Introduction
“Why, you do not even know what will happen tomorrow. What is your life? You are a mist that appears for a little while and then vanishes.” (James 4:14). James pointed out from the notion of the frailty of our lives as well as the obligation as a Christian to live life seeking God’s will and God’s glory. The fragility of our lives are just as a grass, the glory of our own is just like the flowers that withers through time (1 Peter 1:24), our flesh ages through time and from the moment we are born, we are actually moving forward to death for we are but eventually a dust (Psalm 103:14).
“Caring for the sick and dying” is not a foreign phrase to us, especially among Christian community, for healthcare has been closely related to the mission of church since the early centuries. Since the early 2nd century, churches were opened for the sick, and palliative care existed.[1] During the period of a devastating plaque, the first large scale hospital was found by St. Basil of Caesarea for the seriously ill and disabled. The revival of churches and the development of the medical care emerged side by side as inspired by Christ’s example. [2]
One of the famous examples is the father St. Francis of Assisi, who was known for his devotion to the care for leprosy patients. The prayer of St. Francis has also draw guides on encouraging, avoiding temptations as caretakers and puts eternal perspective of life in his writing. “Lord, make me an instrument of your peace. Where there is hatred, let me sow love; where there is injury, pardon; where there is doubt, faith; where there is despair, hope; where there is darkness, light; and where there is sadness, joy. O Divine Master, grant that I may not so much seek to be consoled as to console; to be understood as to understand; to be loved as to love. For it is in giving that we receive; it is in pardoning that we are pardoned; and it is in dying that we are born to eternal life. Amen.”
Chronic Illness and Terminal Illness
Nobody on earth are immune from illness and death. Life lived before death, are usually not spared from pain and illness. Chronic illnesses as according to World Health Organization are usually of long period of time and generally a progressive illness.[3] As defined by U.S. National Center for Health Statistics, a chronic illness is an illness which has a prolonged period of three months and longer.[4] Most often these chronic illnesses brings upon pain physical, emotional and even spiritual torment. Just as Paul the apostle was not spared from a tormenting thorn which brings upon such chronic affliction.
Generally as according to Hui and others, terminal illness refers to an unfavorable prognosis of an irreversibly lethal illness that limits an individual’s life expectancy. [5] Two major circumstances of terminal illness are that of an old ripe age and of those who are relatively young. Terminal illnesses which occur among the aged are often understood and more acceptable as a natural mature process of life. However, if compared to the terminal illnesses which occur to a younger individual, it is most often unacceptable and is seen to be premature death. [6]
Issues that patients face
Pain
Paul once expressed the distress pain that the thorn had brought to him and the purpose that the thorn was not removed was “To keep me from becoming conceited because of the surpassing greatness of the revelations, a thorn was given me in the flesh, a messenger of Satan to harass me.” (2 Corinthians 12:7) C.S. Lewis annotated in his book The Problem of Pain, “We can ignore even pleasure. But pain insists upon being attended to. God whispers to us in our pleasures, speaks in our conscience, but shouts in our pains: it is his megaphone to rouse a deaf world.”
Pain is the common symptoms that a patient encounters. According to the International Association for the Study of Pain, it is a distressing experience of senses and emotions related to with actual or potential physical injury.[7] A main contributor of the hospice movement, Dr. Cicely Saunders suggested on a term “total pain”. This total pain experience model includes the facets of social pain, psychological pain, physical pain, spiritual pain which a patient would encounter in the events of care setting. Therefore, in the case of effective pain management, all of these dimensions should be tended to. [8] The pain includes the events of painful experience and also refers to a situation in which a patient is confined, the senses of loss also brings upon distress in a person which would be discussed as below.[9]
Fear and Losses
“My heart throbs, my strength fails me; And the light of my eyes, even that has gone from me.” (Psalm 38:10) During physical distress, not only do we experience sensory pain but also sense of loss which would bring fear and anxious to a person. In the course of losing health, a chronically or terminally ill person would sense a loss of control. Loss of control over one’s health and ability, individual may need to be dependent to others. Therefore, the loss of physical ability would lead to fear in the individual of being a burden to others.
The loss of sense of self and isolation and loneliness during physical distress is an excruciating process which may lead to depression and anxiety. Certain stigma may even cause the loss of relationship, or abandonment. In some cases, illness would lead to loss of physical assets and resources.
