• Hands and feet becoming increasingly cool.
• Sleeping more and sometimes difficult to be aroused.
• Increasing disorientation, an inability to identify time, place, even one's own name.
• Incontinence.
• Congestion, gurgling sounds.
• Restlessness.
• Breathing becomes harsh and irregular, sometimes too fast, but more often too slow with long periods between each breath.
• Lack of appetite and thirst.
• Decrease in urine output and dark colored urine.
• Emotional withdrawal even from closest friends and family.
• Vision-like experiences, often seeing loved ones.
• Decreased desire for socialization.
• Unusual communication, often expressing their "good-bye" either directly or indirectly.

These are the signs of impending death.[1] Some of them will be stretched out over several days or even weeks. Others may appear only at the very end of earthly life. Some people pass naturally without showing any of these signs. Most will display at least some of them before death.

Those of you who have been present for the death of another know that it is often hard to tell just when death has occurred. A minute or more has passed with no breath, no movement, no sound. You find yourself holding your breath, almost unable to breathe. Then another gasp, labored, harsh, unexpected, and your mental clock is reset again. "It is appointed for man to die once" (Heb. 9:27-28).

The Psalmist says, "I am fearfully and wonderfully made" (Ps 139:14). God has created our bodies with ten basic systems: musculoskeletal, cardiovascular, respiratory, neurologic, digestive, lymphatic, endocrine, reproductive, and urinary. We all learned this in biology class. It seemed so academic back then. A breakdown in any of these systems can be disastrous for our lives and the lives of those we shepherd. A serious breakdown in most of them can lead to death.

I knew that my sister's health was declining. I saw her infrequently, largely due to distance and the busy schedule of a pastor. I got my wake-up call when she was rushed to the hospital after being found in respiratory arrest. When I arrived, hours later, she was in the ICU on a ventilator, unconscious, dying. Hands that once hugged me were cool and clammy. The giggles which once had brought smiles were silent. Her breath was controlled by a machine. The sister, who used to delight in picking on her older brother, lay silent, unresponsive, seemingly oblivious to my presence. There is nothing academic about the death of someone you love.

The ICU was a familiar place to me. I had spent many hours there during my chaplaincy training. I had prayed with many people, some in the very room where my sister lay dying. It was very different to pray for Joyce there. When it involves someone you know and love, a family member or a dear church member, it gets very personal, very painful. "And after you have suffered a little while, the God of all grace, who has called you to his eternal glory in Christ, will himself restore, confirm, strengthen, and establish you" (1 Pet. 5:10). Joyce lay dying, but I was one of many who were suffering that day.

When I entered the ministry I had visions of preaching great sermons, teaching the deep truths of our Reformed faith, reaching the lost for Christ, leading God's people in worship, administering the means of grace, building up the church of God. Somehow being in the sterile confines of a hospital room listening to a machine pump air in and out of my unconscious sister never entered into that picture. It was hard to pray in that room, and harder yet to pray, "not as I will, but as you will" (Matt. 26:39). Few of us think of ourselves as called to minister to those who are dying.

An evangelical minister once asked me to visit one of his church members who was dying. She was a dear, saintly lady with a profound faith who had known and served the Lord for most of her life. The minister sheepishly admitted that he was not very comfortable with death and dying. At least he was honest. Yet God did not call us to be comfortable.

Shepherd the flock of God that is among you. (1 Pet. 5:2)

Pay careful attention to yourselves and to all the flock, in which the Holy Spirit has made you overseers, to care for the church of God, which he obtained with his own blood. (Acts 20:28)

For another patient, as a chaplain, I called the pastor of a rapidly growing evangelical church several times, asking him to visit one of his church members who was actively dying in a local extended care facility (they used to be called nursing homes). Each time he promised that he would come. Each time he failed to arrive. He was just too busy building the kingdom to be concerned with one man who was dying. He actually lost several families because of his unwillingness to serve this one godly man. Remember Jesus' warning,

For I was hungry and you gave me no food, I was thirsty and you gave me no drink, I was a stranger and you did not welcome me, naked and you did not clothe me, sick and in prison and you did not visit me. (Matt. 25:42-43)

You know the rest of this story.

