Journal of Religion and Health, Vol. 17, No. 3, 1978
The Healing of the Dying MICHAEL K. BICE Most of us conceive of dying as the antithesis of health. We assume that health is the state we enjoy until something goes wrong with our bodies so that finally we die. Health seems to be in no w a y related to dying, and the idea that the two could overlap seems incredible. But it is possible to die healthy (and not before one's time), and many do die healthy. If we think about it, then most of us would want to die healthy also. It is the best w a y of going. And the reason we should worry our heads now is that it will pay dividends later! J e r e m y Taylor wrote, ~It is a great art to die well, and to be learnt by men in health." And Sylvia Plath said, "Dying is an art like everything else." More recently, Dag HammarskjSld, in Markings, wrote, "The hardest thing of all--to die rightly-an exam nobody is spared--and how many pass it?" This article is meant to help us understand what it is to die rightly, to die well, and to die healthy as well as to offer some practical advice.
First of all, what is health? From the 1948 Constitution of the World Health Organization, we read, "Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity." From this we learn that the chief characteristic about health is one's sense of wellbeing. Health is the state of complete or total sense of well-being and not just the absence of disease or infirmity. There are many examples of men and women dying with their bodies fragmenting b u t with a pervading sense of well-being. There are also many examples of men and women dying with their bodies physiologically intact b u t with the fatal loss of a sense of well-being (as in Voodoo). The anthropologist L~vi-Strauss writes, "An individual who is aware that he is the object of sorcery is thoroughly convinced that he is doomed according to the most solemn traditions of his group . . . . Physical integrity cannot withstand the dissolution of the social personality. ''1 The important thing is the total sense of well-being. It is very interesting that the word health comes from the Old English word hdl, meaning whole. We still have the expression '~nale and hearty," where the word hale comes from the same word, hdl, and means that the person is full of life or whole. The idea The Rev. Michoel K. Bice, M.D., is an Instructor in the Department of Internal Medicine, Rush Memorial College, and Staff Physician at Rush-Presbyterian-St. Luke's Medical Center, Chicago. 184 0022-4197/78/0700-0184 $00.95
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of health is m e a n t to convey wholeness. The physical body is only p a r t of t he wholeness of our being. It is a necessary part, to be sure, b u t still only a p a r t of the whole. A most important par t is the h u m a n spirit in all its complexity, which manifests itself in a sense of well-being. T h e r e is also t h a t spark of t he Divine in all of us t h a t has allowed poets and religious m e n to glimpse something of the Infinite. So when we t h i n k of health, we m u s t t h i n k in t e r m s of wholeness (called wholistic, or holistic, by those who delight in expanding t he frontiers of language). But wholeness reaches out beyond the person. If we are t r u l y whole or healthy, we are also totally i nt egrat ed into our environment. We are p a r t of a family, a tribe, a community, a nation, a World, at once huge, and yet ever growing smaller, so t h a t it has now been described as a "global village." The religious m a n would also add God to our environment, so t h a t b e i n g whole or h e a l t h y includes some sort of necessary relationship with t he Creator. It is anot her strange quirk of t he English language t h a t the word holy also comes from the same Old English word hall, m e a n i n g whole. Our forefathers saw t h a t holiness and h e a l t h were related and were both manifestations of wholeness. J o h n Donne, the famous poet and priest, summarized this holistic outlook with his words: No man is an Iland, intire of it selfe; every man is a peece of the Continent, a part of the maine; if a Clod bee washed away by the Sea, Europe is the lesse, as well as if a Promontorie were, as well as ifa Mannor ofthy friends or of thine owne were; any mans deathe diminishes me, because I am involved in Mankinde; and therefore never send to know for whom the bell tolls; It tolls for thee. 2 It is one of the gr e a t tragedies of our modern Western society t h a t it has lost t h e feeling of cohesion between its members. Families split up and m em bers die alone. B u t among American Indians and Africans today where the tribal bonds are still intact, t he r e is a feeling t h a t if one m e m b e r suffers or is ill, t h e n the whole family or tribe suffers or is ill. Again, t h a t is a holistic outlook. It is also a h e a l t h y outlook. To die h e a l t h y means to die in wholeness. To die in wholeness m eans t h a t the parts of our whole being are in a necessary equilibrium. It also m eans t h a t we are in a necessary equilibrium with our e n v i r o n m e n t - - o u r loved ones, our community, even the Cosmos. To die h e a l t h y or to die whole means t h a t as our body disintegrates, so the h u m a n spirit and our sense of well-being more and more assert themselves. As the dying person becomes more and more whole or holistic, he even embraces death. D e a t h is accepted and not avoided. D eat h becomes p a r t of living. T h e r e is a beautiful description of this process in an address by F a t h e r E. K. Talbot of the English C o m m u n i t y of the Resurrection: Have you not watched that most lovely of all things, a life which has been secretly, humbly, interiorly dying day by day, and living, ever living unto God: so that now Death is a friend leading the soul to the home and goal which all along has been its home, its goal, which it has waited for expectantly--the soul which has looked for and loved his appearing?