Suffering and Compassion
From a medical perspective, physical pain could be managed effectively through pain management such as medication. Sufferings are often neglected; there are many attempts to “resolve” sufferings are often done through ways of avoidance. [10] Medicine however is often attempted to resolve suffering but it is not able to solve life in its fundamental purpose.[11]
Suffering could be redefined by reframing of an individual’s perspective. As according to Verhey, “Sometimes the suffering requires the reconstruction of an identity, the reformation of a purpose, the revisioning of the whole of a life, the writing of a new chapter in the story of a life.” [12] But suffering could never be fully comprehensible by other individual; it is an inner process of the individual. However, acknowledgement and presence of another person may be a relief to the suffering, or at least to support the individual. It is the being with and for the person that counts, rather than doing to or for the person matters.
Repentance and Hope
The eschatological dimension of suffering and death although includes but beyond the earthly sin, suffering, death. For the wages of sin is death, but the free gift of God is eternal life in Christ Jesus our Lord (Romans 6:23). In this fallen world, sin corrupts not only physical health, but often brings upon spiritual condemnation and emotional cost to an individual. The weight of sin weighs down a person in ways of remorse and shame. [13]
Repentance and forgiveness is essential in the process of reconciliation, the salvation and journey towards healing. As according to the theology of salvation, resurrection and eternal life is the source of hope and healing. As hope plays an active role in the process of dying, it is also a process of healing through seeking salvation.[14] Reconciliation with God through the saving grace of Christ Jesus is the only way towards eternal salvation (John 3:16). On the other hand, self-reconciliation and reconciliation with others is also a pathway toward healing process, and more often it supersedes the aspect of physical healing. [15] In the process of repentance and forgiveness, life review plays an essential role in the healing process and is also very important aspect to assist an individual to reflect on the account of their lives. [16]
Responsibility of the Local Church
Terminal illness is diagnosed by medical officers in accordance with the possibilities that the cure for the illness is not yet found. However the absolute happening of death is indefinite.[17] There is an increasing risk for anxiety and depression among people that are chronically ill or terminally ill. [18] Ministering to the patient involves not only the main point of focusing pastoral care to the patient, but also involves the interaction with the hospital environment and the care to the social circles of the patient which includes family and friends. [19] Support from the community of faith is essential.
Preaching and Teaching
In the ministry to the sick and dying, most pastors are called to do visitation among church congregation. However, there are some cases when the pastor is also called to minister among others related to the church congregation who do not yet know about the faith. Needs to visit and to shepherd the “flock” might sometimes be overwhelming. Therefore, the importance and the need for pastors to prepare spiritual leaders as well as the congregation arise.
The church has a mandate “For I was hungry and you gave me food, I was thirsty and you gave me drink, I was a stranger and you welcomed me, I was naked and you clothed me, I was sick and you visited me, I was in prison and you came to me. (Matthew 25:35-36),” to show charity and love within the body of Christ.[20] In following this mandate, church as a whole community of faith should follow Christ’s example in caring for the sick and dying. “That there may be no division in the body, but that the members may have the same care for one another. If one member suffers, all suffer together; if one member is honored, all rejoice together”. (1 Corinthians 12: 25-26)
“Jesus went throughout Galilee, teaching in their synagogues, proclaiming the good news of the kingdom, and healing every disease and sickness among the people.” (Matthew 4:23) Not only did Jesus teach, but He also preaches and heals the people. As the saying goes, prevention is better than cure. Christian education plays a significant role in biblical teachings, theological training as well as practical ministry of the congregation and the lay leaders. Through equipment of knowledge, the congregation will be able to know what they could do when they face crisis in life or crisis happened to others that they love.
Besides teachings in spiritual formations on facing life, death and sufferings, educational and practical teachings such as dealing with financial, writing of wills, Christian ethical issues and etc.[21] is also needed for the congregation to understand the position that is grounded according to the Bible. Often, there is a disconnection between theology and experience, truth and reality. It is through teaching and preaching, that the congregation could carry knowledge from belief, transfer their belief into knowledge of action, tests and experience the faith when facing real situations. Through this knowledge of acquaintance, people would reach to know the mercy and goodness of the Lord.[22]
Church plays a significant role in teaching and discipleship, besides providing spiritual support by teaching, practical life skills, meeting emotional needs is also an immense extent for churches to provide trainings and education. The needs for lay counseling skills are practical skills that the congregation could acquire and could be put to use when the need arises for peer to peer counseling.
Pastoral Care and Counseling
The typical psychological phases of a terminally ill person as described by Kubler-Ross include denial, anger, bargaining, depression, resignation and acceptance. [23] Denial is seen to be the most common stages when an individual realizes that the fact which was told did not seem to be as expected. After the manifestation of denial phase, recognition of the fact usually brings upon anxiety and pain that provokes the stage of anger and this process would often bring up the question of “Why?” The third stage is usually the stage of bargaining which would occur when fact displays itself, the anger could not be resolved and the sense of helplessness led the individual into seeking for help. Individual would seek to bargain with God with hope for recovery. The phase of depression will cripple in when a person is confronted with hopelessness, helplessness and sense of loss and isolation. Usually this phase will remain until a state of resignation of an individual towards the prolonging of life and immortality, and then the individual is able to face death with acceptance.
