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Body and Spirit: One Journey, One Future
Medical care of older people tends to divide them into discrete parts for the benefit of efficient management and, wherever possible, cure. Pastoral care, concerned with health and wholeness, can bring a unique focus in uniting that which is artificially divided, for the benefit of older people as they approach their final journey.
This paper challenges the notion that spirituality is concerned with one part of the older person’s life, namely the non physical. Rather, it attempts to describe the essential unity of body, mind and spirit and to explore some of the implications for the pastoral care of those who approach death. Dying, in this context, is viewed not as a short term episode in the older person’s life; dying is described as an increasingly long and often arduous journey. For many older people the final chapter is, therefore, often filled with dread and despair. While praying for a quick and pain free death, the reality is that they face increasing debility and associated dependency on others. How can pastoral carers travel with older people on this journey so it is transformed from one of spiritual hopelessness and increasing physical burden to a hope filled future where body, mind and spirit are cared for as one?
Using case studies from various contexts, the focus of the paper is on pastoral carers weaving together the strands of the older person’s life narrative as essential "provisions" for this journey. Along the way, the concept of "quality of life" is briefly critiqued.
In conclusion, the paper suggests some practical strategies for pastoral carers working with older people in any context, so that their experience and contribution can be one of integrity rather than fragmentation.
Essential Unity of Body, Mind and Spirit
Contemporary medicine, aided by computerized tomography, can literally reveal much about the human body that was previously unknown, but can neither map nor scan the human soul. Neuroscience is uncovering new pathways in the brain; for example, linking emotion and consciousness. It is the deep and elusive roots of the self, however, that maintain the "relative stability required for survival" (Damasio, 1999, p. 22). In Genesis we learn that in the creation of humankind God "breathed into his nostrils the breath of life: and the man became a living being" (Gen 2: 7). If we regard spirit as breath (as in "inspire"), then the spirit may be defined as that which enlivens, which gives life to the whole body. "Soul" and "body" are two linguistic expressions of one and the same reality, the human being.
We can say that the body is life, that which is alive, and that the soul is what enlivens or animates. Yet both are so profoundly interrelated that every attempt to objectify either of them without the other in the end leads to absurdity. (Cobb, 2001, p. 70).
The absurdity alluded to by Cobb is given expression when the nurse says, "The patient wanted to talk about spiritual stuff but I said I’d call the chaplain," or when the chaplain says, "I’m sorry I can’t do anything about your pain (or your fatigue or your inability to walk) but I’ll report it to the nurse." This objectification or classification of human needs into artificial categories leaves the older person’s holistic needs unmet. In addressing the self, however, the focus is not on the self in isolation from others; the communication is always within the framework of relationships. Jenson’s definition lends weight to this interpretation: "A person is one whom other persons may address in hope of response" (Jenson, 1997, p. 121).
At the heart of this paper lies the question of who we are as persons journeying to a new future. While acknowledging there are many different faiths and many different paths and many different ways of understanding "future," in this paper the focus is on the distinctive Christian understanding of who we are as persons in relation to the triune God, revealed in Jesus Christ.
To speak of person in Christian anthropology is to counter the false dualism whereby matters of the spirit (or soul) are separated from matters of the body; where the physical belongs to the "real" world and the spiritual belongs to some other "unreal" world. To focus therefore on spiritual aspects of care is not to disembody the spirit from the whole person; rather it is to reconnect the disconnected. Spiritual care occurs in the ordinary, everyday encounters in which one person meets with another, rather than in some rarefied holy, religious or sacred realm which is totally divorced from lived experience. It is this understanding of older persons; whole within themselves, yet related with one another in mutuality and reciprocity, which sets the scene for a meaningful pastoral encounter.
In contrast to our western cultural propensity to focus on the autonomous individual as a separate entity from all other autonomous individuals, this relational framework provides for the essence of spirituality to be explored. It is within this web of relationships that each human person flourishes. Rather than encouraging each individual to retreat into their inner selves to find their own particular spirituality, this broader view takes into account our common dependence on one another.
It is instructive to note here that many writers are grappling with the contemporary meaning of spirituality; how it is to be understood, how it might be measured, and what assessment tools will provide a valid and reliable set of data for pastoral carers. Bryden, from within her own unique world of dementia, is a consummate teacher in the realm of spirituality. She regards the smile, the laugh and the touch as indispensable keys to relationships. "We need love, comfort, attachment, inclusion, identity and occupation as our world around us becomes strange and our ability scrambled" , she says (Bryden, 2005, p. 144). Similarly, in their study of people with Alzheimer’s disease Sabat and Harré found that in order to preserve the self, mutual cooperation with others is needed.
Thus, if there is a loss of the capacity to present an appropriate self, in many cases the fundamental cause is to be found not in the neurofibrillary tangles and senile plaques in the brains of the sufferers, but in the character of the social interactions and their interpretation that follow in the wake of the symptoms (Sabat & Harre, 1992).
Dementia is one of the increasingly prevalent chronic diseases of our age, prompting discussion on pastoral care within this context.
The Arduous Journey of Chronic Illness
Doris was sitting in the nursing home lounge continually tap, tap, tapping the wooden arm of her chair. "Yoo, hoo, is anyone there?" "Yes, Doris, it’s Jane, is there something you want?" "Yes, I want to know if I’m a human being or a lump of wood." "Are you feeling like a lump of wood?" "Well, I don’t mean literally, but I just don’t know who I am and where I am." Standing beside her, Jane, the nurse, impatiently rehearsed the facts: Doris was in a safe place, it wasn’t her own home but she had a permanent bed, her board and lodging was paid for, her sister knew she was here and would be visiting tomorrow. Jane could tell Doris wasn’t the slightest bit reassured. So, pulling up a chair beside her, she gently said: "Tell me something about your childhood, Doris, and about your life before you came here." After a few minutes when Jane needed to conclude the conversation, Doris said: "Oh, thank you. I feel so much better now. That was 100 times better than forty tonics!"
The question "Who am I" is nonsensical unless asked within the context of the person’s social relationships. When an older person who may have dementia, depression and other comorbidities, is left isolated, their sense of self can only be restored in relationship to their whole person and to others. Doris is not asking for a set of facts to be rehearsed; knowing who she is in relation to Jane and her other carers is more important than knowing where she is. Doris is calling for something too often considered beyond the bounds of professional care of older persons; her call is for an intimate relationship. Her preferred lexicon includes words such as faithfulness, commitment, conversation, love, and kindness. This kind of care is not confined to pastoral care workers; it belongs to the whole team (Hudson & O'Connor, 2007, p.132). Pastoral care workers should never underestimate, however, the power of their role modeling. As the chaplain increased her visits, other staff noticed Doris ceased her calling out and chair-tapping; Doris "came alive."
Chronic illness calls for something other than the transient short-lived affair of the postmodern hospital; it calls for committed long-term relationships that require holistic care and faithfulness to the end. By its very nature, chronic disease does not follow a quick decline towards death; it usually involves gradual, progressive loss of independence and associated discomfort. Our rapidly increasing ageing population is concomitantly associated with a steady increase in chronic illness for which there is neither cure nor "quick exit," Florida Scott-Maxwell, who found herself, aged 82, in a nursing home, describes her response:
We wonder how much older we have to become, and what degree of decay we may have to endure. We keep whispering to ourselves, "Is this age yet? How far must I go?" For age can be dreaded more than death . . . It is waiting for death that wears us down, and the distaste for what we may become (Scott-Maxwell, 1968, p. 138)
While caring for people with chronic illness becomes the responsibility of the whole team, there is particular need for pastoral care workers to renew their understanding of ageing within this context. For, as Kimble says, "The bio-medical paradigm is not hermeneutically nor philosophically equipped to explore and create new dimensions for understanding the meaning of growing and being old" (Kimble, 2001). Similarly, Seeber asks "Why shouldn’t gerontology lead the academic enterprise away from the ever-splintering precipice of enquiry toward a more holistic and perhaps more rigorous anthropology and theology of life" (Seeber, 1990, p. 3). Can pastoral care uncover such meaning by providing a beacon of hope for older people with chronic illness?
Hope-less or Hope-filled Journey
Hope implies attaching some meaning to ageing beyond decay, dependency and death.
If we see the increasing trajectory of chronic illness as an insoluble problem (if not a profound affront to our concept of dignity) then we will be impatient with those whose death is prolonged. If, on the other hand we regard every person as unique and irreplaceable, we will welcome each other in our difference and diversity (Hudson, 2003, p. 20).
