Smith, Walter J.

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The Linacre QuarterlyVolume 42 | Number 3 Article 6August 1975Pastoral Care of Dying Patients and Their FamiliesWalter J. SmithFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationSmith, Walter J. (1975) "Pastoral Care of Dying Patients and Their Families," The Linacre Quarterly: Vol. 42: No. 3, Article 6.Available at: http://epublications.marquette.edu/lnq/vol42/iss3/6) Pastoral Care of Dying Patients and Their Families Walter J. Smith, Ph.D . The cultural values of Ameri-can society do not allow people to confront and accept death re-alistically. They have been taught to cope with death by somehow disguising it, pretending that it is not a normal occurrence of every day life. Even those in the health professions, whose responsibility it is to care for the terminally ill, as well as for those who are ex-pected to regain their health, are caught up in this attitude. Their whole education and t raining has prepared them to help make peo-ple well again and thus to extend their lives. When the curative measures are seen to be failing and the process of dying has be-gun, they tend to lose interest and to turn their attention to patients who can "profit more" from their ministrations. Of course, the dying patient continues to be treated, but he usually is not regarded as merit-ing the amount of attention he would receive if his life could be expected to be extended consider-ably by medical and nursing care. Dying is thought of as a medical process rather than as a human experience. The human needs of the terminally ill patient, for com-panionship, for emotional sup-port, and for human comfort, are not given sufficient attention. August, 1975 The spiritual needs are turned over to the chaplain, if there is one, to a local clergyman, if the hospital has any on call, or ig-nored altogether. Modern man has been taught to fear death, to regard it as a gruesome, Ion ely, impersonal process. Dying persons are often removed from the familiar sur-roundings of their own homes and sent to a hospital. Once there, they are frequently isolated by being placed in a private room, particularly if they are close to death, and shut off from all the activities around them. Father Smith, a priest of the Diocese of Brooklyn, and Adjunct Professor of Field Education, Washington Theological Coali-tion, is Director of the Chaplaincy Research Program, Veterans Ad-ministration Hospital, Washing-ton, D.C. 199 In addition, dying patients also have been taught to fear death, to regard it as an unnatural process, and not as a genuine part of hu-man life. Many times they are left to go through it alone, or only wit h whatever non-professional and unskilled help relatives and friends, fearful of dying them-selves, are able to provide. Fre-quently this is not much help at all. Proper care of dying patients demands that they be given the support necessary for them to die peacefully and with that dignity which befits every human person. Relatives and friends are usually not able to provide for this. Thus it becomes the task of a skilled professional person, usually one of the clergy, to help the dying pa-tient have a peaceful, hopeful, dignified death. Before people can effectively help others through the experi-ence of dying, however, they must have faced and dealt with the re-ality and meaning of death in their own lives. Only then will they be able to deal openly and honestly with dying patients and be of real assistance to them. The clergy, above all, are generally ex-pected to have done this for them-selves, and thus to have reached a position from which they can help others to an open and honest confrontation with the inevitable fact that some day they too must die. Pastoral care of the sick, whether in their own homes or in a hospital, necessarily includes pastoral care of the dying. What 200 does this entail? The dying are cared for in a variety of ways by the different faith groups. Some, such as the Eastern Orthodox and the Roman Catholic, have very structured, sacramental means of ministering to the dying patient. Other faith groups have less for-malized methods, but for effective pastoral care of the dying, clergy of all faith groups must provide a personal and interactive ministry to patients and their families in such a way that each knows what the other is thinking and feeling. Provision for calling the clergy to conduct the appropriate reli-gious ceremonies has become quite routine in most American hospitals. When the patient has a tum for the worse and is then regarded as critically ill, a chap-lain or other clergy of the appro-priate faith is called at the time when the family is notified. The Need for Religious Rituals This is very appropriate, for as Nolan l has pointed out, people in every culture have developed re-ligious rituals to help them deal with life's crises. These provide support in times of loss or antici-pated loss. They perform three functions: "(1) support in the ex-pression of grief at the loss; (2) approval of the renunciation of what was lost; and (3) guidance in redefinition and reinvestment of self." Religious rituals help to keep patients close to reality, since they deal with the situation as it actually is. They are designed to assist in maintaining emotional and spiritual strength to see pa-Linacre Quarterly ) tients through the crisis. Because rituals use words, symbolic ac-tions, and materials with which people are familiar, they provide some sense of secui·ity in a situa-tion characterized by very basic uncertainty. For the Eastern Orthodox, Ro-man Catholics, and some