Pastoral Counseling In The Twenty-First Century For Illness, Disease, And Death

By Christopher Bogosh

In the twenty-first century, many pastors have become unbiblical in their approach to illness, disease, and death. Medical science in the West, with its theory of naturalism and its plan to eradicate these human afflictions at all costs, has influenced even some of the most orthodox pastors. In fact, it is the only goal of many pastors today to enhance the wellness and health of Christians in this present life, rather than to help them understand the providential and afflicting hand of God in their suffering. This paper brings to light some of these issues and presents a model for pastoral counseling to those who are facing illness, disease, and death in the twenty-first century.

The Etiology Of Illness, Disease, And Death

Around the world, ill health, infections, and death are viewed from a variety of perspectives that are influenced by culture, religion, philosophy, and science. In the West, for the most part, these afflictions are seen in a naturalistic context, particularly by the medical sciences That is, illness, disease, and death are caused by impersonal and mechanistic forces in nature. Beyond this point, however, medical science has to join the ranks of false religion, philosophy, and the social sciences and admit that they really have no ultimate answer for the etiology of ailments, pathological conditions, and organic death. Why? No objective evidence exists that explains how these impersonal and mechanistic forces were set into motion. There is a plethora of theories, but there are no concrete answers.

The predominant assumption found in the medical sciences is built on an evolutionary paradigm. Simply stated, this view holds that life started on the earth in molecular form and evolved into cells that contain genetic material called DNA. In the course of cell division, the DNA underwent random aberrations known as mutations. Some of these genetic abnormalities resulted in illness and death for the cells. Other mutations gave rise to cells that became deadly agents like viruses and bacteria. Still other mutations caused the evolution of complex organisms, resulting eventually in a plethora of different species, including Homo sapiens, or human beings. In a nutshell, illness, disease, and death are the result of blind natural forces that are interwoven into the very fabric of our existence.

According to the majority opinion in modern medical science, this is the way life is, and it was never any other way. Ailments, infections, the eventual extinction of our physical bodies, and all the pain and suffering that go along with them are part and parcel of who we are. We cannot escape these conditions! Yet it is the mission and final goal of medical science to hunt down and eradicate these enemies. There is a paradox at this point that medical science with naturalistic assumptions cannot explain. If these enemies are interwoven into the very fabric of our existence, how can they be eradicated?

As with all ideas about the genesis of our existence, certain presuppositions exist that require belief. The doctor with a naturalistic approach to medicine assumes that the world and human beings came into existence through a series of random events, and that illness, disease, and death are in part the result of various mutations that evolved with mankind. On the other hand, the Christian begins with an assumption that God created everything by a deliberate act, and the entire creation was in a state of bliss (Gen. 1:31). The world was free from infectious diseases, pathologic conditions, genetic abnormalities, and death at this time, and all was wellness, health, and life — the state for which humanity longs. [1] The first man and woman had a choice: obey God and choose wellness, health, and life, or rebel against God and choose illness, disease, and death (Gen. 2:17). They chose the latter. Sickness, physical malady, and death were the result, as promised by God, for the man, the woman, and all their posterity; the eternal state of health, wellness, and life was lost. [2] In the Christian paradigm, all suffering and misery stems from the rebellion of mankind against God.

This rebellion incurred the curse of God, and all of mankind was plunged into a state of total depravity. The entire creation was cursed by God as a result, and all of mankind entered into a persistent state of misery that is characterized by illness, disease, pain, suffering, and eventual death. Yet none of it took God by surprise; in fact, it was all according to His incomprehensible plan (Eph. 1:4, 11). This is a riddle, I admit, but it also provides a foundation for hope. God is in control of ailments, physical maladies, and death, but not as a cruel despot. These afflictions are used by Him as a means to accomplish His goals. God is not an impersonal and mechanistic force; He is a personal, interested, and involved God. He was so concerned that He entered into our misery — the misery caused by our own rebellion — and He bore the weight of illness, disease, pain, suffering, and death upon Himself. Jesus Christ willingly took upon Himself the curse that we deserved, thereby absorbing sin’s effects. He provided a way for restoration to all those who believe and obey Him.