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A similar description of dying in a holistic sense, where the terminally ill person feels he even has some control over t he situation, is given in a recent book by Eric J. Cassell, Clinical Professor of Public H e a l t h at the Cornell University Medical College: I think that those who die well and in control have something to teach the living about the body and about living. They show us that it is possible to come to peace with the body, both to be controlled by its limitations and to control it to a far greater extent than unlearned existence would suggest. They teach us that control is not denial or repression. That which we deny or repress about ourselves or within ourselves controls us by the fact of our constant need to deny rather than to come to terms. Control implies acceptance of limitations plus an awareness that the limitations provide room for the continued exercise of self, even unto death. The beauty and potential of growth lie not only in intellectual transcendence and the formation of transcendent emotional bonds, but also in the possibility of dynamic unity with the body. ~ This concept of the body being in some sort of dynamic uni t y is one of t he characteristics of health. W he t he r we are living or w h e t h e r we are dying, we can still preserve this dynamic unity, this wholeness. And then, in the words of Dr. Cassell, we can "come to peace with the body." After all, it is this sense of peace, w h e t h e r we are living or dying, t h a t all m en long for. Dr. Hans-Jfirgen Becken, a G e r m a n missionary in Africa for t w ent y-t hree years, recently wrote: When the generator is switched offat night in the mission hospitals in Zululand and the electric lights go out, the patients do not complain; but sometimes they ask for a burning candle, since in its light "it is easy to pray and even easy to pass away." This indicates that they are not concerned exclusively with body health; rather they look for peace. 4 Peace is the most obvious characteristic of health or wholeness. It is also the f u n d amen tal prerequisite to health or wholeness. World peace is the goal of nations. I n n e r peace is the ambition of those who practice transcendental meditation. B u t peace within and peace without is the aim of all men. Most people know t h a t the Hebrew word s h a l o m means peace. But it is not just a formal greeting or a polite farewell. Its f u n d a m e n t a l meaning is "totality," "well-being," '~harmony," and "health." (The adjective, shalem, is translated "whole.") Peace is not just a state of mind for an individual, as Western m an tends to t h i n k of it today. Rather, t r ue peace is holistic in t h a t it takes into account the whole person in all his complexity. It takes into account the totality of interpersonal relationships. It recognizes a h a r m o n y with the Cosmos.
2 With these holistic concepts in mind, it is now appropriate to t u r n to a discussion of two patients with a terminal illness. Both patients died at peace after a healing of t h e i r life situation. The first pa t ient experienced healing primarily t h r o u g h a personal religious faith. The second experienced healing through t he
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coming together of a fragmented family. But both died rightly, died well, and died healthy. A woman in her fifties was admitted to .St. Christopher's Hospice in London with advanced metastatic cancer. She looked very ill and was pale, thin, and anxious. When she was admitted, she said to the doctor, '~I hope you can do a great deal for me." She was not a practicing Christian and God had never been a reality in her life. Furthermore, her illness had been complicated by the fact t h a t her doctors, who had diagnosed the cancer, would not tell her the truth. So when she was admitted to St. Christopher's, her first question was, "Doctor, is it cancer?" Because she really wanted to know the truth, her new doctor told her. Needless to saY, the news was a great shock to her. She seemed to collapse--physically, mentally, and spiritually. But t h a t was short lived. A most remarkable change then began to come over this woman. She began to sleep better and even began to look younger. For the first time in three months she became free of pain, and t h a t with. only h a l f the dose of morphine t h a t she had been on. By the time she died five weeks later, she h a d more t h a n passed t h a t final e x a m - - t h e hardest thing of all--to die rightly. 5 How to explain the last five weeks of this dying patient? First, it must be said t h a t knowing the truth was a great relief to this woman. True peace does not come through deception. Secondly, the secret of her sense of well-being came out at the end when a nurse produced a type of log t h a t she had k e p t - recording significant words the patient had spoken during the course of those five weeks. The following are only some of the things t h a t this woman had said. It is obvious t h a t there is a very definite progression in her attitude. I want help. I want to find God. Why has all this happened to me? I'm beginning to understand. I am awake at night sometimes thinking. I put up barriers and take them down. My husband is different. He is happier; he has a different smile on his face. He was an atheist but now he says there is a God. He is finding it hard to understand. The Lord is personal to me now. I no longer say '~why?". There is a purpose in all this. My husband went into the chapel and prayed to God this morning. We talk about my faith together. What is apparent is t h a t this woman begins with a cry for help. She says, '~I want help. I want to find God." She ends up having received help when she says, ~'The Lord is personal to me now." It has been said t h a t one of the great fears t h a t the dying have is the fear of being abandoned, s Dr. Elisabeth K~bler-Ross tells the story of once visiting a terminally ill patient and finding her sitting on the edge of the bed with the telephone off the hook in her hands. '~What in the world are you doing?" the doctor asked. "Oh, just to hear a sound," she replied. 7 The presence of another h u m a n being, who may say nothing or do nothing except to sit by the bed, is a great inspiration. That person's presence emphasizes the corporate side of h u m a n life. Wholeness and h e a l t h
