Under the Valley's Shadow

by Charles W. Dickson (July / August 2000 • Volume 16 • Number 4)

For new ministers and others, this overview of the stages of dying can help you bring some understanding, care, and dignity to those with terminal illnesses

One of the initial experiences a new pastor and rostered lay minister may have upon leaving the confines of the seminary and entering the world of parish or congregational life is that of feeling inadequate. However well-trained today's leaders are, there seems to be certain areas, that vary with each person of course, in which they feel inept to deal with.

The feeling I am describing may be connected with many areas of pastoral and rostered lay ministry, including preaching, worship rites, teaching, counseling, ministering to the sick, and other functions.

But as I listen to and work among leadership, I have discovered that ministering to those who are dying is high on the list of inadequacies.

If pastoral leadership is to begin to minister effectively to the dying, they must first familiarize themselves with the generally recognized emotional stages through which the terminally ill pass.

Some years ago these stages were identified by Dr. Elizabeth Kubler-Ross, a German psychiatrist and physician. Once these stages are recognized, leaders can then place themselves in a position to minister more effectively.

The remainder of this article will concern itself with the problem of dealing with these stages with the hope and prayer that it will be useful to the servants of Christ.

Denying Death
The first reaction of the person when he is told he is going to die is usually one of denial, according to Kubler-Ross. "No, not me" is a typical reaction. An example of a well-entrenched denial was a woman with whom I worked, who was diagnosed as having a rapidly-spreading cancer.

She began to engage in long and expensive rituals in an attempt to disprove the diagnosis. She was convinced the X-rays were mixed up with someone else and asked for reassurance that the pathology report could not be back so soon.

Having failed in these attempts, she proceeded to go "shopping" for other doctors, requesting re-examinations in the hope that the original conclusion was an error. Gradually, the foundations began to crumble as each succeeding doctor corroborated the original diagnosis.

While most dying persons do not go to this extent, the process of denial seems to be the first definite stage in the person's emotional preparation for death. Denial has been called "the human shock absorber to tragedy," according to former Chaplain Carl Nighswonger of the University of Chicago Medical Center. It is a kind of emotional anesthetic to an otherwise unbearable reality.

The pastor can deal with this stage by first remembering not to break down denial by insisting the person face up to reality; secondly, by not supporting one's denials by holding out false hope; and thirdly, by being a good and sensitive listener.

If we attack people's denials, it may only serve to make them intensify their defenses which only prolongs the denial stage. If we hold out false hope, we may deny persons the chance to move through the other stages, leading to a peaceful and dignified Christian death.

However, if pastors will cultivate their listening skills at this point, they will allow the dying person some room to talk. The original denials may be replaced by partial acceptance and the person may than start talking about health and illness and mortality and immortality, as if they were twin siblings permitted to exist side by side. This will help them face death while still maintaining hope.

Reacting with Anger
The second major reaction of the dying is generally one of anger, coupled with rage, envy, and resentment. These occur when denials begin to break down. Individuals may take out their wrath on the hospital staff, relatives, pastoral staff, or God.

This stage is a difficult one for pastoral leadership to deal with. Our question is understanding why such wrath is being vented. The problem is that we fail to place ourselves in the dying person's position and sense the frustration that goes with facing impending death.

An effective ministry at this stage involves our forgetting our personal concerns and hurt feelings and recognizing that some dying people have the need to express hostility.

Once they have ventilated their rage, the dying often seem to be relieved of a burden. This allows us to discover the other side of the person's personality — the side where there is warmth, and a capacity for love, insight, and affection that are all gifts of the Holy Spirit. If we listen, the dying can teach us much during this period.

Negotiating a Deal
After the anger subsides, the dying person may enter a stage of bargaining. This involves a kind of drama of attempting to negotiate a deal which may involve several people.

Such deals may be with the doctors. That is, if the dying person promises to cooperate fully, maybe the doctors will make an extra effort to get him or her out of the valley. Some negotiations may be with one's pastor consisting of promises to be a more faithful parishioner. Other promises may be directly with God whom the person hopes can be persuaded to intervene.

