Pastoral Care of the Terminally Ill
In terminal illness several stages have been identified. Initially there is a stage of denial, although usually this is a temporary response that is replaced by partial acceptance. The denial can be followed by a stage of anger expressed in ‘Why me?’, and often the anger can be directed against carers, whether medical professionals, family members or pastors. Next is the stage of attempted bargaining, usually with God, to delay the end. This is followed by the stage of depression due to the patient realising what he is going to lose because of his illness, be it a bodily part, a physical activity, or an important function such as earning power. The final stage is that of acceptance, which is not necessarily a happy stage, but the time when the patient stops fighting his illness and may regard death as a relief. These different stages are coping mechanisms to deal with a difficult situation and throughout there is usually a hope of a miracle cure. Similar stages occur with family members, for they can also engage in denial, express anger (even at the terminally-ill person), attempt to bargain, become depressed, and reluctantly accept the situation.
Yet some qualifications must be made.
First, each patient will not have all the stages nor will other patients have them in the same order.
Second, the pastor should not be surprised if a Christian patient responds to the diagnosis with a serenity developed out of a mature confidence in the sovereignty of God, and may not exhibit any of the stages.
Third, the presence of these stages in a person’s response may not be due primarily to loss of personal well-being but rather to concern for family members. For example, a wife and mother of young children will be concerned as to what will happen to her husband and children during the time of her illness and also after her death.
Fourth, stages in terminal illness will vary depending on the age of the ill person: the emphasis associated with each stage will be stronger if the patient is young rather than old.
The Pastor and the Stages of Terminal Illness
The pastor has to assess which stage the ill person is in. If he is still in a stage of denial, the pastor should not judge him for what he is saying, although from the pastor’s perspective the person’s attitude will seem unrealistic and perhaps even give the impression of being difficult. The pastor should not tell the patient immediately in the stage of anger that his anger is wrong, for anger is often a legitimate human response to a wrong situation. Nor should the pastor take the person’s anger personally, even if the anger is addressed against him on occasion. Rather the pastor should realise that anger is often a desire for attention, opening the door for interaction and explanation. When pastoring those in the bargaining stage, it is important not to give false assurance to the patient; often the best response in this situation is to listen. There may be a desire to visit a faith healer or for the pastor to anoint him with oil as an application of the teaching of James 5:14-15. The pastor can perform the latter, but he has to make clear that there is no guarantee of healing. Those in the depression stage usually want to confess their faults and the pastor should be ready with words of forgiveness and assurance. The pastor may find that the stage of acceptance may be sullen submission rather than gentle acquiescence. The person may not want to talk, but since this is the last stage it is important that the pastor gently but faithfully speak to him regarding his spiritual condition.
Many of the problems experienced by the terminally-ill can be classified under the concept of fear. There is fear of unknown consequences, perhaps enhanced by knowledge they have of others who experienced terminal illness. Most people fear suffering and pain, in terminal illness there will be both physical and emotional suffering: physical suffering includes pain, nausea and shortness of breath; emotional suffering includes denial and depression. Then there is fear of physical disfigurement caused by the onward progression of the disease. Also, many people fear the process of dying rather than death itself.
A patient has at least four types of need: physical, emotional, spiritual, and social. The physical needs are met by control of distressing symptoms and excellence of nursing care. Emotional needs can be helped by proper handling of the psychological issues; better information and instruction about the management of the illness also helps, and anti-anxiety and anti-depressant medication can relieve some of these emotional needs. Social needs are usually met by people being prepared to spend time with the terminally-ill and assuring them that they are still of value despite their illness.
Each of the support agencies are concerned with helping the patient to have an as comfortable as possible period of terminal illness. Yet the pastoral role is different, for the pastor’s main concern is with the patient’s spiritual needs and with the spiritual needs of the family. In distinction from the other service providers, the pastor not only has to cope with the fact of death, he has to explain the meaning of death both to the patient and to the family.
A common expression of spiritual need involves the question. “Why me?” and it may be helpful, once the initial anger has subsided, for the pastor to explain the biblical teaching on suffering. Another expression of spiritual need occurs when the patient wants to review his life and to make a verbal statement of regret for certain actions; this may be the outworking of a guilty conscience, or may be an aspect of the stage of depression, but the pastor must also be sensitive to the possibility of the Holy Spirit working in the person to lead them to confession of sin, and therefore the pastor must be ready to speak of divine forgiveness based on the atoning death of Christ.
In the main, the terminally-ill with whom the pastor will interact will be Christians. Christians can go through the stages and fears mentioned above, and in addition can experience other influences. While each situation will be different, there are certain problems that are common with Christians undergoing terminal illness.
First, there can be a strange unwillingness to be helped, arising out of the conviction that God wants to use weakness to demonstrate his power. This desire for independence is a spiritual conflict.
