchant, M. Div., LMFT, and Kelly Dunn

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