The Providence Of God In Illness, Disease, And Death

Perhaps you are wondering: if Jesus restored Christians to wellness, health, and life, then why do they still experience sickness, infectious diseases, and eventual death? Jesus started the restoration, but the full restorative act is yet to come (Rev. 21ff). A day will come when Christ will return, restore the world, and do away with illness, disease, and death altogether. In the present, however, these afflictions and all the suffering that goes along with them are universal and are used by God to accomplish His goals. One of God’s goals is to drive people to seek the hope of restoration found only in Christ. To the non-Christian, illness, disease, and death are but a gentle foretaste of the eternal torments reserved for them without Christ (Matt. 25:41). A second goal is to warn (Deu. 28:58ff.). These afflictions can be used to warn people of ungodly living. A third goal is to sanctify Christians (Rom. 8:28-29). Sickness, illness, infections, and the dying process, with all of their attendant misery, are a means to prepare Christians for everlasting wellness, health, and life in their eternal rest to come (Rev. 21:4).

The ultimate and overarching goal of all illness, disease, and death is to bring glory to God, whether through judgment, affliction, restoration, or endurance (John 9:2 –3).

In a temporal and eschatological sense, illness, disease, and death are always beneficial, but not necessarily pleasant, to the Christian. Christians truly believe “that all things work together for their good” (Rom. 8:28, emphasis mine). This means, as Dr. Robert Smith comments in The Christian Counselor’s Medical Desk Reference, that getting “over the illness should not be the primary goal” for a Christian. [3] He writes further:

What glorifies [God] is what is best for all believers; therefore what glorifies Him will be the best for the sick believer. Getting well is not necessarily the best thing.… The hope for the believer is victory, not relief. Relief is not inherently wrong, but it becomes wrong when it is the primary goal. God promises victory in illnesses and trials, not deliverance from them.

This distinction is very important, especially in light of the philosophic underpinnings of modern medicine. The biblical view of illness, disease, and death is the polar opposite; yet, how many Christians seek relief from these afflictions at all costs?

The Christian is sanctified by God’s providential hand in the experience of sickness, infectious disease, congenital defects, and dying. First, a Christian who suffers these afflictions will enter into the experience of Christ and become more like Him in suffering (Rom. 8:29). Second, illness, disease, and death are reminders of the fleetingness of this life and the hope of eternal rest to come (James 4:14; Rom. 8:18). Third, endurance under misery and suffering testifies to a Christian’s character and to God’s sustaining grace (Job 2:3-6; 1 Cor. 10:13). Fourth, affliction, sickness, disease, and impending death are used to increase a believer’s ministry. [4] The Christian who sees the providential hand of God behind his afflictions as a means of sanctification will find great comfort in knowing that God is in control. “God never lays a rod upon his children’s back,” writes William Bridge, “but he first puts a staff into their hand to bear it.” [5]

If the providence of God is behind illness, disease, and death and these afflictions benefit the Christian, then why seek medical treatment? The reason is that Christians must be good stewards of their bodies. There is an important categorical difference at this point. Christians do not seek medical treatment simply in order to get well; rather, Christians seek wellness and health in order to take care of their bodies (1 Cor. 6:19-20). If the possibility exists for a Christian to improve his physical health, then he should do so, “that [he] may continue serving the Lord as long and as productively as possible.” [6] By the same token, a Christian can be a poor steward of his body when he seeks medical treatment that will only prolong his suffering or destroy his body. I am reminded of a Christian lady who received radiation treatment for cancer. She suffered more from the medical treatment and the complications to her body than from the disease itself. Her latter days were miserable and painful. A weighty and difficult task for the pastor is to discern the providence of God in illness, disease, and death; the need for wellness, health, and life in this present existence; and how to utilize medical science biblically.

The Pastor: Illness, Disease, And Death

There is perhaps no area of pastoral care more prone to misstep than ministry to those who are ill, afflicted with disease, or near death. Some of the most frequent pitfalls for a pastor are personal insecurity in dealing with illness, disease, and death; making personal experiences normative; sentimentality; working from personal rather than biblical presuppositions; rigid application of certain protocols from counseling books; not understanding the relationship between what is considered subjective and objective data in medicine; playing doctor; providing people with reasons to avoid personal responsibility; not looking at people holistically; not understanding side effects of medications; being intimidated by the medical community; and providing people with false hopes of healing when they have received a terminal diagnosis. These are but a few of the errors that the pastor must be on guard against.