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have a necessary relatedness to others. We are all part of each other. As John Donne says, "every man is a peece of the Continent, a part of the maine." Furthermore, for the religious person, wholeness and health have a necessary relatedness to God. The dying woman realized the Cosmic dimension to h u m a n life in her newfound religious faith. She even says, "There is a purpose in all this." There is no doubt that the discovery of a personal Lord was a tremendous boost in overcoming her fear of being abandoned. She knows that God will not leave her and she rejoices that she can share this same faith with her husband. She has accepted death; it has become part of her living. So gradually, as her body dies, her spirit soars. She is free of pain. She sleeps better. She even looks younger. She is at peace with herself, reconciled with her husband, and reassured by the peace of God. She is one with the whole creation. And so she dies whole and healthy. There is an interesting parallel between the final stage in the life of this woman and the final stage in the development of the ego according to the scheme of Erik H. Erikson. The final or eighth stage is called "ego integrity" and is characterized by an inner harmony Ca post-narcissistic love of the h u m a n ego") and an outer harmony (in integration into "world order and spiritual sense"). At the stage of ego integrity, even death is accepted. Erikson says of this final stage, "It is the acceptance of one's one and only life cycle as something that had to be and that, by necessity, permitted of no substitutions . . . . In such final consolidation, death loses its sting. ''s The second patient was a fifty-three-year-old woman admitted to a chronic disease hospital in Boston, dying of ovarian cancer. She had six children from two previous marriages. H e r third marriage was unhappy for all concerned. It soon became apparent that her family was disintegrating. A married son was in trouble with the police. A second son had begun to drink heavily and had lost his job. A third son had simply run away. A daughter, aged twenty-three, had refused to do anything about a positive Pap smear, while a younger daughter had stopped talking and just stared out the window at school. It was no wonder that the patient was most anxious when admitted to the hospital. By the sheer force of her personality she had been able to keep the family together and in some sort of harmony while at home. Now she seemed to be losing control. This was especially upsetting for her, as she had always been a type of matriarch. Her doctor observed that, for her, "the greater tragedy was not dying but losing control during the last days of her life." Accordingly, it was decided to manage the patient at home where she preferred to be and to help her to remain in control of her family. Members of the hospital staff and various social agencies visited each of the children and were able to establish some rapport. This enabled the children to face up to the crisis of their mother's illness. They were also helped to cope with their own problems. Meanwhile, with the help of skilled home nursing, the mother was enabled to spend most of her last six months at home. She was able to preside over the healing of the various troubles in the family. Finally, she was readmitted to the hospital with massive, recurrent pleural effusions and ascites, but now resistant to all treatment. Before she died she was able to thank the stafffor all
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their help. And she died with a reunited family at her bedside. It was a good death. She died where she had always b e e n - - a t the center of her family. If she had been in the hospital for all of her last six months, it m a y be argued, she m a y have received better treatment for her cancer. But then the family problems would certainly have been exacerbated. Furthermore, her anxiety would have increased as she was made to surrender her control of the family. Her doctor concluded, ~'What was not lost was an intact person, and, it is to be hoped, an intact and functioning bereaved family. ''9 That is true wholeness. That is dying healthy.
3 To die healthy or whole is obviously related to living healthy or whole. If the latter has been the case, then the former is more likely. Through most of our lives, the physician has a unique opportunity to assist us in our growth towards wholeness. He is the one who is consulted at times of illness. But he is often consulted for all manner of other problems that arise in day-to-day living. A physician who has a holistic outlook recognizes that his responsibility is not just in curing a particular disease but in caring for the whole person. One of the great problems that has developed with the rise of a super-scientific medicine and technology has been the fragmentation of the patient into various organ systems, which are the exclusive domain of certain subspecialists. It sometimes becomes difficult to find a doctor who can put the patient together again and care for the whole person. I have been following for some weeks an elderly female patient who was discharged from a large teaching hospital after she was told that nothing further cquld be done for her. After the diagnosis of carcinoma of the right maxillary sinus was made, she was treated with total excision of the maxillary sinus together with an exenteration of the right orbital contents. It was a mutilating procedure, although the surgeon hoped for a cure. When I first saw her a week after discharge, she was very depressed and complaining of a constant headache, together with multiple aches and pains so disabling that she could barely walk. After I had reviewed her chart and examined her, it was apparent that most of her symptoms were the result of her feeling of abandonment by her doctors at the time when she needed them most. My job was not just to order some tranquilizer or analgesic but to let her know that I understood the situation and, above all, that I cared. I must care for her physical condition, her emotional condition, and even her spiritual condition. To ignore the latter, for she was a very religious Southern Baptist, would have affected my care for the whole person. If religious faith is important to her, then that must also be important to me. It turned out that I spent almost as much time in encouraging her faith as I did in checking her symptoms. But the result was remarkable. Over the course of the next few weeks, her sense of well-being improved and her symptoms disappeared. Her appetite improved and she put on weight. From her former feeling of helplessness and abandonment, she now