We all face the issues of approaching death in our families and covenant communities. God does not limit his kingdom to young people and families with children. God is glorified even in the death of his saints (Ps. 116:15). For all who live in this broken and fallen world, death is inevitable. The wise woman of Tekoa may have deceived King David, but she spoke truthfully when she said: "We must all die; we are like water spilled on the ground, which cannot be gathered up again" (2 Sam. 14:14). Death was the terrible price for Adam's first sin. The Apostle Paul draws the right conclusion: "Therefore, just as sin came into the world through one man, and death through sin, and so death spread to all men because all sinned" (Rom. 5:12). Everyone dies. For that matter, as a pastor you are always ministering with people who are approaching death. To understand the importance of ministry to those who are dying, you need only consider that Christ died for dying people.

Death is common to all, but not all approach death in the same way. Many Christians seem conflicted between resisting death at all costs and accepting death as God's will for their life. Some Christians engage in heroic struggles against death. Some go to great lengths (and great expense) to ward off the inevitable as if this were their Christian duty. I fear this attitude has more in common with Dylan Thomas's challenge, "do not go gentle into that good night" than it does with the teaching and examples set forth in Scripture. Scripture does not contemplate the extraordinary means provided within our modern healthcare system for warding off physical death. There is a simple truth in Scripture, the number of our days is set by God's perfect will.

Since his days are determined, and the number of his months is with you, and you have appointed his limits that he cannot pass, look away from him and leave him alone, that he may enjoy, like a hired hand, his day. (Job 14:5-6)

And thus the godly prayer, "So teach us to number our days that we may get a heart of wisdom" (Ps. 90:12).

Another finds a quiet acceptance of her own impending death. A friend had endured the loss of her beloved husband to a stroke several years earlier. She developed a form of cancer that caused her bones to break from within, resulting in intense pain. I visited her on a day when the pain was terrible. She just smiled at her pastor as always. I noted that the nurse had spoken of her pain and asked how she could smile. She smiled again and said, "You remind me that Jesus is always right here beside me." On another occasion she mentioned Christ's presence reassuring her that it was okay to die. "But you haven't told me that yet." She was right, I hadn't. She was ready to go to be with the Lord. I was not ready to let her go. That was the first time I ever prayed that God would gently take one of his children home. Have you ever prayed that prayer? "Therefore encourage one another with these words" (1 Thess. 4:18). It is precisely during the struggle within our own hearts that we should be "praying at all times in the Spirit, with all prayer and supplication. To that end keep alert with all perseverance, making supplication for all the saints" (Eph. 6:18). "For everything there is a season, and a time for every matter under heaven: a time to be born, and a time to die" (Eccl. 3:1-2).

One author speaks from extensive experience about the spiritual work of dying.[2] Four tasks are outlined: remembering, reassessing, reconciliation, and reunion. I would add one further task—preparing for the journey.

Remembering

Many people share a strong need to tell their life's story. A missionary nurse wanted to tell her story so that others would be encouraged to labor in foreign missions, as she and her husband had done for many years. A sweet Christian gentleman wanted to tell his life's story so that people would not forget the farm where he had grown up, a farm that had been demolished by the Navy for an airbase. A lady who was born in Indonesia and lived extensively in Holland before coming to the USA wrote her autobiography in order to make sense out of the many personal uprootings which had occurred over the course of her life. If one thinks of life as a tapestry, much of our lives are lived looking only at the back side with its seemingly random threads. At the end of life many seek to turn the tapestry around to see the picture that God has created in their own lives. The faithful shepherd is willing to sit and listen to these stories, and be present while the person reflects on the meaning of his or her life.