How should a pastor counsel a person facing illness, disease, or death? First and foremost, a pastor must discern to the best of his ability whether or not that person is a believer. If a person is not a Christian, then the goal of counseling must be evangelism. Illness, disease, and impending death are excellent evangelistic tools, so don’t pass them up! One of my goals in counseling afflicted non-Christians is to uncover their hopelessness without Christ. A simple question like “What is going to help you through this?” will usually open up the conversation. Conversation will usually come to a point where I can communicate a few biblical truths. It is important to pray for these people and follow-up with them. We need to remember that every bit of gospel truth, in both word and deed, is used by the Holy Spirit to reveal Christ. [7]

When working with Christians facing illness and disease, the pastor will be able to counsel biblically. Initially he must gather accurate data. First, he must find out how the condition was diagnosed. [8] Second, he needs to inquire about the history of the condition. Third, he has to discover the effects of the condition on the person’s lifestyle. Fourth, he has to determine how the condition impacts the person’s thinking and attitudes. Fifth, he will need to find out how relatives and friends respond to the person’s condition. Sixth, he should learn about any medications that may have been prescribed. [9] The purpose of gathering data is not to verify or disprove a diagnosis, but it is to help the pastor counsel appropriately.

The pastor should cover the following topics when counseling, but not necessarily in this order. First, the afflicted person will need to understand how non-Christian health practitioners view illness, disease, and death so that he will not be confused by the presuppositions of naturalistic medicine. Second, the person must be taught a biblical understanding of illness, disease, and death. He needs to hear that the ultimate cause of afflictions is sin, not blind, random processes. He also needs to know that his affliction is according to God’s incomprehensible plan, and that God is still in control no matter how he feels. Third, the person must be reminded that Jesus bore all of his afflictions, no matter how ill or diseased he may become. The person needs to understand that at present, God is using this affliction to sanctify him and to direct his eyes to Christ in deeper faith. Fourth, the person must come to terms with the fact that this affliction is beneficial in some way. God is using it for His purposes, so it is up to Him, and not medical science, to remove it, although He may use medical techniques to do so. Fifth, the person must seek to promote good health as a steward, even if it means turning away from medical procedures that may cure the disease but destroy the body.

The pastor should seek to discern, to the best of his ability, when medical intervention is advantageous and when it is futile, and he should know how to counsel biblically in either case. If medical intervention is advantageous, the pastor’s counseling will be directed toward recovery. But if medical intervention is futile, his counseling will be directed towards comfort and accepting death. [10] It is important for the pastor to know that medical science has, in some cases, created extensive suffering, pain, psychological distress, fruitless hope, disfigurement, and immobility for many people in sincere but biased attempts to eradicate illness, disease, and syndromes at all costs. The goal of bodily stewardship, and not the healing of the body, must always be in the forefront of a pastor’s thinking. Death is sometimes a welcome option for the Christian, especially if the future will be filled with extreme pain, sickness, bodily disfigurement, family distress, hopeless grasping after cures, suffering, misery, and increased expense due to protracted medical intervention.

The pastor will play an important role when counseling individuals who are terminally ill, diseased, and dying. First and foremost, the pastor must be aware of his own insecurities concerning death. He can do a lot of damage by saying, “Don’t worry, everything will be okay,” or “We will pray for your healing.” Statements like this do not benefit the dying person or his family but serve to alleviate the pastor’s discomfort. For a Christian, the role of the pastor is to provide comfort and assurance of heaven, not false hopes of healing. In addition to the counseling about medical treatments mentioned above, the pastor must prepare the dying person and family for death. Today, hospice services are available to provide comfort and care in the dying process, and the pastor needs to be knowledgeable about these services. [11] He should understand the dying process, be knowledgeable about the medications used for palliation, assist the family in funeral arrangements, and be the level-headed point of contact for the family. The pastor will also need to provide bereavement counseling for the family after the person dies.

Traditional Hospice And Christianity

Within the last forty years, hospice and palliative care services have gained a reputable position in the medical community. This was due mostly to the pioneering work of Dr. Elisabeth Kübler-Ross, who in 1969 published On Death and Dying, a scathing indictment of the medical community’s ignorance, insensitivity, fear, and approach towards death and dying. In the words of Time magazine, Kübler-Ross “has brought death out of the darkness.” Not long after Kübler-Ross’s book came out, federal legislation facilitated a hospice benefit for Medicare, and private insurers followed suit. This benefit is now available to people with a prognosis of three months or less to live. [12] As a result, hospice agencies sprouted throughout the nation.

