1. Healing Bodies and Souls at the End-Of- Life James Hallenbeck, MD Director, Palliative Care Services VA Palo Alto HCS

2. Key Points Clergy bear much in common with physicians in how we “minister” to dying patients Clergy bear much in common with physicians in how we “minister” to dying patients In training emphasis on knowledge, ritual skills and death In training emphasis on knowledge, ritual skills and death Little specific training on dying Little specific training on dying Inadequate attention to communication Inadequate attention to communication Changes in how we die pose new challenges Changes in how we die pose new challenges “Remedial training” is required “Remedial training” is required

3. Questions Doctors Must Face 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 we die? What do you think will happen when we die? Are you Saved? Are you Saved? Don’t you believe in miracles? Don’t you believe in miracles?

4. Questions Clergy May Face 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 anything. We can’t just let him starve to death, can we? He won’t eat and the doctors won’t do anything. We can’t just let him starve to death, can we? They are talking about discontinuing life- support. If they take her off the machine, isn’t that like killing? They are talking about discontinuing life- support. If they take her off the machine, isn’t that like killing? Since she died, I can’t sleep or function. I’ve lost 20 lbs. I wish I could join her. Why did she have to die first? Since she died, I can’t sleep or function. I’ve lost 20 lbs. I wish I could join her. Why did she have to die first?

5. Changes in How We Die Most deaths now in institutions Most deaths now in institutions Families less able to care for dying patients Families less able to care for dying patients Most deaths due to chronic illness Most deaths due to chronic illness Dying usually takes a long time Dying usually takes a long time Dying is expensive Dying is expensive Many options available Many options available Treatments, care systems, where to die Treatments, care systems, where to die Many now view dying itself as a choice

6. Top 5 Causes of Death 1900

7. Top 5 Causes of Death 1994

8. Where Do We Die

9. Dying Takes a Long Time From brief transition period to LIFE STAGE From brief transition period to LIFE STAGE Social Implications – new systems needed Social Implications – new systems needed Cultural Implications – meaning of stage and relation to other life stages Cultural Implications – meaning of stage and relation to other life stages Personal Implications- what is to be accomplished in dying? Personal Implications- what is to be accomplished in dying? When does dying begin?

10. Implications Focus on death/afterlife Focus on death/afterlife Care for dying as simple kindness Care for dying as simple kindness Dying understood as inevitable, beyond mortal control Dying understood as inevitable, beyond mortal control Focus on dying Complicated systems of care Difficult and confusing choices Dying understood as optional, a matter of personal choice From:To:

11. Overlapping domains Physical PsychologicalSocial Spiritual

12. Alternate View Physical PsychologicalSocial Spiritual

13. Communication Challenges Ambiguity Ambiguity “Can I go?” “Can I go?” Hidden meanings Hidden meanings “Can I have a sleeping pill?” “Can I have a sleeping pill?” In most cultures explicit discussion about death and dying taboo

14. Communication layers Thinking Thinking Knowledge, facts Knowledge, facts Meaning Meaning Emotional Emotional Spiritual Spiritual

15. Example: “Why did I get this awful disease?” Explore ambiguity: “What did you mean when you said…” Explore ambiguity: “What did you mean when you said…” Address thinking: “Why do you think you got it?” Address thinking: “Why do you think you got it?” Address feeling: “It is sad that this happened…” Address feeling: “It is sad that this happened…” Spiritual: How would you address the spiritual implications in this question? Spiritual: How would you address the spiritual implications in this question? Choices in communication: Most “why” questions, if not technical, are spiritual in nature…

16. Communication – more than words… Words Words Work with words that are comfortable for the person Work with words that are comfortable for the person Ritual Ritual Physicians listening to heart and lungs, feeling pulse Physicians listening to heart and lungs, feeling pulse Religious rituals Religious rituals Context Context Who is present Who is present Body language Body language Time and circumstance Time and circumstance

17. Presence The Dying and their families very sensitive to the presence of others, looking to us for cues as to how to respond The Dying and their families very sensitive to the presence of others, looking to us for cues as to how to respond Does our presence communicate: Does our presence communicate: Peace or Distress? Peace or Distress? A desire to be there or elsewhere? A desire to be there or elsewhere? At home or not at home? At home or not at home? We must become the change we want to see Gandhi

18. Teamwork Clergy, like physicians may be used to “going it alone” Clergy, like physicians may be used to “going it alone” Shared notions of confidentiality Shared notions of confidentiality Clergy, like physicians, may be used to being “the boss” Clergy, like physicians, may be used to being “the boss” Care for the dying requires teamwork Care for the dying requires teamwork Shared responsibility: – communicating with other team members Shared responsibility: – communicating with other team members Ability to elicit and receive feedback on one’s work from people in other disciplines Ability to elicit and receive feedback on one’s work from people in other disciplines

19. Healing into Death Healing happens of itself – our role to promote healing Healing happens of itself – our role to promote healing Healing transcends bodily integrity Healing transcends bodily integrity Healing differs from cure in that it is an ongoing process – cure is a outcome Healing differs from cure in that it is an ongoing process – cure is a outcome While cure may not always be possible, healing is…

20. SUMMARY New ways of dying require the acquisition of new skills on the part of clergy, as well as physicians New ways of dying require the acquisition of new skills on the part of clergy, as well as physicians While we can find great wisdom in our traditions, specific behaviors must adapt to our new circumstances While we can find great wisdom in our traditions, specific behaviors must adapt to our new circumstances If we are to be of better service to those for whom we care, we must take responsibility for improving skills in end-of-life care If we are to be of better service to those for whom we care, we must take responsibility for improving skills in end-of-life care