Episco-palians, the Sacrament of the Sick serves these purposes. It is meant to ritualize the process of antici-patory grief in a therapeutic man-ner. If the patient's family, or friends, or some of the hospital personnel who have been caring for him or her are also present, they lend each other and the pa-tient mutual support. Their feel-ings toward one another and about the illness can be expressed in a shared ceremony as the help of God is sought to give the pa-tient emotional and spiritual strength to endure whatever hard-ship and suffering are entailed. Feelings of guilt are relieved by the Sacrament of Reconciliation. When the bread of the Eucharist is shared, unity with the whole Christian community, from which the patient may feel some separa-tion, is symbolized and main-tained, and the hope of future life in union with God is expressed. Other faiths make use of Scrip-ture readings and prayers for these same purposes. Some which have been found to be very ap-propriate and consoling are: Isaiah 61 :1-3; Lamentations 3:17-26; Romans 5:6-11; 8 :14-17, 31-35, 36-39; Colossians 1:22-29; Matthew 11:25-30; and John 6:35-40. Some of the Psalms August, 1975 make very appropriate prayers to offer at the bedside, particularly Psalms 4, 6, 13, 16, 23, 27, 34, 41, 57, 62, 63, 121, 130, and 146. In addition, spontaneous inter-cessory prayers, which take into consideration the actual condition of the patient and his or her needs and concerns, are most helpful in offering the patient both spiritual and emotional support. It has been shown, however, that mere rituals and prayers, without faith on the part of the patient, give little assistance. In this instance, they become more of a distraction, which turns at-tention away from anticipatory grieving, rather than a helpful means of support through the process.:' Pastoral care provides emotion-al and spiritual support through this process of anticipatory griev-ing which is experienced by both dying patients and their relatives and fl'iends. As Nolan (1974) has pointed out, "Grief can be a re-action to any significant loss. In-deed, the dying person himself grieves. As he consciously or un-consciously anticipates death, he fears separation from the signifi-cant persons and things in his world. The dying patient also ex-periences acute or gradual loss of various capacities and functions: cognitive skills, motor skills, and capacity for pleasure." Nighswonger3 has indicated that studies conducted in the "Death and Dying Program" at the hospitals and clinics of the University of Chicago have shown the necessity of a combined 201 approach, whereby both the pa-tient's and the family 's anticipa-tory grief processes are dealt with concurrently. When this is done, the dying patient is much better able to cope with death, and to die in a peaceful and dignified manner. The family also is en-abled to accept the death of the patient with greater equanimity. Some patients wish to talk about their impending deaths, and many find that physicians and nurses either have not the time to spend with them, or else are made so uncomfortable by the thought of death that they shy away from this prospect. The clergy can help here, not only by listening to the patient, but in addition by helping the family and the professional staff to be able to do so also. It is well not to give too much assistance to patients, but to let them experience the therapeutic value of doing everything they can for themselves. I t is good to be near to lend a hand when nec-essary, and to aid in the grieving, allowing and encouraging the open expression of the emotions being felt. No one ought to be apologetic about the emotions they feel either during religious experiences or in grief. It is much better to express them than to try to shut them off and thus pen them up inside with the likelihood that they will harm later adjust-ment. Pastoral Care During the Stages of Dying Care for the dying patient en-tails a willingness to deal openly 202 and honestly with them. Hence when the patient denies that he is dying, good pastoral care does not attempt to break down this de-nial. It is seen for what it is: usually only a passing stage. When the denying can no long-er be sustained, the patient will be likely to be angry and to ex-press hostility. This also should be understood in its context, as one of the normal stages through which dying patients are likely to pass. It is only natural that they be angry when they are about to experience such a great loss -life itself. When the patient is in a period of depression, this should be ac-knowledged and empathy should be shown, but no effort ought to be made to cheer up the dying person. This would not only be unrealistic, since the patient has very good reason to be depressed, but would interfere with the nor-mal process of grieving. It will help, however, if someone is able to stand by and give assurance, quietly and confidently, that this unpleasant mood will eventually pass. It should be realized that fac-ing the reality of inevitable and impending death is not the same as despair. The dying patient may actually welcome death as a relief from pain and suffering. This may well be in harmony also with deeply held religious convictions and values, with confidence that death will be merely a passage to a better world. Linacre Quarterly ) Sometimes dying patients are in greater pain than the medical and nursing staff realize, and are not receiving sufficient medica-tion even to keep them moderate-ly comfortable. Appeals may then be made to the clergy for help, either by patients themselves or by their families. As neutral per-sons, the