When a person decides that medical intervention is futile and death is imminent, he should be referred to hospice services. [13] At this juncture, another significant challenge confronts the pastor. Certain assumptions about palliation of symptoms, death, and the afterlife are made by hospice agencies that guide the care they give. [14] One assumption is described by Kübler-Ross in her book Death: the Final Stage of Growth and holds that death gives birth to a new stage of life, an afterlife that is in harmony with one’s private beliefs. This assumption is an attempt to unite naturalism with polytheism. Another assumption is that the body is the prison house of the soul. To quote from Gone from My Sight: the Dying Experience, a popular booklet by Barbara Karnes that is handed out to thousands of patients and families who enroll in hospice services, “The separation becomes complete when breathing stops. What appears to be the last breath is often followed by one or two long spaced breaths and then the physical body is empty. The owner is no longer in need of a heavy, non-functioning vehicle.” This assumption stems from a Platonic understanding of soul and body, which asserts that the necessary immaterial soul is imprisoned in an unnecessary physical body. A third assumption is that man is the center of the universe: “The good death and all its ingredients, once the options have been offered, is the choice of the final decision maker…the patient,” writes one author. [15] This idea stems from secular humanism and denies the transcendence and sovereignty of God. Fourth, fear, anxiety, guilt, and all other uncomfortable feelings are viewed as unnecessary evils that must be eradicated. Hospice agencies have an arsenal of medications to numb the patient, and clinicians usually affirm the idea that everything will be okay in the end no matter what is felt or believed. This assumption is based on a hedonistic view of life that denies the immanence of God. [16] These are four basic assumptions that underline, direct, and drive traditional hospice care in the United States.

Because these four presuppositions militate against Christian beliefs, it is crucial for the pastor to have not only a clear understanding of these underpinnings, but also of biblical theology, anthropology, and eschatology. Christianity has always affirmed that God is the final decision maker and not man or “the patient.” God is transcendent and sovereign; He rules over all, controls all, and determines all (Isa. 40:10-15). He created man, gives life to man, and determines when He will take life away from man (Gen. 2:7; Eccl. 3:2). A proper theology underscores God’s transcendent and sovereign activity and is the foundation on which any worthwhile counsel is given.

It is equally important to understand that the “wages of sin is death” (Rom. 6:23). We die because of sin; death is not some “final stage of growth” in a naturalistic process. Death and the dying process are always the culmination of misery, pain, and suffering due to our sin. So, a “good death” in this sense of the term is a misnomer, for there are no “good deaths.” Death is the result of man’s rebellion against his Creator! It must be remembered, however, that death itself is no longer a curse for the Christian but a point of transition; it is where “mortality puts on immortality” (1 Cor. 15:55 –57). So in this sense death is beneficial, and Christians can die well, but death itself is never “good.” Death and the dying process are real and miserable, and this must never be minimized, trivialized, or misrepresented as something that is “good.”

At the time of death, the soul leaves the body and enters into the intermediate state. [17] At this point the believer’s soul is made perfect in holiness and passes into the glorious reality of heaven to experience eternal bliss. [18] When an unbeliever dies, his soul enters into a state of eternal torment, and he is separated from the grace of God forever (Luke 16:23-24). Both the bodies of believers and unbelievers return to the dust and await the resurrection. This body is not the “heavy, non-functioning vehicle” of Platonism; it is what God has created and will take back on the Day of Judgment. In this state of bodily decay, the believer is still united to Christ; the unbeliever’s body is alienated from Christ and the hope of eternal life forever.

The Pastor And Hospice

When a Christian decides that medical intervention is futile, death is imminent, and hospice is a viable option, it is important for the pastor to be involved immediately. [19] If the individual agrees, the pastor should be present at the initial hospice admission visit and be identified as the person managing the spiritual care. [20] This important step will accomplish three things. First, it will allow the pastor to direct the philosophy of care given. This is of utmost importance. Second, it will place the pastor in a position to communicate on behalf of the dying member and the family to the hospice agency. This step will eliminate a lot of stress for the individual and family. Third, it will allow the pastor to counsel the person and family without the unbiblical influences mentioned earlier.

