Oftentimes caregivers, friends, and family are unsure of what to say and what to do to comfort the sick and the dying. Midwife for Souls provides specific Catholic insight and highlights the power of prayer as a guide. This best-selling book has been revised to include a new section of inspiring stories and lessons learned in hospice ministry.
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Midwife for Souls
Spiritual Care for the Dying
A pastoral guide for hospice care workers and all who live with the terminally ill
by Kathy Kalina
Nihil Obstat: Reverend Timothy Shea, S.T.L.
Imprimatur: Seán Cardinal O’Malley, O.F.M. Cap.
Archbishop of Boston
October 23, 2006
Library of Congress Cataloging-in-Publication Data
Midwife for souls: spiritual care for the dying / by Kathy Kalina.
— Rev. ed.
Originally published: St. Paul Books & Media, © 1993.
Includes bibliographical references.
ISBN-10 Print: 0-8198-4856-5
ISBN-10 eBook: 0-8198-4873-5
ISBN-13 eBook: 978-0-8198-4873-4
1. Caregivers—Religious life. 2. Hospice care—Religious aspects—Christianity. 3. Terminal care—Religious aspects—Christianity. I. Title.
The Scripture quotations contained herein are from the New Revised Standard Version Bible: Catholic Edition, copyright © 1989, 1993, Division of Christian Education of the National Council of the Churches of Christ in the United States of America. Used by permission. All rights reserved.
English translation of The Apostles’ Creed © 1988 English Language Liturgical Consultation (ELLC). 1988, and used by permission. See www.englishtexts.org.
Cover design by Rosana Usselmann
Cover photo by Mary Emmanual Alves, FSP
All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system without permission in writing from the publisher.
“P” and PAULINE are registered trademarks of the Daughters of St. Paul.
Copyright © 1993, 2007, Kathy Kalina
Published by Pauline Books & Media, 50 Saint Paul’s Avenue, Boston, MA 02130-3491. www.pauline.org.
Pauline Books & Media is the publishing house of the Daughters of St. Paul, an international congregation of women religious serving the Church with the communications media.
the ultimate Jewish mother.
Let us love
with the urgency of the dying
and the innocence of the newborn.
Let us love
with the abandon of adolescence
and the certainty of adulthood.
Let us love
generously and openly
taking all risks—
for as we have been loved,
we must love in return.
And in the love that redeems us,
we open our hands and hearts
gathering a bouquet
to offer to heaven.
Katherine Mary Krsak
1. Hospice Care
The Dignity of the Dying
The Death Event in a Fragmented Society
Midwifery for Souls: Birthing to Eternal Life
2. Family: The Basic Unit of Care
Wounds and Battle Scars
A Privileged Guest on the Journey
You Are Not in Charge
You Can’t Fix Sick Families
…But God Can
3. The Work of Dying
The Urgency to Love
Am I Going to Die?
4. Signs of Active Labor
Dying Is a Physical Process
Dying Is a Spiritual Process
“An Angel from Heaven Appeared…”
A Time for Detachment
5. Praying Them over the Wall
A Time of Ultimate Choice
Complications in the Dying Process
Depending on Miracles
Near “Bad Death” Experiences
The Request for Death
Death of the Young
Sudden Death Experience
“A Time to Die”
Calling in the Family
The Final Farewells
Ministering to the Bereaved
7. Pastoral Care
Working with the Family Minister
Praying for Those Who Don’t Pray
Prayer with Families and Patients
8. Spiritual Exercises for the Midwife
Become a Pray-er
Live in a State of Grace
Live a Life of Forgiveness
Live a Life of Joy
9. The Problem of Suffering
The Cause and the Cure
The Question of “Assisted Death”
The Presence of Christ
10. Harvested Fruit
Allow Yourself to Receive
Allow Patients to Float Their Own Boat
Bow Your Head to the Mystery of Suffering
Practice Unconditional Love
Learn How to Pray Out Loud
Speak When Inspired
Take Care of the Story
Be Able to Beg Forgiveness
Get Bossy Sometimes
Honor the Patient’s Journey
Don’t Ever Think It’s Easy
Prayer for the Dying
Prayer at the Time of Death
Prayer for the Family
Chaplet of Divine Mercy
2. Scriptural Comfort for the Dying and Their Families
MIDWIFE FOR SOULS IS A BOOK on hospice care, but it is much more than that. It is a “how to” for family members, friends, and hospice professionals involved in caring for terminally ill patients as they enter into the phase of their last moments, when life slowly ebbs away and death releases the soul to go home to God. These last days or hours are very difficult for family members, who often watch helplessly by the loved one’s bed, not knowing what to do or say.
The author is a nurse, but she is also a deeply spiritual person writing from her personal experience. Kathy Kalina makes no apologies for being “one hundred percent Catholic,” but her deep understanding of what human beings go through as their lives come to an end makes the book useful to everyone regardless of religious preference. It is written in a style that is both poetic and beautiful as well as practical and credible. It talks about how powerful prayer can be; it talks about how important it is for hospice caregivers to be attuned to this God if they are to be effective “midwives for souls.”
I highly recommend this book for all who care for the dying whether as professionals, friends, or family members. The many stories of peace and joy coming into people’s lives, even in the last few moments before death, point to why euthanasia must never be an alternative for anyone. Hospice care relieves pain and suffering—physical, psychological, social, and spiritual—so that patients can face the end of their lives in peace and with dignity. Just as midwives help mothers deliver a child, so hospice caregivers help the soul as it is “born into eternal life.” It is a sacred mission; it is a true vocation. I rejoice that a book on the “Spiritual Care of the Dying” has finally been written.
Josefina B. Magno, M.D.
President, International Hospice Institute
I HAVE COME TO BELIEVE THAT there are no accidents. My dear friend Dodie urged me to become a hospice nurse, and I assisted at her death in that capacity six months later. I’ll never forget sitting beside her bed as she told me that she had no intention of dying, thank you very much. Inspired by the grace that abounds at such times, I told her, “I am here as the midwife of your soul.”
I don’t think I’ve ever prayed harder in my life, and I don’t think I’ve ever felt such spiritual strength. Twelve hours later, with an expression that radiated wonder and peace, