Healing Bodies and Healing Bodies and Souls at the End-Of-Souls at the End-Of-

Life Life

James Hallenbeck, MDJames Hallenbeck, MD

Director, Palliative Care Director, Palliative Care Services Services

VA Palo Alto HCSVA Palo Alto HCS

Key PointsKey Points

Clergy bear much in common with Clergy bear much in common with physicians in how we “minister” to dying physicians in how we “minister” to dying patientspatients

In training emphasis on knowledge, ritual In training emphasis on knowledge, ritual skills and skills and deathdeath Little specific training on Little specific training on dyingdying Inadequate attention to communicationInadequate attention to communication

Changes in how we die pose new Changes in how we die pose new challengeschallenges

““Remedial training” is requiredRemedial training” is required

Questions Doctors Must Questions Doctors Must FaceFace

Why did God do this to me?Why did God do this to me? Do you believe in God?Do you believe in God? What do you think will happen when What do you think will happen when

we die?we die? Are you Saved?Are you Saved? Don’t you believe in miracles?Don’t you believe in miracles?

Questions Clergy May Questions Clergy May FaceFace

Can’t they do something for the pain?Can’t they do something for the pain? He won’t eat and the doctors won’t do He won’t eat and the doctors won’t do

anything. We can’t just let him starve anything. We can’t just let him starve to death, can we?to death, can we?

They are talking about discontinuing They are talking about discontinuing life-support. If they take her off the life-support. If they take her off the machine, isn’t that like killing?machine, isn’t that like killing?

Since she died, I can’t sleep or Since she died, I can’t sleep or function. I’ve lost 20 lbs. I wish I could function. I’ve lost 20 lbs. I wish I could join her. Why did she have to die first?join her. Why did she have to die first?

Changes in How We DieChanges in How We Die

Most deaths now in institutionsMost deaths now in institutions Families less able to care for dying Families less able to care for dying

patientspatients Most deaths due to chronic illnessMost deaths due to chronic illness Dying usually takes a long timeDying usually takes a long time Dying isDying is expensive expensive Many options available Many options available

Treatments, care systems, where to dieTreatments, care systems, where to dieMany now view dying itself as a choice

Top 5 Causes of Death Top 5 Causes of Death 19001900

Rank Cause of Death Percentage

1 Influenza,Pneumonia

11.8

2 Tuberculosis 11.3

3 Gastritis,Enteritis

8.3

4 Heart Disease 8.0

5 Stroke 6.2

Top 5 Causes of Death Top 5 Causes of Death 19941994

Rank Cause of Death Percentage

1 Heart Disease 32.1

2 Cancer 23.5

3 Stroke 6.8

4 COPD 4.5

5 Accidents 3.9

WhereWhere Do We Die Do We Die

60%20%

20%

OtherNursing HomeHospital

Dying Takes a Long TimeDying Takes a Long Time

From brief transition period to LIFE From brief transition period to LIFE STAGESTAGE

Social Implications – new systems Social Implications – new systems neededneeded

Cultural Implications – meaning of Cultural Implications – meaning of stage and relation to other life stagesstage and relation to other life stages

Personal Implications- what is to be Personal Implications- what is to be accomplished in dying?accomplished in dying?

When does dying begin?

ImplicationsImplications

Focus on Focus on deathdeath/afterlife/afterlife

Care for dying as Care for dying as simple kindnesssimple kindness

Dying understood as Dying understood as inevitable, beyond inevitable, beyond mortal controlmortal control

Focus on Focus on dyingdying Complicated Complicated

systems of caresystems of care Difficult and Difficult and

confusing choicesconfusing choices Dying understood Dying understood

as as optionaloptional, a , a matter of personal matter of personal choicechoice

From:From: To:To:

Overlapping domainsOverlapping domains

PhysicaPhysicall

PsychologiPsychologicalcal

SocialSocial

SpiritualSpiritual

Alternate ViewAlternate View

PhysicaPhysicall

PsychologiPsychologicalcal

SocialSocial

SpiritualSpiritual

Communication Communication ChallengesChallenges

AmbiguityAmbiguity ““Can I go?”Can I go?”

Hidden meaningsHidden meanings ““Can I have a sleeping pill?”Can I have a sleeping pill?”

In most cultures In most cultures explicit discussion explicit discussion about death and about death and

dying taboodying taboo

Communication layersCommunication layers

ThinkingThinking Knowledge, factsKnowledge, facts Meaning Meaning

EmotionalEmotional

SpiritualSpiritual

Example: “Why did I get Example: “Why did I get this awful disease?”this awful disease?”

Explore ambiguity: “What did you mean Explore ambiguity: “What did you mean when you said…”when you said…”

Address thinking: “Why do you think you Address thinking: “Why do you think you got it?”got it?”

Address feeling: “It is sad that this Address feeling: “It is sad that this happened…”happened…”

Spiritual: Spiritual: How would you address the How would you address the spiritual implications in this spiritual implications in this question?question?

Choices in Choices in communication:communication:

Most “why” questions, if not technical, Most “why” questions, if not technical, are spiritual in nature…are spiritual in nature…

Communication – more Communication – more than words…than words…

WordsWords Work with words that are comfortable Work with words that are comfortable

for the personfor the person RitualRitual

Physicians listening to heart and lungs, Physicians listening to heart and lungs, feeling pulsefeeling pulse

Religious ritualsReligious rituals ContextContext

WhoWho is present is present Body language Body language Time and circumstanceTime and circumstance

PresencePresence

The Dying and their families very The Dying and their families very sensitive to the presence of others, sensitive to the presence of others, looking to us for cues as to how to looking to us for cues as to how to respondrespond

Does our presence communicate:Does our presence communicate: Peace or Distress?Peace or Distress? A desire to be A desire to be there there or or elsewhereelsewhere?? At home or not at home?At home or not at home?

We must become the change we We must become the change we want to seewant to see

GandhiGandhi

TeamworkTeamwork

Clergy, like physicians may be used Clergy, like physicians may be used to “going it alone”to “going it alone” Shared notions of confidentialityShared notions of confidentiality

Clergy, like physicians, may be used Clergy, like physicians, may be used to being “the boss”to being “the boss”

Care for the dying requires teamwork Care for the dying requires teamwork Shared responsibility: – communicating Shared responsibility: – communicating

with other team memberswith other team members Ability to elicit and receive feedback on Ability to elicit and receive feedback on

one’s work from people in other one’s work from people in other disciplinesdisciplines

Healing into DeathHealing into Death

Healing happens of itself – our role Healing happens of itself – our role to promote healingto promote healing

Healing transcends bodily integrityHealing transcends bodily integrity Healing differs from cure in that it is Healing differs from cure in that it is

an ongoing an ongoing process process – cure is a – cure is a outcomeoutcome

While cure may not While cure may not always be possible, always be possible,

healing is…healing is…

SUMMARYSUMMARY

New ways of dying require the New ways of dying require the acquisition of new skills on the part of acquisition of new skills on the part of clergy, as well as physiciansclergy, as well as physicians

While we can find great wisdom in our While we can find great wisdom in our traditions, specific behaviors must traditions, specific behaviors must adapt to our new circumstancesadapt to our new circumstances

If we are to be of better service to If we are to be of better service to those for whom we care, we must take those for whom we care, we must take responsibility for improving skills in responsibility for improving skills in end-of-life careend-of-life care