During the crisis, sharing of feeling and brief on the process of death will reduce fear and help individual to aware of the approaching of physical dying. This is also a way of preparation for patient to experience the fulfillment in life and to live the end of life with dignity.[24] Counseling the terminally ill requires the building of trust in the relationship. Counselors would put more emphasis on the reflection of the departure or the current unfinished task that an individual has.[25]
Caring and serving the patient’s family members is equally important. Family members face fear, uncertainty, and helplessness. As uncertainty brings in fear and anxiety, assistance from minister who are familiar with the hospital will give assurance to the family members. As some will face crisis in faith when facing life crisis, therefore both spiritual guidance, pastoral care and practical help from church is cruicial.
Caring for the Patient
Visitation and Practical Care
“I was naked and you clothed me, I was sick and you visited me, I was in prison and you came to me.” (Matthew 25: 36) Visitation is a means to find time to be available and be with the sick and the needy. It is a way to sustain meaningful social relationship with the sick and dying.
Pastoral ministry is the “representative ministry” of a church. [26] Pastor’s visits are more often seen as the representative of the congregation. Not only as a representative, but also at times stands for the truth of the Lord and the love of the church. Through visitation, pastors could serve as a bridge between medical professionals and patients or family members. Someone who is both an outsider and an insider to show close concern and care yet able to see things in a different ways and help families to deal with situations and tasks through a spiritual light.
Visitation is a general way that a congregation could participate in caring ministry to show love within the body of Christ. However, overwhelming visitation might interrupt the rest and recuperation that the patient needs. Therefore, as a community in church, a scheduled organized visit and visitation in small groups is encouraged. Practical care such as home cooked food which is suitable for patient or domestic help to get groceries is also a way to show love to both patient and caregiver.
Palliative and Hospice care
According to Robert Twycross, “the purpose of palliative care in hospice is to allow the individual support and freedom to find spiritual healing, even in the face of physical death.” Churches have the privilege of spiritual support and also having combined resources and wide relational networks. One of the ways to care for the sick and the dying in a direct way is to provide them not only physical needs with medical, but also pain management, pastoral care, peace, comfort and dignity that a hospice care can offer. As Martha L. Twaddle mentioned in the book Dignity and Dying: A Christian Appraisal, “the focus of hospice care is not dying, but healing for families, patient, and all involved in the end-of-life journey.”[27]
The structure of a hospice care is interdisciplinary, which comprises not only medical team, but also counselors, social workers, pastors and others. Whereas churches have a power of collective resources and network, therefore it has a resourceful background to mobilize resources and manpower in this hospice care ministry, no matter in an in-house palliative care or in-center care.. Although the development of hospice care among Christian group is still yet to grow[28], there has been an increase awareness and initiative recently among Christian groups of doctors and nurses to offer hospice care. Faith hope love hospice care is one of the hospice care initiative established in recent years to attend to the need of creating awareness among Christian community among Klang Valley, to collaborate resources and to mobilize volunteers.
Caring for the Caregiver and Family members
Respite Care
Churches hold not only a responsibility of pastoral care to the patient, but also take on a privilege in knowing the caregiver and the family members of the patient. Besides caring for the patient, it is also crucial to offer care for the caregiver and family members who are the closest to facing the issues that the patient face. According to the National Institute on Aging, U.S., respite care is a means of offering temporary break and care provided to the main caregiver.[29] Although professional help might be needed in providing respite care for the patient, but with respect to this, the social needs of a patient during respite care could be fulfilled through the bond of trust and closeness between church, and especially to the caregiver and family members.
Furthermore as discussed in the above section, the initiative of hospice care established among Christian churches is also an approach to provide respite care for the primary caregiver and the family members. It is through respite care; a caregiver could be rested and recharged both physically, spiritually, mentally, socially and emotionally.