Hope, in this context, is neither constrained by cheerful optimism, nor by frenetic attempts to keep old age and death at bay. Finitude need not imply failure to thrive or survive; rather, our finitude constitutes a sure and certain sign of freedom, promise and hope. The location of this freedom, promise and hope is, for the Christian pastor, the Scriptural narrative of the God who comes among us in the humanity of Jesus Christ, made known in the power of the Spirit. Freedom, promise and hope are manifest, not in old age itself, but in the gift, the overflowing generosity of God’s grace. Hope derives therefore from a source outside ourselves, and speaks of a reality far removed from mere optimism. Lewis warns against phony cheerfulness which merely "hopes for the best" or with fingers crossed, hopes to "just get by." Rather, he sees in the Christian hope the miracle of death’s sting being pulled forever.
If we allow our words, our manner, our status or professionalism, or – deadliest of all in certain circumstances – our breezy faith and heroic confidence, to distance us from those who doubt and stumble, weep and hurt, we surely betray the God of the cross and of the grave, obscuring the truth that their vexation is but a shadow of God’s own anger, and their tears an earthly drop in the ocean of heavenly grief (Lewis, 1994, p. 9).
When death is perceived as the end of mortal life in all its exigencies, hope will no longer be understood as a mere antidote to despair; and death will be openly discussed. As Luther famously said, "In the midst of life we are in death" (Luther, 1956, p. 158). To be in the midst of life is to be involved in a unique story.
Entering Life’s Narrative
Charles has remained in his nursing home bed, mute and immobile for nine years. No longer able to recognize or to respond to his family in any meaningful way, unable to engage with friends, he is now almost totally deprived of visitors. An old photo, sitting askew on the wall beside his bed, points to a time when he served his country at war. Some faded artificial flowers are the only remnants of the last gift he received. Now, his past means little, as busy nurses clang the bed-rails up and down, not infrequently tearing his frail skin in the process. Leaking urine and feces, legs contracted tight together, Charles does not exemplify wholeness or dignity and many nurses question the value of his existence.
What right to life does Charles have, what is his claim to care? Is he there merely as a recipient of our compassion? Who is this person? When Charles" life is weighed on the scales of quality and dignity he defies logical measurement; he serves no useful purpose, neither does he exhibit any potential. Those who are old and suffer the double jeopardy of dementia score very low on the autonomy ladder; they cannot articulate their rights and they have no part in decision making about their own lives. Furthermore, they show us no gratitude for all our care, so how do we judge whether it is worth it? What is the chaplain’s response to Charles’s vulnerability and voicelessness? How is the nurse’s impassioned plea "Shoot me if I ever get like that!" to be understood?
This paper does not allow a comprehensive discussion on quality of life issues; however, Charles" story often prompts the response that his quality of life is zero. Is there a way in which quality of life can be conferred in relationships, rather than measured according to an objective scale? In this respect Alisdair MacIntyre warns us against the temptation to mere benevolence. Benevolence is insufficient as a means to care, he says, for it generally presents us with a generalised Other – "one whose only relationship to us is to provide an occasion for the exercise of our benevolence" (MacIntyre, 1999, p.119).
Rather than making judgements about Charles" quality of life, perhaps it is more apt for pastoral care workers to ask what our place within this narrative is. What character do we play? Are we merely incidental, are we brought in at the end, just before the last act, or do we see ourselves as integrally involved in the whole of this particular person’s narrative? To be part of a story invokes the concept of companions on a journey.
Pastoral Care as Companion
Drawing once more from the world of dementia, Goldsmith sees his role as chaplain in the following terms:
Who are you – walking to the toilet every few minutes? Who are you – wiping bottoms, answering the same question time and time again, sitting with those who weep and absorbing the anger and the frustration of those who do not know where they are? Who am I? I am a minister of the Gospel of love, and this angry lady is my sister and this weeping man my brother (Goldsmith, 2000).
Goldsmith’s profound understanding of companionship also recalls Doris’s story (above). Who will come with me on this strange journey? How will I know who I am if you do not (metaphorically or physically) hold my hand? This failure to enter the narrative has particular implications for pastoral care of those close to death, or for those who are bereaved. Pastoral care in the presence of death calls for something beyond artificial cheerfulness or glossing over the stark reality of death. Thus Wolterstorff, on the death of his son, pleads with his comforters not to make light of his grief:
Death is awful, demonic. If you think your task as comforter is to tell me that really, all things considered, it is not so bad, you do not sit with me in my grief, but place yourself off in the distance away from me. Over there, you are of no help. What I need to hear from you is that you recognise how painful it is. I need to hear from you that you are with me in my desperation. To comfort me, you have to come close. Come sit beside me on my mourning bench. (Wolterstorff, 1987, p. 34).