Second, there will be disappointment at the appearance of stress symptoms, because it indicates the patient suffers from the same reaction as non-Christians.
Third, well-meaning Christian friends will give a book or cassette message that they are convinced is the answer to the patient’s need. Fourth, there can be temporary loss of faith, which can be expressed either in lack of assurance or in denial of the truth of the gospel.
The Pastor’s Goals in Situations of Terminal Illness
First, the pastor must aim to avoid mere professionalism in such a situation. He will have dealt previously with terminal illness, either in his family or through his ministry; also he will have studied appropriate literature and attended relevant courses; these factors can help prepare for involvement with terminally-ill people, but they also allow for the danger of professionalism. This danger is increased through the reality that visitation of the ill person will be one of a variety of activities to be undertaken that day by the pastor. The pastor needs to remind himself of the uniqueness of each terminally-ill person, and should respond to him as if he were the only person he was helping.
Second, with regard to a non-Christian family, his aim must be to teach the family of their need of the gospel, and especially aim to lead the ill member to trust in Christ.
Third, with regard to a Christian family, one aim is to prepare the person to die as a Christian. This involves helping to create a certain outlook. The ill person should be encouraged to loosen his hold on his possessions (this can be done by completing a will and having it lodged with his lawyer – doing this also helps reduce tension in the other family members). It is useful also to attempt to change the perspective of the ill person and help him move from his desire of explanation as to why he has the illness (a question that the Bible does not answer) to see his illness as the way God has chosen for him to leave this life and enter into heaven, in this way, life now is not devoid of meaning, but rather it receives meaning because of the life to come.
Geoffrey Clark gives a fourfold set of aims for a pastor dealing with a dying Christian.
First, he is to unite the person with his family, encouraging them to share his pain and also to support them through each stage.
Second, the pastor must aim to ensure the dying person that he is still a member of the human race, that his suffering has not made him an outcast.
Thirdly, the pastor should aim to help the person sense his membership of the church of Christ, particularly his union already with the church triumphant in glory.
Fourthly, and primarily, the pastor is to help the person know that Jesus is with him and will be with him all the way.
Terminal illness should not be regarded as the beginning of the end as far as spiritual development is concerned. Rather the final months of life can be ones in which spiritual development continues and even increases in intensity. The pastor can provide some helps, such as a reading programme in which relevant biblical passages can be reflected on, or give to the patient some items for prayer and keep him informed of any developments. Although the person may be almost housebound, he should be encouraged to be an ongoing member of the church, and this can be achieved by a short service in his home attended by a few members of the congregation. Church members should be encouraged to offer appropriate support, such as cooking meals for the family or arranging patient sitting to give family members a break.
The Pastor and the Family
There are a variety of issues that can arise in this relationship, but I will mention two.
First, with regard to moral issues, such as the effects of the use of drugs in medication, there may be a clash of values between the pastor and the other care providers or between the pastor and the family members. While it is unlikely that the pastor’s moral values will have much weight with the medical carers, it is feasible that he will be asked by the family regarding the use of drugs that, while providing relief from pain, will hasten the end of life. In this situation, the pastor is caught between two valid but opposing principles: the necessity of easing pain and the necessity of preserving life. There is a tendency with Christians to interpret such principles as if they were always inflexible, rather than assessing how they can be used to express higher virtues such as love and mercy. In a situation when a person is dying, and would die in agony without medication, it is an act of compassion to give medication, even if the medication hastens death. The pastor should assure the family that they are not breaking the sixth commandment when they allow medication and he should also remain alert to the possibility of guilt being felt by family members after the death.
Second, the pastor must also aim at enabling the family to face the looming separation in a Christian manner. This does not mean they have to experience a negative anticipation for several weeks. The period of terminal illness can be a time of family bonding, when family members can express their love and appreciation of one another and also make any appropriate confessions of wrong attitudes. It is appropriate for the pastor to ask the ill person to initiate and continue to contribute to this as it will help the family realise they are not adding to his burdens. The dying person should be encouraged to be a help to his relatives in the grieving process. They may have a sense of guilt, either for past failures or even for their inability to help him at this time of crisis. It is also an effective means of removing possible causes of guilt after the decease of the person. Such bonding is not merely based on family relationships but has the added dimension of experiencing the mercy and grace of God and of looking forward together to heaven.
Pastoral Visitation of the Terminally-Ill
Interaction with an ill person involves several basic actions, some of which are drawn from common sense and others from biblical principles. Common sense indicates that pastoral visits should be frequent but short unless the patient suggests otherwise. Although at times it will be right to allow others to be in attendance, the pastor will need occasions when he can engage in personal dialogue with the patient in order to discover his spiritual state.