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has a feeling of being in control as she sets the dates of her own return visits, at first weekly, now at ever longer intervals. The ultimate prognosis for this patient is, of course, guarded. Consequently, part of the physician's job is to anticipate her dying so t h a t she m a y be prepared to die in wholeness and peace. Among doctors in general and psychiatrists in particular, there is a curious reticence to discuss any religious issue with their patients. A psychiatrist m a y have no qualms about exploring the details of a patient's sexual fantasies, but if a patient admits to praying to St. Anthony three times a day, then, more often t h a n not, the subject is changed. And yet, in illness and especially in the face of death, the patient m a y raise some profoundly religious issues. '~Why me?" This is one of the commonest questions. We m a y attempt an answer by explaining how our patient got sick, but t h a t is not the same as why. Then there are other religious issues, such as the meaning of h u m a n life, guilt, and remorse over lost opportunities. Of course, there is no simple answer to any of these questions. And the worst possible answer for the dying patient who asks "Why?" is a n y t h i n g t h a t suggests t h a t it is the '~will of God." That is both cruel and probably f a l s e p w h o can be sure of the "will of God"? If it is the special temptation of religious "do-gooders" to offer such pat answers, it is the special temptation of m a n y scientifically oriented doctors to avoid such questions entirely. It is understandable t h a t some doctors find such questions too provoking of anxiety in themselves. It is much easier to be a doctor t h a n a patient. It is easier to face other people's problems t h a n our own. One reason why doctors have been slow to recognize their responsibility in caring for the dying patient is t h a t the doctor has not faced up to his own mortality. From my experience in t e a c h i n g courses on death and dying to both nurses and medical students, I find t h a t the nurses are much more attuned to the subject matter. Perhaps the medical student, in his frantic struggle to become a doctor, which in our society is a type of omnipotent god and therefore immortal, cannot face his own mortality without some conflict and a t t e n d a n t anxiety. If a doctor is to be sensitive to his patient's religious questions, he must first listen. He must resist the temptation to interrupt the patient and suggest t h a t the chaplain will stop by. Most religious questions t h a t the sick patient asks are not on points of doctrine or church order requiring a theologian for an answer. Rather, they are about h u m a n life and personal relationships. For the dying patient, the doctor often becomes a type of priest. In his care for the patient he m a y seem to bless and absolve. Even when the dying patient has no obvious faith or denies having any, the doctor is still a type of priest in t h a t he can mediate wholeness and peace. Dr. Paul S. Rhoads, former Chief of Medicine at Northwestern University Medical School, summed up the doctor's role in caring for the terminally ill with these words: Ours is not an ecclesiastical priesthood and we should never attempt to make it so, but it is a priesthood of a sort, nonetheless--one for which medical school has not prepared us. To be prepared for it, somehow each of us must, in his own way, have searched for meaning in his daily tasks. Whether he considers himself religious in the conventional sense or not, he must have given some consideration to the universe in which he lives, to the place of man in it, and to the force or mind or God--call it what you will--behind
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it all . . . . How he will act in this exquisitely personal r e l a t i o n s h i p will depend upon how he sees h i m s e l f in this m i g h t y scheme of things. If, as our religion teaches, t h e r e is a touch of t h e divine in every m a n - - a n d w h a t perceptive p h y s i c i a n who h a s seen t h e h e r o i s m with which o r d i n a r y people meet the g r e a t e s t c a l a m i t i e s can doubt i t ? - - t h e g r e a t e s t satisfaction we can derive is in helping to unlock t h e resources t h a t are t h e r e to m e e t the challenge of t e r m i n a l illness . . . . O u r t a s k is to be a friend who is a w a r e of t h e road a h e a d a n d is willing to go along t h a t road with t h e p a t i e n t . . . l o
Dr. Elisabeth K~ibler-Ross was once asked how she would offer comfort and/or meaning to a dying patient. She replied: T h e r e are m a n y ways of offering comfort to a d y i n g p a t i e n t and this should not be dependent on his religious faith. Comfort m e a n s your being with him, giving h i m physical comfort, p a i n relief, back rubs, moving h i m a r o u n d if he is u n a b l e to move, holding his hand, listening to his needs. This w a y you can help p a t i e n t s w h e t h e r t h e y h a v e faith or no faith. Real love and faith is often conveyed b e t t e r b y action t h a n b y words.ll
With such advice, I heartily concur. In my own experience, I have been impressed about the effect of h u m a n touch, either of holding the patient's hand or resting my hand on his forehead. It lets the patient know that we are not afraid to touch him; and, if we are not afraid, then that in itself can calm the patient's own fears. But there is something even more fundamental, and it has to do with the very basis of h u m a n life. We have physical bodies that are obvious, plus a mysterious otherness that, for the sake of convenience, we might call the h u m a n spirit. It is this same h u m a n spirit that is turned on by the touch of another and that begins to well up so that not infrequently there are a few tears. But these are not tears of sadness, they are tears of release. They are the tears accompanying something that is becoming whole deep down inside the patient. They are the tears that signal the healing of the dying.
References 1. L6vi-Strauss, C., Structural Anthropology. New York, Basic Books, 1963, pp. 167, 168. 2. Donne, J., Devotions upon Emergent Occasions, No. XVII. In Complete Poetry and Selected Prose of John Donne, Dean of St. Paul's. London, Nonesuch Press, 1962, pp. 537, 538. 3. Cassell, E. J., The Healer's Art. Philadelphia and New York, J. B. Lippincott Company, 1976, pp. 228. 4. Becken, H-J., The Experience of Healing in the Church in Africa. Contact 29. Geneva, Christian Medical Commission World Council of Churches, October 1975, pp. 9. 5. West, T., "The Truth," St Christopher's Hospice Annual Report. 1974-1975, pp. 34-36. 6. Ktibler-Ross, E., "Dying with Dignity," Canadian Nurse, 1971, 67, 32. 7. Kiibler-Ross, E., "The Art of Dying:l," The New York Times, January 15, 1973. 8. Erikson, E. H., Childhood and Society. New York , W. W. Norton and Co., 1963, pp. 268. 9. Krant, M. J., "The Organized Care of the Dying Patient," Hospital Practice, 1972, 7, 103-105. 10. Rhoads, P. S., "Management of the Patient With Terminal Illness," J. Am. Med. Assoc., 1965, 192, 664. 11. Kfibler-Ross, E., Questions and Answers on Death and Dying. New York, Macmillan Publishing Co., 1974, pp. 160.