Reassessing

Some people find it challenging to find meaning for their final days. No longer able to be productive or to do the things they once did, their sense of personal identity is challenged. Combine this with physical discomfort, financial stresses, and declining energy and these people find it hard to keep on living. Interestingly, as a chaplain I get the question, "Why hasn't God taken me home yet?" far more often than the question, "Why is God letting me die?" Sometimes the faithful shepherd will need to use the authority of his office to give permission to the person to seek and find meaning in other things. For example, the elderly man who always thought of himself first as a business man, may now need permission to find new meaning as a great-grandfather. The retired pastor who longs to return to preaching may need permission to turn his full attention and energies to prayer and the loving care of his wife. "Remember also your Creator in the days of your youth, before the evil days come and the years draw near of which you will say, 'I have no pleasure in them' " (Eccl. 12:1).

Reconciliation

I hardly need to tell any of you about the broken relationships which occur in the lives of the flock. Even the godliest among us has experienced these breaks firsthand. Christ has entrusted to his church a precious ministry of reconciliation. We know that true reconciliation begins by our being reconciled to God in Christ, and continues through repentance and both the seeking and granting of forgiveness.

A World War II hero was struggling in his final days. He was troubled by dementia and recurring nightmares in which he saw again the faces of the enemy soldiers whom he had shot. "They were only boys," he kept repeating. "Boys and old men." Night after night he would awaken his wife with his screams. His health was declining, his dementia made it difficult to make any progress in pastoral counseling, and his wife and family were exhausted. One afternoon as we were talking, he recalled a grandmother, a dear Baptist woman who had taken him to Sunday School and worship, and prayed for him. I spoke to him of that precious faith, as I had done before, and left doubting that my visit had made any lasting impact. Very early the next morning I received a phone call from his wife. She was very excited. He had slept quietly through the night. No nightmares. No screams. In fact, before he slept he had asked his wife to pray with him for his salvation. When I visited again he was a very different man. I told him that I believed that God had answered the prayers of his grandmother some eighty years earlier. He died in complete peace a few weeks later, ready to meet his Savior, and perhaps also the enemy soldiers he had killed. He had found peace in the blood of Christ.

I also remember a delightful woman of faith who had a very broken family. The East Coast siblings did not get along with the West Coast siblings. As this woman approached death, the children from California flew out here to Maine. The hospital here is only a medium-sized facility. So it felt very cramped as we sought to keep the two groups apart. I met and prayed with each and urged them to put aside their differences at least long enough to support their mother. It seemed to work, and on the day of her death, the entire family gathered round her bed holding hands as I read Scripture and prayed with them. As she peacefully slipped from this life, there were tears and hugs all around. I thought to myself, this is a good example of reconciliation. After a time the family members drifted out of the room until just two daughters remained, one from the East Coast, one from West. I stepped out to give them some privacy, but they followed. As they walked by me one said, "We'll have to go shopping for something for her to wear in the casket." The other retorted, "What she has in her closet will be just fine." Maybe it's not the perfect example. The faithful shepherd will seek to facilitate reconciliation, recognizing that in this life it does not always come.

This provides a good place to pause before continuing to discuss the spiritual work of dying. In the next article we will consider the fourth task, reunion, and finally preparations for the journey. Then we will turn to the role of the pastor at the bedside, as part of the hospice or palliative care team, and even in assessing pain. May the Great Physician make us faithful stewards of his gifts to bring his love and compassion even to those who are dying.

Endnotes

[1] Drawn from a document entitled "Preparing for Approaching Death," Copyright © North Central Florida Hospice, Inc. 1996. Most Hospice organizations have and make use of some variation of this document in order to teach families what to expect when a loved one dies. You can read the entire document at hospicenet.org.

[2] Barbara S. Derrickson, "The Spiritual Work of the Dying: A Framework and Case Studies," Hospice Journal 11:2 (1996): 11-30.

Gordon Cook is the pastor of Merrymeeting Bay Orthodox Presbyterian Church in Brunswick, Maine. He also serves as the Pastoral Care Coordinator for Mid Coast Hospital in that community, and as a hospice chaplain. Ordained Servant January 2010