The pluralism that hospice programs advocate is a blessing in disguise for the pastor. The patient directs the spiritual care he receives, and to go against the patient’s convictions is discriminatory and therefore illegal. However, it will be necessary for the dying individual, or family if the person is unconscious, to identify the pastor as the person managing the spiritual aspects of the patient’s care. The next important step is for the pastor to explain his role clearly. First, he will assist the family in their social needs (funeral arrangements, visitation, etc). Second, he will provide all the necessary counseling for the dying individual and family, as well as the bereavement follow-up. Third, he will work with the other hospice professionals in order to provide comfort and management of pain and symptoms for the individual and family

As mentioned earlier, the goal of hospice care is to alleviate suffering, not only spiritually, but mentally, and physically. [21] This is an admirable goal and should be viewed as such. Jesus alleviated mental and physical anguish everywhere he went. In order to accomplish this task, hospice agencies have several medications to assist them. [22] There are two groups of medications that the pastor must be aware of: psychotropic drugs and narcotics. These medications concern the pastor because they can have adverse and unwanted side-effects, can be abused, can cause an overdose, and can hasten death. The pastor needs to be observant when these medications are in use.

It will be important for the pastor to establish with the dying individual, if conscious, the level of pain and discomfort he is willing to endure, and to communicate this desire along with the dying individual to the hospice nurse. [23] Because of sin and the curse on the creation, it is impossible to eliminate pain and discomfort entirely. The goal, therefore, is to keep the individual as physically and mentally comfortable as possible, while maintaining consciousness, clarity, and the ability to communicate, but not to obtund him. [24] The pastor should encourage the individual to make his last days on earth a blessing to others through his undying testimony of God’s grace to him in Jesus Christ.

The Pastor And End Of Life Counseling

Hospice agencies will typically follow a framework by Kübler-Ross called “stages of death.” In this framework, five transitional stages lead up to death: 1) denial and isolation, 2) anger, 3) bargaining, 4) depression, and 5) acceptance. I have found that the conditions of these stages are accurate, but the idea that a progression exists is not correct, at least in my experience. I believe it is more accurate to see these elements in constant flux and not as “stages” but as “states.” Typically, when a person hears that he is going to die, denial does indeed set in, but it is usually in the form of an unrealistic acceptance of death. It is not until reality sinks in that true denial, periods of isolation, bargaining, depression, and periods of acceptance begin to occur. All of these stages are in constant flux as a person nears death. A person may be more accepting one day and depressed the next, and so on. There is no clear-cut progression as described by Kübler-Ross, but her work is accurate and valuable insofar as it pertains to the existence of the various states. The pastor should seek to identify these states when counseling.

As mentioned earlier, the main focus of counseling is to alleviate spiritual, mental, and physical suffering, to help the Christian individual and family understand properly this providential affliction, and to assist them in accepting death. Narcotics may be used to control physical pain and suffering, and psychotropic drugs may be used for mental and bodily suffering. When the person receives a terminal diagnosis and as he nears death, significant changes will occur not only physically but mentally. The individual may experience depression, anxiety, mania, hallucinations, and a host of other psychological afflictions due to the crisis, spiritual malady, physical sickness, underlying psychosis, or the disease process. Psychotropic drugs and narcotics can be used effectively to maintain mental stability and to provide important physical comfort to the individual that will permit the pastor to counsel biblically. So it is incumbent on the pastor to identify these physical and mental afflictions and report them to the hospice nurse so that she can give the proper medications and adjust the dosages as needed. [25]

Where counseling should begin depends on how well the Christian individual and family are coping with the impending death. No matter where the pastor begins, there are four hopeful teachings that he should consciously and continuously intertwine as he counsels. First and foremost, he must bring to remembrance the victory that Christ has over death (1 Cor. 15:55). Although death may be a fearful foe and dying may be miserable, Christ has gained the victory and has eliminated its sting. Death for the Christian is the doorway to Immanuel’s Land, and the place where mortality puts on immortality. It is the place where illness, disease, pain, suffering, and death will be completely done away with. Second, the pastor should bring the hope of assurance to the individual. It is important to communicate clearly that God accepts everyone who sincerely believes in Jesus and His righteousness as his only hope for salvation and that He will never leave him nor forsake him (John 10:27-29; Rom. 8:31– 39). Third, the pastor should address the individual’s many questions: What is the providence of God in all of this (Rom. 8:28)? Why is God doing this? What will happen to my family after I am gone? How will God be glorified? Fourth, the pastor should remind the individual of the beautiful promises of eternal life to come. There are several passages a pastor can turn to in this area. Three of my favorites are John 14:1– 6 and Revelation 21:1–4 and 22:1–5. At all times, the pastor must remember to pray and to sing psalms, hymns, and spiritual songs with the dying individual and his family.

The pastor will also have some very important social work to do, so it will be important to mobilize the diaconal team in the congregation. The family and dying individual will require extensive and organized support, both during and after the death. Diaconal care includes organizing visitation, providing opportunities for the family to get away, providing meals, watching children, taking care of pets, and assistance around the house. The pastor will need to make funeral arrangements. This is a difficult but important and necessary step. After the individual dies, the hospice nurse will pronounce the patient dead, and the funeral home will remove the body from the house. Making many of the funeral arrangements beforehand eliminates a great amount of unnecessary stress on the family, and planning the funeral with the dying individual and the family can be a healthy experience. The pastor must recognize that he is only one part — but an important part — of the hospice team and church team, and that he cannot do it all.

Finally, the pastor has the important responsibility of providing bereavement counseling for the family. Immediately following the death, the pastor should plan to visit the closest family members daily for a few days, until the funeral, then weekly for four weeks, and monthly for the next two months. [26] The pastor must keep in mind that the impact of death does not usually hit the family until a month or two later. Counseling should initially focus on helping the person(s) grieve. It is not normal for family members to be insensitive to the death of a loved one; they should feel sadness and grief. If this is not obvious to the pastor, he should ask whether or not the person(s) has cried over the death. Helping to process the death, understanding the death biblically, and moving on in fervent service for Christ will be the primary goal of the pastor in bereavement counseling. [27]

Pastors in the twenty-first century need to re-examine their approach to counseling the ill, diseased, and dying. The pastor has a responsibility to communicate the true etiology of our afflictions and to trace the providential hand of God that is behind them all. This is a difficult but necessary task in today’s medical milieu. It is essential for people to come to terms with these truths and to establish a biblical understanding of illness, disease, and death. This is their only hope! Medical science has become a negative, in many ways, simply because so many pastors have been bound by its subtle influence. However, the pastor must not be swayed; he must maintain a biblical and balanced understanding of illness, disease, and death in order to counsel appropriately in the twenty-first century and beyond.

Appendix A

Commonly Used Psychotropic Drugs and Narcotics

Psychotropic Drugs

Medications: lorazepam; diazepam

Uses: Anxiety, restlessness, difficulty sleeping

Side Effects: drowsiness, forgetfulness, dizziness, weakness, confusion

Adverse Reactions (particular in the elderly): risk of falling, severe agitation or confusion, hallucinations, agitation, confusion

Medications: haloperidol; olanzepine; chlorpromazine

Uses: Hallucinations, agitation, confusion, mania

Side Effects: drowsiness, dry mouth, slow breathing

Adverse Reactions: risk of falling, severe agitation or confusion

Medications: prochlorperazine; metoclopramide; chlorpromazine

Uses: Nausea and vomiting

Side Effects: dizziness, sleepiness, restlessness, tremor, dry mouth, constipation or diarrhea

Adverse Reaction: increased nausea

Medications: Phenobarbital; diazepam

Uses: Seizures

Side Effects: drowsiness, hallucinations, flushing, nausea, “hangover headache”

Adverse Reactions: risk of falling, severe agitation

Medications: diphenhydramine; lorazepam; temazepam

Uses: Insomnia

Side Effects: drowsiness, dizziness

Adverse Reactions: risk of falling, severe irritability or anxiety

It is also important to note that antidepressant medications are sometimes used to control neurological pain (sharp, tingling or burning pain). If the hospice clinician desires to use an antidepressant it is not necessarily for depression, although it may be. It will be important to find out if the antidepressant is used for depression. Some of the most common antidepressants used in hospice are: neurontin, nortriptyline, trazadone, venlafaxine, amitriptyline, paroxetine, fluoxetine, mirtazapine, bupropion, and sertraline.

Narcotics

Medications: morphine; oxycodone; hydromorphone; fentanyl

Uses: Pain management

Side Effects: drowsiness, dizziness, confusion, constipation, hallucinations, nausea, difficulty urinating, rash, itch; risk of withdrawal symptoms if stopped abruptly (nausea, cramps)

Adverse Reactions: risk of falling, constipation; very slow breathing

Appendix B

Signs and Symptoms that May Occur as a Person Nears Death:

One to Three Months

1. Withdrawal from the world and people
2. Decreased food intake
3. Increased sleep
4. Introversion and less communication

One to Two Weeks

1. Disorientation
2. Confusion
3. Agitation
4. Talking to unseen people (Hallucinations & Delusions)
5. Picking at clothes
6. Physical signs and symptoms:

A. Decrease in blood pressure

B. Increase or decrease in pulse

C. Color changes to the skin (pale, grayish, bluish)

D. Increased perspiration

E. Respiration irregularities

F. Congestion and raspy breathing

G. Sleeping but responding to tactile stimuli

H. Complaints of body feeling tired and heavy

I. Not eating, taking in little fluids (do not force a person to eat)

J. Body temperature can be either hot or cold

Days to Hours

1. Intensification of “one to two week signs”
2. Sudden surge of energy
3. Physical signs and symptoms:

A. Continued decrease in blood pressure

B. Glassy eyes, tearing and half open eyes

C. Irregular breathing with long pauses between breaths

D. Increased restlessness or even no activity at all

E. Purplish knees, feet, hands, and “blotchy”

F. Pulse weak and hard to find

G. Decreased urine output, may wet or stool the bed

Minutes

1. “Fish out of water” breathing
2. Cannot be aroused or awakened
3. Cold, clammy, pale, gray, ashen, or bluish body

Works Cited

• Bridge, W., The Works of William Bridge. Beaver Falls, PA: Soli Deo Gloria Publications, 1989.
• Smith, R., The Christian Counselor’s Medical Desk Reference. Stanley, NC: Timeless Texts, 2000.
• Rev. Christopher W. Bogosh, BTh, RN
• Hazleton Area Reformed Presbyterian Church, 680 Roosevelt Street, Hazleton, PA 18201. 570-450-0148. www.hazletonrpc.com