The Healing of the Dying MICHAEL K. BICE Most of us conceive of dying as the antithesis of health. We assume that health is the state we enjoy until something goes wrong with our bodies so that finally we die. Health seems to be in no w a y related to dying, and the idea that the two could overlap seems incredible. But it is possible to die healthy (and not before one's time), and many do die healthy. If we think about it, then most of us would want to die healthy also. It is the best w a y of going. And the reason we should worry our heads now is that it will pay dividends later! J e r e m y Taylor wrote, ~It is a great art to die well, and to be learnt by men in health." And Sylvia Plath said, "Dying is an art like everything else." More recently, Dag HammarskjSld, in Markings, wrote, "The hardest thing of all--to die rightly-an exam nobody is spared--and how many pass it?" This article is meant to help us understand what it is to die rightly, to die well, and to die healthy as well as to offer some practical advice.
First of all, what is health? From the 1948 Constitution of the World Health Organization, we read, "Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity." From this we learn that the chief characteristic about health is one's sense of wellbeing. Health is the state of complete or total sense of well-being and not just the absence of disease or infirmity. There are many examples of men and women dying with their bodies fragmenting b u t with a pervading sense of well-being. There are also many examples of men and women dying with their bodies physiologically intact b u t with the fatal loss of a sense of well-being (as in Voodoo). The anthropologist L~vi-Strauss writes, "An individual who is aware that he is the object of sorcery is thoroughly convinced that he is doomed according to the most solemn traditions of his group . . . . Physical integrity cannot withstand the dissolution of the social personality. ''1 The important thing is the total sense of well-being. It is very interesting that the word health comes from the Old English word hdl, meaning whole. We still have the expression '~nale and hearty," where the word hale comes from the same word, hdl, and means that the person is full of life or whole. The idea The Rev. Michoel K. Bice, M.D., is an Instructor in the Department of Internal Medicine, Rush Memorial College, and Staff Physician at Rush-Presbyterian-St. Luke's Medical Center, Chicago. 184 0022-4197/78/0700-0184 $00.95
9
Institutes of Religion and
Health
The Healing of the Dying
185
of health is m e a n t to convey wholeness. The physical body is only p a r t of t he wholeness of our being. It is a necessary part, to be sure, b u t still only a p a r t of the whole. A most important par t is the h u m a n spirit in all its complexity, which manifests itself in a sense of well-being. T h e r e is also t h a t spark of t he Divine in all of us t h a t has allowed poets and religious m e n to glimpse something of the Infinite. So when we t h i n k of health, we m u s t t h i n k in t e r m s of wholeness (called wholistic, or holistic, by those who delight in expanding t he frontiers of language). But wholeness reaches out beyond the person. If we are t r u l y whole or healthy, we are also totally i nt egrat ed into our environment. We are p a r t of a family, a tribe, a community, a nation, a World, at once huge, and yet ever growing smaller, so t h a t it has now been described as a "global village." The religious m a n would also add God to our environment, so t h a t b e i n g whole or h e a l t h y includes some sort of necessary relationship with t he Creator. It is anot her strange quirk of t he English language t h a t the word holy also comes from the same Old English word hall, m e a n i n g whole. Our forefathers saw t h a t holiness and h e a l t h were related and were both manifestations of wholeness. J o h n Donne, the famous poet and priest, summarized this holistic outlook with his words: No man is an Iland, intire of it selfe; every man is a peece of the Continent, a part of the maine; if a Clod bee washed away by the Sea, Europe is the lesse, as well as if a Promontorie were, as well as ifa Mannor ofthy friends or of thine owne were; any mans deathe diminishes me, because I am involved in Mankinde; and therefore never send to know for whom the bell tolls; It tolls for thee. 2 It is one of the gr e a t tragedies of our modern Western society t h a t it has lost t h e feeling of cohesion between its members. Families split up and m em bers die alone. B u t among American Indians and Africans today where the tribal bonds are still intact, t he r e is a feeling t h a t if one m e m b e r suffers or is ill, t h e n the whole family or tribe suffers or is ill. Again, t h a t is a holistic outlook. It is also a h e a l t h y outlook. To die h e a l t h y means to die in wholeness. To die in wholeness m eans t h a t the parts of our whole being are in a necessary equilibrium. It also m eans t h a t we are in a necessary equilibrium with our e n v i r o n m e n t - - o u r loved ones, our community, even the Cosmos. To die h e a l t h y or to die whole means t h a t as our body disintegrates, so the h u m a n spirit and our sense of well-being more and more assert themselves. As the dying person becomes more and more whole or holistic, he even embraces death. D e a t h is accepted and not avoided. D eat h becomes p a r t of living. T h e r e is a beautiful description of this process in an address by F a t h e r E. K. Talbot of the English C o m m u n i t y of the Resurrection: Have you not watched that most lovely of all things, a life which has been secretly, humbly, interiorly dying day by day, and living, ever living unto God: so that now Death is a friend leading the soul to the home and goal which all along has been its home, its goal, which it has waited for expectantly--the soul which has looked for and loved his appearing?