Bereavement Care
Grief is a strong emotion in face of the departing of a loved one. Sometimes it might not only happened in the account of death, it might happened when loss of function in a loved ones, for example dementia, infertility or in the case of mental illness. There were five stages of grief as described by Elisabeth Kübler-Ross which includes stages of denial, anger, bargaining, depression and acceptance.[30] However, there are remarks made about describing these as “aspects” of grief, instead of stages to regard these emotions without specifying a timeline unto it. [31] People find themselves in shock and denial when they realized the departure of the loved ones, some might find themselves disorganized to perform tasks. While accompanied with grief, caregivers might find themselves relief however with sense of rational guilt. Sense of sadness in grief could also take along anger in the unpleasant fact that their loved ones were taken away from them. Then, the feelings of emptiness might be accompanied with sense of depression. However, eventually the fact of the departure of the loved ones is embraced with resolution and re-establishment. [32]
Grief happened ultimately and especially in the account of death. As taken record in the Bible, there are strong emotions expressed in face of death when King David heard news of the death of his son. “And the king was deeply moved and went up to the chamber over the gate and wept. And as he went, he said, “O my son Absalom, my son, my son Absalom! Would I had died instead of you, O Absalom, my son, my son!”( 2 Samuel 18:33) In the New Testament, even Jesus Christ wept (John 11:35) when a friend died. [33] However, at the end of the day our assurance is found in the hope of the assurance of salvation and the resurrection of Christ. “But we do not want you to be uninformed, brothers, about those who are asleep, that you may not grieve as others do who have no hope. For since we believe that Jesus died and rose again, even so, through Jesus, God will bring with him those who have fallen asleep.” (1 Thessalonians 4:13-14)
Although the resurrection hope is found in Christ, it is important to acknowledge the emotions and grief the bereaved are going through. Funeral rites and memorial services is one of the way churches could help in organizing and participating to comfort the families and friends of the deceased and to remember the departed souls. Through allowing family members to participate in the funeral and services is a way to allow their grief to be heard. From my personal experience of the departure of my dad, I personally think it is also very important to allow not only adult to participate in funeral and services, the participation of children especially closely related to the deceased is also equally important in remembering their loved ones, so that there will not be disenfranchised grief among loved ones.
Grief is a process that takes time to recover. Continuous care and commitment is needed for church to help to the bereaved. Community of church could avail in pastoral counseling, social support in presence, spiritual support through prayer or through practical assistance in daily needs. Especially those who are in need of financial support, the church could offer practical help for orphans and widows.
Conclusion
The needs for the chronically ill and terminally ill is the willingness to acknowledge and the availability to be present. This is significant not only to the patient but also to the support for the family members especially the primary caregiver to the patient. Physical, emotional, social and spiritual needs for both patient, family members and friends are to be recognized and addressed by churches both before and after the event of actual death.
To recapitulate, Churches play a vital role when it comes to the needs of life education, caring of the needy souls and facing the issue to answer difficult questions of life, sufferings, weakness and eventually death. Church plays a role both as insider and outsider to answer the question of life. Death is usually the taboo among cultures, but it is encouraged that this matter of fact could be arisen in a sensible way. Through this, the issue of life could be prepared, evaluated and the fact of death could be prepared well in dignity when there is a possible chance, both for the patient and the family.
So that when the day comes, everyone is prepared in a good hope from the Lord. In sufferings to say: Therefore I will boast all the more gladly of my weaknesses, so that the power of Christ may rest upon me. For the sake of Christ, then, I am content with weaknesses, insults, hardships, persecutions, and calamities. For when I am weak, then I am strong. (2 Corinthians 12:9–10). In face of death to hold on the hope just as Paul said, “In the day of Christ I will have reason to glory because I did not run in vain nor toil in vain” (Philippians 2:16). In the same way, to have good hope from the Lord that the “labor is not in vain in the Lord” (1 Corinthians 15:58). Our souls are rest assured in the hands of the Lord.
[1] Jennifer L. Woodruff Tait, “Healthcare and hospitals in the mission of the church,” Christian History, Issue 101. https://christianhistoryinstitute.org/magazine/issue/healthcare-and-hospitals-in-the-mission-of-the-church.
[2] Rosie Beal-Preston, “The Christian Contribution to Medicine,” Triple Helix, Spring 2000. https://www.cmf.org.uk/resources/publications/content/?context=article&id=827.
[3] “Noncommunicable Diseases”, World Health Organization, accessed November 1, 2018, https://afro.who.int/health-topics/noncommunicable-diseases
[4] “Medical Definition of Chronic disease”, MedicineNet, accessed November 1, 2018, https://www.medicinenet.com/script/main/art.asp?articlekey=33490
[5] David Hui et. al., “Concepts and Definitions for ‘‘Actively Dying,’’ ‘‘End of Life,’’ ‘‘Terminally Ill,’’ ‘‘Terminal Care,’’ and ‘‘Transition of Care’’: A Systematic Review,” Journal of Pain and Symptom Management 47, no. 1 (January 2014): 83, 86, https://doi.org/10.1016/j.jpainsymman.2013.02.021.