Notes

1. It is important to distinguish between what I call microbiological death and biological death. In the garden, Adam, Eve, and the animals ate plants, so this required the death of the plant for digestive purposes on the microbiological level. So death in one sense always existed prior to the fall. The Bible teaches that biological death — that is, the death of a living species with blood in it — did not occur until after the fall (Gen. 2:17; Lev. 17:11; Rom. 6:23).
2. See Genesis 3ff.; Revelation 20:14; and Romans 5:12; 6:23.
3. Robert Smith, The Christian Counselor’s Medical Desk Reference (Stanley: Timeless Texts, 2000), 31.
4. In my experience, I have come across many Christians who think that they have an excuse to stop ministering when they become ill, contract a disease, or even face death. This kind of thinking is radically unbiblical (cf. Job 2:10; the supreme example to the contrary is Christ on the cross: Luke 23:24, 39-43; John 19:25-27; Mat. 26:53-54). Although it may be a struggle to cope under these afflictions and still minister, the excuses not to minister are based on sentimentality and a low view of God’s providence. As long as a Christian is in a state of consciousness, he should seek to minister to others, even if that means a death bed ministry of prayer. For a powerful testimony to God’s sustaining grace in one man’s death-bed experience that still ministers to us today, see the Memoirs of Thomas Halyburton, ed. Joel R. Beeke (Grand Rapids: Reformation Heritage Books, 1996), 226-94.
5. William Bridge, The Works of William Bridge (Beaver Falls: Soli Deo Gloria Publications, 1989), 2:191.
6. Smith, 41.
7. The two-fold effect of the Gospel is in view here (2 Cor. 2:15 –16).
8. It is very important for the pastor to discern between what are called symptoms (subjective findings) and signs (objective findings) Technically, in order for a disease to be diagnosed, factual evidence (blood pressure, lab tests, MRI, etc.) must exist. The medical community has a tendency to label subjective complaints (symptoms) as a disease without any objective findings (signs), and this is wrong. Alcoholism, and a plethora of psychological conditions, are examples of so-called diseases that are diagnosed from subjective data.
9. Smith, 49-51. It is not necessary to know the dosages, but it is important to understand why the medication was prescribed and any side effects.
10. It is extremely important that the pastor recognize his boundaries at this point. He should never make the decision to pursue or not to pursue medical intervention. The pastor should act as a guide who provides factual information in light of medical findings and provides counsel that is biblical. Ultimately, the person or his family must make the final decision to pursue or to forgo medical treatment. This does not mean, however, that a pastor does not give his opinion in light of medical findings, but only that he should not make the decisions for the parties involved.
11. It is important for the pastor to realize that hospice agencies have their own presuppositions about life and death that stem from the ideas of Dr. Kübler-Ross and New Age spirituality. It is also worth noting that many hospice agencies advocate euthanasia and support the “Right to Die” movement. For the sake of the person dying and the family, the pastor needs to become a part of the hospice team and advocate for the family during this difficult time. More will be said on this later.
12. The three-month window is not very rigid and has been broadened recently. A terminal prognosis is still necessary, but a terminal prognosis can be given if a person decides that he no longer wants to take medications that are necessary to sustain life. If a treating physician is of the opinion that death would occur if certain medications were stopped, then hospice services may be referred. When a person signs on to hospice care, he is reviewed at three-month intervals for the first two certification periods and six months thereafter. If the person improves (and many do), he is discharged from service.
13. Unfortunately, there are many physicians who refuse to refer their patients to hospice because of a drive to cure the disease at all costs. In these instances, the patient and family must request hospice services and/or to have a second opinion from another doctor.
14. I will focus on the assumptions about life and death made by hospice agencies that are considered worthy of Medicare reimbursement. Most private insurers follow these guidelines as well.
15. Quoted from a standard admission packet that is handed out to patients prior to enrollment in hospice services.
16. The term “immanence” is a concept from philosophy that describes God’s presence and activity in the world. It is the action behind God’s transcendent providence. This view is in contradistinction to Pantheism, which believes that God’s essence is identical with the creation.
17. The “intermediate state” is the time between the death of the body and departure of the soul in this present life, and the resurrection of the body and reunion of the soul at the second coming of Christ.
18. Heb. 12:23; 2 Cor. 5:1, 6, 8.
19. There are some important things for the pastor to know about hospice care. First, the goal of hospice care is not to cure the disease, but to reduce the symptoms of the disease by providing physical, emotional, and spiritual support to the patient and family. This means that treatment is palliative in nature and does not include such measures as cardiopulmonary resuscitation (CPR) or other advanced life support systems. The person signing onto hospice agrees to forgo any further medical treatment for his disease. This is an important fact that the pastor must keep in the forefront at all times. He must make sure the dying individual and the family understand clearly the decision that is being made. Second, the admitting nurse should explain what is called a “do not resuscitate” (DNR) order and what this means to the family. Basically, CPR and other life saving measures will not be performed at the time of death; therefore, the hospice agency, and not an ambulance, should be called. Third, the nurse should explain repeatedly that all the care given is palliative, and medical treatment such as intravenous infusions and tube feedings are usually contraindicated. Fourth, the nurse should make sure a health care proxy is identified and the proper forms are filled out. She should explain the health care proxy’s role and make sure he understands that he may have to make important decisions on behalf of the dying individual. Fifth and ongoing, the nurse will provide teaching about medications and the progression toward death and will seek to provide support to the patient and family.
20. Hospice agencies are required by law to provide chaplaincy (spiritual) services for the dying and their families.
21. I do not advocate a trichotomist view of man, but for practical purposes I will distinguish between the mind, body, and soul. Edward T. Welch, in his book Blame it on the Brain: Distinguishing Chemical Imbalances, Brain Disorders, and Disobedience (Phillipsburg: P&R Publishing, 1998), does an excellent job explaining the relationship between body and soul, their integrated components, and how they affect one another.
22. See appendix A for a list of commonly used medications and their side effects.
23. It is important to mention that when a person is in an unconscious state, he will still experience pain and discomfort. This is usually evident through wincing, irritability, picking, rapid breathing, raspy breathing, and moaning. See appendix B for a list of physical and mental signs and symptoms that appear when a person is nearing death. Also, the nurse is skilled at assessing pain and discomfort. She should establish this baseline with the patient right away, and should also explain that as the disease progresses and death nears, more medication may be required to alleviate pain and discomfort. The main thing the pastor needs to do is to make sure a biblical balance is maintained, and the member is not overly influenced by the nurse, who will be inevitably biased in her approach.
24. The pastor should never assume that he knows the level of suffering or pain a person is experiencing. Pain, discomfort, and suffering are subjective and are always what the person says they are.
25. The individual may report having guilt, remorse, visions, bizarre dreams, and visitations from people he was acquainted with who have already died. These may be important areas where repentance and forgiveness are needed, especially if guilt and remorse is the cause. On the other hand, these experiences may be pleasant, such as experiences of the heavenly reality to come or a reunion with long-dead saints. It is important for the pastor to explore these things with the parishioner and to recommend the use of medication wisely. Do not write off dreams, visions, or other experiences too quickly, because these experiences are doorways into the subconscious world of the dying individual (I do not mean to sound Freudian or Jungian!) and they will help the pastor to counsel effectively.
26. This is not a rigid schedule, because each situation is unique. Visits should be based on the family’s needs.
27. Moving on with life does not mean doing away with memories. In fact, tapping into memories can be a good way to get people to grieve and move on with their lives.