The two most important spiritual functions during a visit are Scripture reading and prayer. While there may be a temptation to engage in rational arguments it is better to let Scripture deal with the spiritual problems of the patient such as the need of divine assurance of God’s presence, of his forgiveness, of his personal commitment to his people. This can be done by reading familiar and comforting Bible passages such as Romans 8 or Isaiah 53. The psalms are a source of much consolation and the words of the psalmists can be used by the patient to express his longings. It will be helpful if the pastor builds up gradually a collection of suitable biblical passages for use in such occasions, and in addition he can collect suitable hymns or other poetic pieces that will help him to express words of comfort.
Prayer in the presence of the sick person is also a source of help to him. The pastor must avoid the temptation to address his prayer to the patient rather than to God. A Christian does not lose his sense of worship and reverence when he is ill and it can be a cause of spiritual distress if he becomes aware that the pastor in his prayer is not focussing on God but on the patient. Prayer should be reverent, short, and easily understandable.
The demeanour and attitudes of the pastor are also of importance. While the meeting should be short, the pastor should not give the impression that he is in a hurry to leave. He must listen attentively to the patient’s words and respond gently and kindly, attempting to direct the patient’s thoughts to spiritual matters. The pastor is not there to cross-examine but to enter into personally penetrating pastoral dialogue. It is usually sufficient for the pastor to leave one or two spiritual thoughts with the patient on each occasion, and over a period of time the advice given in this way will be considerable.
The pastor should anticipate periods of silence from the patient. Oden points out that the patient ‘may be struggling valiantly for slow-growing self-understanding or difficult language that is not ready to hand’. To interrupt in such situations may stifle the patient not only during the immediate visit but on subsequent occasions as well.
Models for the Pastor in Such Situations
No doubt, there are many models that could be used, drawn from both the Bible and modern societal roles. I will suggest four models of ministry that should help pastoral care of the terminally-ill.
First, the pastor is a preparer of the person who is now ill. This aspect of modelling occurs in the life of the congregation, before the person becomes ill. It involves regular references in the pastor’s teaching ministry to the death of a Christian. The pastor does not want a Christian to have a morbid preoccupation with death, rather he should be instructed about what death will mean for him as a Christian.
Secondly, the pastor is a fellow traveller with the ill person. From one perspective, identifying an illness as terminal is only a medical term for one stage in a human life, for in reality all of us are living lives that are terminal. The pastor does not minister to a dying person as one who is not going to die himself. This reality should make the pastor sympathetic to his dying friend and also willing to learn from one who, in a sense, is merely ahead of him in life’s journey. Thus, in almost an ironic way, the pastor is the pupil in his relationship with the terminally-ill person. The pastor is dealing with a factor (dying) that he has not yet experienced. The dying person knows existentially more than the minister does about the experience. Because of this, God will use the experience to teach valuable lessons to the pastor. Not only will he be reminded of his own mortality, he will once again realise his need of divine grace to minister in a situation in which only God can provide the help and also see the faithfulness of God as once again he come with his grace.
Thirdly, the pastor is a comforter of the ill person. The Greek word parakaleo literally means ‘to call near’ or ‘to call to one’s side’. In the New Testament the term is used of the actions of each person of the Trinity and of the ministry of believers. With regard to the latter, comfort is perceived as a ministry to the sick and bereaved. In 1 Thessalonians 4, Paul identifies the prospect of the second coming of Jesus as one source of comfort for bereaved believers.
Fourthly, the pastor is a reconciler. The ministry of reconciliation involves a variety of functions. The most important is that of reconciling sinners to God by the presentation of the gospel, and if the patient is unconverted, then this aspect is a priority, although sensitivity will mark the pastor’s approach. As far as believers are concerned, reconciliation may be needed between the patient and other people, or between the patient and his circumstances, or between the patient and God’s will for him, and the pastor should attempt to bring about these aspects of reconciliation.
Blessings of the Pastoral Role in this Situation
Firstly, it is likely that the pastor has already been regarded as a spiritual guide and a trusted friend by the ill person. In all probability, the person signed the call to the pastor and in doing so was inviting him to function as shepherd. The perception of the role of the pastor as shepherd involves not only preparing the flock to live for Jesus throughout life but also to preparing the flock to die confident in Jesus. The terminal illness of a believer is an opportunity for the pastor to fulfill in its most essential requirement the call that was given to him by his friend.
Secondly, pastoral involvement with the dying is an opportunity to see the power and grace of God at work in the lives of his weak children. As the pastor ministers spiritual counsel and prayer over a period of weeks, he will see God working through his ministry for the benefit of the patient, as hope becomes stronger. And he will be involved in the inestimable privilege of sharing in a believer’s going home to the Father’s house.
Pastoral care of the terminally ill will be a regular aspect of pastoral ministry. Each situation brings its own demands and will stretch to breaking point the spiritual resources of the pastor. But each situation will prove that Christ is able to equip his pastors for the task. Despite the intense emotional cost and heavy burdens of losing a loved member of the church, the involvement should be one that is richly rewarding in the long-term.