[6] Alan Billings, Dying and Grieving: A Guide to Pastoral Ministry (London: Society for Promoting Christian Knowledge, 2002), 99-100.
[7] “IASP Terminology”, International Association for the Study of Pain, accessed November 10, 2018, http://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698
[8] Anita Mehta and Lisa S. Chan, “Understanding of the Concept of ‘‘Total Pain’’: A Prerequisite for Pain Control”, Journal of Hospice and Palliative Nursing 10, no. 1 (January/February 2008): 27, https://nursing.ceconnection.com/ovidfiles/00129191-200801000-00008.pdf.
[9] Anita Mehta and Lisa S. Chan, “Understanding of the Concept of ‘‘Total Pain’’: A Prerequisite for Pain Control”, Journal of Hospice and Palliative Nursing 10, no. 1 (January/February 2008): 28, https://nursing.ceconnection.com/ovidfiles/00129191-200801000-00008.pdf.
[10] Marsha D M Fowler, “Suffering”, in Dignity and Dying: A Christian Appraisal, ed. John F. Kilner, Arlene B. Miller and Edmund D. Pellegrino (Cumbria: Paternoster Press, 1996), 49-50.
[11] Marsha D M Fowler, “Suffering”, in Dignity and Dying: A Christian Appraisal, ed. John F. Kilner, Arlene B. Miller and Edmund D. Pellegrino (Cumbria: Paternoster Press, 1996), 48.
[12] Allen Verhey, Reading the Bible in the Strange World of Medicine (Grand Rapids: William B. Eerdmans Publishing Company, 2003), 107.
[13] Vigen Guroian, Life’s Living toward Dying (Grand Rapids: Wm. B. Eerdmans Publishing Co., 1996), 85.
[14] Mark D.Sullivan, “Hope and hopelessness at the end of life.” The American Journal of Geriatric Psychiatry 11, no. 4 (Jul/Aug 2003): 393.
[15] Vigen Guroian, Life’s Living toward Dying (Grand Rapids: Wm. B. Eerdmans Publishing Co., 1996), 87.
[16] Vigen Guroian, Life’s Living toward Dying (Grand Rapids: Wm. B. Eerdmans Publishing Co., 1996), 90.
[17] Larry A. Platt and Roger G. Branch, Resources for Ministry in Death and Dying (Nashville: Broadman Press, 1988), 130.
[18] “Serious, Chronic, or Terminal Illnesses”, Anxiety and Depression Association of America, accessed November 1, 2018, https://adaa.org/serious-chronic-or-terminal-illnesses
[19] Larry A. Platt and Roger G. Branch, Resources for Ministry in Death and Dying (Nashville: Broadman Press, 1988), 140.
[20] Alex Tang, A Good Day to Die (Singapore: Genesis, 2005), 103.
[21] Alex Tang, A Good Day to Die (Singapore: Genesis, 2005), 104.
[22] Dr. Tony’s class notes.
[23] Larry A. Platt and Roger G. Branch, Resources for Ministry in Death and Dying (Nashville: Broadman Press, 1988), 122-127.
[24] Larry A. Platt and Roger G. Branch, Resources for Ministry in Death and Dying (Nashville: Broadman Press, 1988), 133.
[25] Larry A. Platt and Roger G. Branch, Resources for Ministry in Death and Dying (Nashville: Broadman Press, 1988), 130.
[26] Alan Billings, Dying and Grieving: A Guide to Pastoral Ministry (London: Society for Promoting Christian Knowledge, 2002), 95-96.
[27] Martha L. Twaddle, “Hospice Care”, in Dignity and Dying: A Christian Appraisal, ed. John F. Kilner, Arlene B. Miller and Edmund D. Pellegrino (Cumbria: Paternoster Press, 1996), 187.
[28] Alex Tang, A Good Day to Die (Singapore: Genesis, 2005), 107.
[29] “What Is Respite Care?”, National Institute of Aging, accessed November 23, 2018, https://www.nia.nih.gov/health/what-respite-care.
[30] Larry A. Platt and Roger G. Branch, Resources for Ministry in Death and Dying (Nashville: Broadman Press, 1988), 122.
[31] Alan Billings, Dying and Grieving: A Guide to Pastoral Ministry (London: Society for Promoting Christian Knowledge, 2002), 133.
[32] Alan Billings, Dying and Grieving: A Guide to Pastoral Ministry (London: Society for Promoting Christian Knowledge, 2002), 138-139.
[33] Alan Billings, Dying and Grieving: A Guide to Pastoral Ministry (London: Society for Promoting Christian Knowledge, 2002), 77-78.
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