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A similar description of dying in a holistic sense, where the terminally ill person feels he even has some control over t he situation, is given in a recent book by Eric J. Cassell, Clinical Professor of Public H e a l t h at the Cornell University Medical College: I think that those who die well and in control have something to teach the living about the body and about living. They show us that it is possible to come to peace with the body, both to be controlled by its limitations and to control it to a far greater extent than unlearned existence would suggest. They teach us that control is not denial or repression. That which we deny or repress about ourselves or within ourselves controls us by the fact of our constant need to deny rather than to come to terms. Control implies acceptance of limitations plus an awareness that the limitations provide room for the continued exercise of self, even unto death. The beauty and potential of growth lie not only in intellectual transcendence and the formation of transcendent emotional bonds, but also in the possibility of dynamic unity with the body. ~ This concept of the body being in some sort of dynamic uni t y is one of t he characteristics of health. W he t he r we are living or w h e t h e r we are dying, we can still preserve this dynamic unity, this wholeness. And then, in the words of Dr. Cassell, we can "come to peace with the body." After all, it is this sense of peace, w h e t h e r we are living or dying, t h a t all m en long for. Dr. Hans-Jfirgen Becken, a G e r m a n missionary in Africa for t w ent y-t hree years, recently wrote: When the generator is switched offat night in the mission hospitals in Zululand and the electric lights go out, the patients do not complain; but sometimes they ask for a burning candle, since in its light "it is easy to pray and even easy to pass away." This indicates that they are not concerned exclusively with body health; rather they look for peace. 4 Peace is the most obvious characteristic of health or wholeness. It is also the f u n d amen tal prerequisite to health or wholeness. World peace is the goal of nations. I n n e r peace is the ambition of those who practice transcendental meditation. B u t peace within and peace without is the aim of all men. Most people know t h a t the Hebrew word s h a l o m means peace. But it is not just a formal greeting or a polite farewell. Its f u n d a m e n t a l meaning is "totality," "well-being," '~harmony," and "health." (The adjective, shalem, is translated "whole.") Peace is not just a state of mind for an individual, as Western m an tends to t h i n k of it today. Rather, t r ue peace is holistic in t h a t it takes into account the whole person in all his complexity. It takes into account the totality of interpersonal relationships. It recognizes a h a r m o n y with the Cosmos.
2 With these holistic concepts in mind, it is now appropriate to t u r n to a discussion of two patients with a terminal illness. Both patients died at peace after a healing of t h e i r life situation. The first pa t ient experienced healing primarily t h r o u g h a personal religious faith. The second experienced healing through t he
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coming together of a fragmented family. But both died rightly, died well, and died healthy. A woman in her fifties was admitted to .St. Christopher's Hospice in London with advanced metastatic cancer. She looked very ill and was pale, thin, and anxious. When she was admitted, she said to the doctor, '~I hope you can do a great deal for me." She was not a practicing Christian and God had never been a reality in her life. Furthermore, her illness had been complicated by the fact t h a t her doctors, who had diagnosed the cancer, would not tell her the truth. So when she was admitted to St. Christopher's, her first question was, "Doctor, is it cancer?" Because she really wanted to know the truth, her new doctor told her. Needless to saY, the news was a great shock to her. She seemed to collapse--physically, mentally, and spiritually. But t h a t was short lived. A most remarkable change then began to come over this woman. She began to sleep better and even began to look younger. For the first time in three months she became free of pain, and t h a t with. only h a l f the dose of morphine t h a t she had been on. By the time she died five weeks later, she h a d more t h a n passed t h a t final e x a m - - t h e hardest thing of all--to die rightly. 5 How to explain the last five weeks of this dying patient? First, it must be said t h a t knowing the truth was a great relief to this woman. True peace does not come through deception. Secondly, the secret of her sense of well-being came out at the end when a nurse produced a type of log t h a t she had k e p t - recording significant words the patient had spoken during the course of those five weeks. The following are only some of the things t h a t this woman had said. It is obvious t h a t there is a very definite progression in her attitude. I want help. I want to find God. Why has all this happened to me? I'm beginning to understand. I am awake at night sometimes thinking. I put up barriers and take them down. My husband is different. He is happier; he has a different smile on his face. He was an atheist but now he says there is a God. He is finding it hard to understand. The Lord is personal to me now. I no longer say '~why?". There is a purpose in all this. My husband went into the chapel and prayed to God this morning. We talk about my faith together. What is apparent is t h a t this woman begins with a cry for help. She says, '~I want help. I want to find God." She ends up having received help when she says, ~'The Lord is personal to me now." It has been said t h a t one of the great fears t h a t the dying have is the fear of being abandoned, s Dr. Elisabeth K~bler-Ross tells the story of once visiting a terminally ill patient and finding her sitting on the edge of the bed with the telephone off the hook in her hands. '~What in the world are you doing?" the doctor asked. "Oh, just to hear a sound," she replied. 7 The presence of another h u m a n being, who may say nothing or do nothing except to sit by the bed, is a great inspiration. That person's presence emphasizes the corporate side of h u m a n life. Wholeness and h e a l t h