One physician told me of a person near death who had a son planning to get married and was proceeding with plans as his mother had wished. She was sad to think she could not attend the big day for her eldest and favorite child.

She persuaded the hospital staff to give her enough medicine so she could be kept reasonably comfortable for a few hours during the wedding. She had made all kinds of promises if she could only live long enough to attend his wedding and left the hospital on the day of the wedding appearing to be the happiest person in the world.

After the wedding, she returned to the hospital looking tired and exhausted. When the doctor walked into her room, even before he could say hello, she greeted him with, "Now don't forget, I have another son."

Bargaining seems to be a normal emotional part of the whole process of dying. Regardless of who the process is directed toward, some sense of guilt or uncompleted desires are usually involved. Pastors can neither brush aside nor reinforce these feelings, but through the art of sensitive listening, help the person move through this very difficult period.

Lacking Hope
Once denial, anger, and bargaining seem to have run their course, the dying person may experience a sense of depression which Kubler-Ross sees as a stage in which the person feels there is no hope. A pastor's initial response may be that of trying to cheer him up, but this represents an expression of a pastor's own needs and inability to cope with the saddened facial expression or tear-filled eyes.

The dying have a need to go through a stage of depression. The person may also not want to communicate with us during this stage. Death means loss — loss of self and loss of all those people and things we love.

Depression is a tool by which the dying are preparing for this loss, that is, a gradual separation from the world — including you. As one patient related to a hospital chaplain with whom I worked, "I hope that as my hand grows colder and colder, there will be a warm hand like yours to hold."

A pastor needs to stay with the dying person even if the person doesn't say much. The dying are still aware of your presence and need you there.

Accepting Death
Finally, if the person has sufficient time, he will move through periods of denial, anger, bargaining, and depression and reach the final stage of preparation for death­–acceptance.

In this stage people who are dying usually detach themselves from everything and everybody around them. Having mourned the loss of so many meaningful people and places, the dying now begin to contemplate the end with a sense of quiet expectation. We must be careful not to disturb this process.

A classic example of a lack of understanding of this stage was related to me by another chaplain about a 58-year-old woman who was dying from abdominal cancer. She had reached the stage of accepting death, felt strongly that her marriage had been a good one, and was now ready to die in peace.

But she told the chaplain that she was angry at her husband for his inability to accept the fact that she was ready to die. He was continuing to plan future operations with surgeons in an effort to "turn back the clock."

Finally, in the presence of her husband, she turned to the chaplain with whom she had been able to relate her feelings and pleaded, "Talk to this man and make him understand." Once the woman's husband was able to sit down with the chaplain and began to realize that his wife was prepared for death, he was able to understand her. This paved the way, for what shortly after became a death with dignity.

It is difficult for most of us to comprehend that a person may reach a point when death comes as a great relief and that these persons are ready to detach themselves from everything and everyone around them. The pastoral ministry is vital at this stage and a combination of sensitive listening and judicious use of the gospel's proclamation are tools which pastors have at their disposal.

In Moses' song to the people of Israel, in the book of Deuteronomy, he cries:

O that they were wise, that they understood this, that they would consider their latter end. (32:29)

And Emily Dickinson, in a moment of hope, wrote:

Death is a dialogue between the spirit and the dust.
Dissolve says death, the spirit, Sir I have another trust.¹

Our hope, in understanding these stages, is that we may enable those who are dying to conclude their lives with peace and dignity. It may also mean giving meaning and purpose to pastoral leaderships' own lives because they have passed with the dying person through the valley of the shadow.

In the end neither life will have been a journey in vain.

Charles W. Dickson, of Hickory, North Carolina, is an ELCA parish pastor and has served as chaplain of the University of Florida Medical Center at Gainesville.

Endnote
1. "Death is a Dialogue," by Emily Dickinson taken from the web site "American Literature Chronology­19th Century" at http://www.shsu.edu.eng-wpf-amlitchron/19th.html