clergy may then be able to initiate a conference of doctor, nurse, patient and family to ar-range a schedule for sedation which will be more satisfactory for all concerned. When patients get close to death, they need even more sup-port from the companionship and concern of their families and the staff. The clergy also should be in attendance at this time. Even though the patient is seemingly unconscious, there still may be some awareness covered over by an inability to respond. Prayers for the dying are comforting to all at this time, particularly since they assist in dealing with the grief of the impending separation. In most hospitals it is typical that the physician and the nurse spend a little time with the fami-ly. In a brief informa tional conver-sation, they support the family's expectations of death with an ap-propriate rationale. But usually that is all. Whatever help the family receives from that point on will usually come from other hos-pital staff, most likely social work-ers or chaplains. This arrange-ment lightens the work load of both the physicians and the nurses and enables them to fulfil their obligations to other pa-August, 1975 tients. But if no one at the hos-pital is available to come to the aid of families, they are treated as if they did not exist. The clergy then become coun-selors who help the relatives to accept the reality of the patient's impending death, and to work through the process of grieving about the coming separation. Families usually want to talk to someone about the loss they are about to encounter. For the most part, what they need is a sympa-thetic ear; the counselor's job en-tails little more than listening with patience and understanding, while they recount their concerns about past, present, and future. It may be found helpful.at times to take the family to the hospital chapel, if there is one, and pray with them there about their own apprehensions and anxieties and those of the patient. Should the Patient Be Told? Thus far it has been assumed that both the patient and the family know about the serious-ness of the patient's condition and of the likelihood of his early de-mise. Often the very imparting of this knowledge to the patient and the family is a problem in and of itself. There is a tendency for both the physician and the family to conceal the truth in order to protect the dying person. John Hinton's4 study of dying patients has shown that this ploy seldom succeeds. He visited patients pe-riodically during the course of their illnesses and paid particular attention to the comments they 203 made regarding their expectations of recovery. Some patients had terminal illnesses and others did not. He found that regardless of what they had been told, most pa-tients with terminal illnesses knew that they were going to die before too long. He also noticed that they welcomed the opportu-nity to talk about the disturbing and fearful prospect of their im-pending death. This has been the experience of most chaplains also. It is usually assumed that someone in the family must be told that the patient has a ter-minal illness. The questions are: "Who should do the telling?", "Who should be told?", "When should the in for mat ion be given?", and " How should this be done?" The customary time at which all this takes place is when the patient is placed by his physician on the list of critically ill. The family is then notified of this fact and asked to come to the hospital. This immediately arouses suspi-cion in the minds of the relatives that all is not going very well, and by the time they arrive at the hospital they are somewhat pre-pared to receive disturbing news. Upon arrival they are taken to some place where they can have some privacy and are told as gent-ly as possible by the doctor that unless there is some unlikely turn for the better, the patient is not going to recover. The physician then answers any questions they may have. Other staff members may also be present: a nurse, a social worker, a chaplain. One or 204 all of these give whatever support may be necessary to avert an emo-tional breakdown, or at least to minimize it and offer some com-fort. But, should the patient be told? And if so, when and how? Mutual pretense keeps patient and fami-ly at a distance from one another, and both feel this isolation as a disturbance to their caring rela-tionship. Patients usually feel it more than the family, and some-times ask a chaplain to intervene so that there is a coming together in mutual knowledge. Only then can there be acceptance on both sides of the unpleasant and in-evitable outcome. When all the hospital staff, as well as the patient and family, are united in mutual knowledge and acceptance of the prospective death of the patient, everyone is in a better position to cope with the suffering and grief. As a re-sult the patient has a greater chance of concluding his or her life with dignity and in peace. REFERENCES 1. Nolan. Thomas. "Ritual and Therapy." in Bernard Schoenberg, et al (eds.) , Anticipatory Grief (New York : Columbia University Press). 1974. 2. Gorer, Geoffrey, Death, Grief.. and Mourning (Garden City. N.Y.: DOII -hleday). 1965. 3. Nighswonger, Carl A., "The Vec-tors and Vital Signs and Grief Syn-chronization," in Bernard Schoenberg. et al (eds.), Anticipatory Grief (New York: Columbia University Press) , 1974. 4. Hinton. John, Dying (Baltimore: Penguin Books). 1967. Linacre Quarterly 

Pastoral Care of Dying Patients and Their Families

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Pastoral Care of Dying Patients and Their Families

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