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have a necessary relatedness to others. We are all part of each other. As John Donne says, "every man is a peece of the Continent, a part of the maine." Furthermore, for the religious person, wholeness and health have a necessary relatedness to God. The dying woman realized the Cosmic dimension to h u m a n life in her newfound religious faith. She even says, "There is a purpose in all this." There is no doubt that the discovery of a personal Lord was a tremendous boost in overcoming her fear of being abandoned. She knows that God will not leave her and she rejoices that she can share this same faith with her husband. She has accepted death; it has become part of her living. So gradually, as her body dies, her spirit soars. She is free of pain. She sleeps better. She even looks younger. She is at peace with herself, reconciled with her husband, and reassured by the peace of God. She is one with the whole creation. And so she dies whole and healthy. There is an interesting parallel between the final stage in the life of this woman and the final stage in the development of the ego according to the scheme of Erik H. Erikson. The final or eighth stage is called "ego integrity" and is characterized by an inner harmony Ca post-narcissistic love of the h u m a n ego") and an outer harmony (in integration into "world order and spiritual sense"). At the stage of ego integrity, even death is accepted. Erikson says of this final stage, "It is the acceptance of one's one and only life cycle as something that had to be and that, by necessity, permitted of no substitutions . . . . In such final consolidation, death loses its sting. ''s The second patient was a fifty-three-year-old woman admitted to a chronic disease hospital in Boston, dying of ovarian cancer. She had six children from two previous marriages. H e r third marriage was unhappy for all concerned. It soon became apparent that her family was disintegrating. A married son was in trouble with the police. A second son had begun to drink heavily and had lost his job. A third son had simply run away. A daughter, aged twenty-three, had refused to do anything about a positive Pap smear, while a younger daughter had stopped talking and just stared out the window at school. It was no wonder that the patient was most anxious when admitted to the hospital. By the sheer force of her personality she had been able to keep the family together and in some sort of harmony while at home. Now she seemed to be losing control. This was especially upsetting for her, as she had always been a type of matriarch. Her doctor observed that, for her, "the greater tragedy was not dying but losing control during the last days of her life." Accordingly, it was decided to manage the patient at home where she preferred to be and to help her to remain in control of her family. Members of the hospital staff and various social agencies visited each of the children and were able to establish some rapport. This enabled the children to face up to the crisis of their mother's illness. They were also helped to cope with their own problems. Meanwhile, with the help of skilled home nursing, the mother was enabled to spend most of her last six months at home. She was able to preside over the healing of the various troubles in the family. Finally, she was readmitted to the hospital with massive, recurrent pleural effusions and ascites, but now resistant to all treatment. Before she died she was able to thank the stafffor all
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their help. And she died with a reunited family at her bedside. It was a good death. She died where she had always b e e n - - a t the center of her family. If she had been in the hospital for all of her last six months, it m a y be argued, she m a y have received better treatment for her cancer. But then the family problems would certainly have been exacerbated. Furthermore, her anxiety would have increased as she was made to surrender her control of the family. Her doctor concluded, ~'What was not lost was an intact person, and, it is to be hoped, an intact and functioning bereaved family. ''9 That is true wholeness. That is dying healthy.
3 To die healthy or whole is obviously related to living healthy or whole. If the latter has been the case, then the former is more likely. Through most of our lives, the physician has a unique opportunity to assist us in our growth towards wholeness. He is the one who is consulted at times of illness. But he is often consulted for all manner of other problems that arise in day-to-day living. A physician who has a holistic outlook recognizes that his responsibility is not just in curing a particular disease but in caring for the whole person. One of the great problems that has developed with the rise of a super-scientific medicine and technology has been the fragmentation of the patient into various organ systems, which are the exclusive domain of certain subspecialists. It sometimes becomes difficult to find a doctor who can put the patient together again and care for the whole person. I have been following for some weeks an elderly female patient who was discharged from a large teaching hospital after she was told that nothing further cquld be done for her. After the diagnosis of carcinoma of the right maxillary sinus was made, she was treated with total excision of the maxillary sinus together with an exenteration of the right orbital contents. It was a mutilating procedure, although the surgeon hoped for a cure. When I first saw her a week after discharge, she was very depressed and complaining of a constant headache, together with multiple aches and pains so disabling that she could barely walk. After I had reviewed her chart and examined her, it was apparent that most of her symptoms were the result of her feeling of abandonment by her doctors at the time when she needed them most. My job was not just to order some tranquilizer or analgesic but to let her know that I understood the situation and, above all, that I cared. I must care for her physical condition, her emotional condition, and even her spiritual condition. To ignore the latter, for she was a very religious Southern Baptist, would have affected my care for the whole person. If religious faith is important to her, then that must also be important to me. It turned out that I spent almost as much time in encouraging her faith as I did in checking her symptoms. But the result was remarkable. Over the course of the next few weeks, her sense of well-being improved and her symptoms disappeared. Her appetite improved and she put on weight. From her former feeling of helplessness and abandonment, she now