The mourning bench is a risky place, especially for those of us who want to be sure we have the "right words" before we even sit down. The mourning bench is a frightening place for those of us who are afraid to come too close. The mourning bench is not the sole province of the specialist pastor or qualified counsellor, for the so-called unqualified person may know instinctively how to come close. On this mourning bench there is no hierarchy; we are on the same level; roles of the bereaved person and the pastor overlap and the one who is dying or grieving may indeed become our teacher.
When spirituality and ageing are viewed from this perspective then we are all encouraged towards a new future where carers and older persons together focus on our distinctive boundaries but on our interdependence. It is the unique role of pastoral care to integrate what has become fragmented.
Pastoral Care: Integrated or Fagmented?
Integrated pastoral care means taking seriously the value of comprehensive assessment, planning and documentation. However, words like diagnose, define and manage can often signify fragmentation, particularly when the "pastoral care plan" is segregated from any holistic planning process. The contribution of pastoral care workers to an integrated care plan has the potential to transform a mere "tool" into a living document of care. Such a document counters the focus on efficiency and auditing compliance with an emphasis on trust, companionship, kindness and commitment. Defined pathways and measurable outcomes are then integrated with human (and humane) care which addresses the older person in their totality: heart and soul and mind and body.
Some practical pointers for a closer integration of pastoral care include (depending on context of care):
well defined policies situating pastoral care within the health care team;
a well integrated system for documentation and care planning;
comprehensive guidelines for referral;
open communication with management;
agreed systems for reporting relevant matters to others in the care team;
adequate educational preparation for all aspects of pastoral care;
careful time management;
ongoing review and regular training;
a transparent system of performance review; and
supportive care for pastoral care workers.
This paper has addressed some aspects of the dominant dualism whereby older persons' bodily needs are separated from their spiritual needs. The question has been raised concerning the impact of chronic illness on contemporary pastoral care, highlighting the urgent need for companionship, faithfulness and love throughout what is often a long episode of care. Accompanying older persons on their journey towards death, entering their life narrative, has been shown to suggest a beacon of hope in a seemingly hope-less situation.
The title "body and spirit: one journey, one future" is intended to convey the inter-relationship of the whole person in their unique life’s journey, which cannot be separated from their inter-relationships with others. Thus, there is not one future for the person’s body and another for their soul, but one future for the whole person. Within the Christian faith these relationships are modeled in the Trinitarian relationships of Father, Son and Holy Spirit; where there is perfect unity within diversity and where there is no hierarchy. The purpose of this intra-Trinitarian relationship is for the generous outpouring of love, without qualification and in opposition to all concepts of power or coercion. There is no distinction between weak and strong, old and young, mentally alert and cognitively impaired, pastor or person in need. All share the one journey towards the one future when we will all relate to one another out of the love which has been so graciously given to us.
Rosalie Hudson, Ph.D., RN, Dip Arts, B App Sci (adv.nsg) Grad Dip Geront. Nsg, B Theol, M Theol, PhD, FRCNA, FAAG; is an Associate Professor and Honorary Senior Fellow in the School of Nursing and Social Work at the University of Melbourne. Rosalie is a consultant/educator in aged care and palliative care with 12 years experience as director of nursing of a 50-bed nursing home as well as clinical and administrative experience in hospice/palliative care in community and inpatient settings. She has published widely on end-of-life issues, palliative care, pastoral care, dementia, and the ethics of aged care, in nursing and theological journals. Her fourth co-authored book, Palliative Care and Aged Care was published in 2007 (Ausmed Publications: Melbourne). Rosalie is engaged in sessional teaching in undergraduate and postgraduate nursing programs in the School of Nursing & Social Work, University of Melbourne, and in pastoral care programs within the Melbourne College of Divinity. She is a regular speaker at conferences both nationally and internationally. Her publications and speaking engagements have included a close working relationship with the Rev. Dr. Elizabeth MacKinlay, Director of the Centre for Ageing and Pastoral Studies (CAPS, Australia).
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