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has a feeling of being in control as she sets the dates of her own return visits, at first weekly, now at ever longer intervals. The ultimate prognosis for this patient is, of course, guarded. Consequently, part of the physician's job is to anticipate her dying so t h a t she m a y be prepared to die in wholeness and peace. Among doctors in general and psychiatrists in particular, there is a curious reticence to discuss any religious issue with their patients. A psychiatrist m a y have no qualms about exploring the details of a patient's sexual fantasies, but if a patient admits to praying to St. Anthony three times a day, then, more often t h a n not, the subject is changed. And yet, in illness and especially in the face of death, the patient m a y raise some profoundly religious issues. '~Why me?" This is one of the commonest questions. We m a y attempt an answer by explaining how our patient got sick, but t h a t is not the same as why. Then there are other religious issues, such as the meaning of h u m a n life, guilt, and remorse over lost opportunities. Of course, there is no simple answer to any of these questions. And the worst possible answer for the dying patient who asks "Why?" is a n y t h i n g t h a t suggests t h a t it is the '~will of God." That is both cruel and probably f a l s e p w h o can be sure of the "will of God"? If it is the special temptation of religious "do-gooders" to offer such pat answers, it is the special temptation of m a n y scientifically oriented doctors to avoid such questions entirely. It is understandable t h a t some doctors find such questions too provoking of anxiety in themselves. It is much easier to be a doctor t h a n a patient. It is easier to face other people's problems t h a n our own. One reason why doctors have been slow to recognize their responsibility in caring for the dying patient is t h a t the doctor has not faced up to his own mortality. From my experience in t e a c h i n g courses on death and dying to both nurses and medical students, I find t h a t the nurses are much more attuned to the subject matter. Perhaps the medical student, in his frantic struggle to become a doctor, which in our society is a type of omnipotent god and therefore immortal, cannot face his own mortality without some conflict and a t t e n d a n t anxiety. If a doctor is to be sensitive to his patient's religious questions, he must first listen. He must resist the temptation to interrupt the patient and suggest t h a t the chaplain will stop by. Most religious questions t h a t the sick patient asks are not on points of doctrine or church order requiring a theologian for an answer. Rather, they are about h u m a n life and personal relationships. For the dying patient, the doctor often becomes a type of priest. In his care for the patient he m a y seem to bless and absolve. Even when the dying patient has no obvious faith or denies having any, the doctor is still a type of priest in t h a t he can mediate wholeness and peace. Dr. Paul S. Rhoads, former Chief of Medicine at Northwestern University Medical School, summed up the doctor's role in caring for the terminally ill with these words: Ours is not an ecclesiastical priesthood and we should never attempt to make it so, but it is a priesthood of a sort, nonetheless--one for which medical school has not prepared us. To be prepared for it, somehow each of us must, in his own way, have searched for meaning in his daily tasks. Whether he considers himself religious in the conventional sense or not, he must have given some consideration to the universe in which he lives, to the place of man in it, and to the force or mind or God--call it what you will--behind
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it all . . . . How he will act in this exquisitely personal r e l a t i o n s h i p will depend upon how he sees h i m s e l f in this m i g h t y scheme of things. If, as our religion teaches, t h e r e is a touch of t h e divine in every m a n - - a n d w h a t perceptive p h y s i c i a n who h a s seen t h e h e r o i s m with which o r d i n a r y people meet the g r e a t e s t c a l a m i t i e s can doubt i t ? - - t h e g r e a t e s t satisfaction we can derive is in helping to unlock t h e resources t h a t are t h e r e to m e e t the challenge of t e r m i n a l illness . . . . O u r t a s k is to be a friend who is a w a r e of t h e road a h e a d a n d is willing to go along t h a t road with t h e p a t i e n t . . . l o
Dr. Elisabeth K~ibler-Ross was once asked how she would offer comfort and/or meaning to a dying patient. She replied: T h e r e are m a n y ways of offering comfort to a d y i n g p a t i e n t and this should not be dependent on his religious faith. Comfort m e a n s your being with him, giving h i m physical comfort, p a i n relief, back rubs, moving h i m a r o u n d if he is u n a b l e to move, holding his hand, listening to his needs. This w a y you can help p a t i e n t s w h e t h e r t h e y h a v e faith or no faith. Real love and faith is often conveyed b e t t e r b y action t h a n b y words.ll
With such advice, I heartily concur. In my own experience, I have been impressed about the effect of h u m a n touch, either of holding the patient's hand or resting my hand on his forehead. It lets the patient know that we are not afraid to touch him; and, if we are not afraid, then that in itself can calm the patient's own fears. But there is something even more fundamental, and it has to do with the very basis of h u m a n life. We have physical bodies that are obvious, plus a mysterious otherness that, for the sake of convenience, we might call the h u m a n spirit. It is this same h u m a n spirit that is turned on by the touch of another and that begins to well up so that not infrequently there are a few tears. But these are not tears of sadness, they are tears of release. They are the tears accompanying something that is becoming whole deep down inside the patient. They are the tears that signal the healing of the dying.
References 1. L6vi-Strauss, C., Structural Anthropology. New York, Basic Books, 1963, pp. 167, 168. 2. Donne, J., Devotions upon Emergent Occasions, No. XVII. In Complete Poetry and Selected Prose of John Donne, Dean of St. Paul's. London, Nonesuch Press, 1962, pp. 537, 538. 3. Cassell, E. J., The Healer's Art. Philadelphia and New York, J. B. Lippincott Company, 1976, pp. 228. 4. Becken, H-J., The Experience of Healing in the Church in Africa. Contact 29. Geneva, Christian Medical Commission World Council of Churches, October 1975, pp. 9. 5. West, T., "The Truth," St Christopher's Hospice Annual Report. 1974-1975, pp. 34-36. 6. Ktibler-Ross, E., "Dying with Dignity," Canadian Nurse, 1971, 67, 32. 7. Kiibler-Ross, E., "The Art of Dying:l," The New York Times, January 15, 1973. 8. Erikson, E. H., Childhood and Society. New York , W. W. Norton and Co., 1963, pp. 268. 9. Krant, M. J., "The Organized Care of the Dying Patient," Hospital Practice, 1972, 7, 103-105. 10. Rhoads, P. S., "Management of the Patient With Terminal Illness," J. Am. Med. Assoc., 1965, 192, 664. 11. Kfibler-Ross, E., Questions and Answers on Death and Dying. New York, Macmillan Publishing Co., 1974, pp. 160.
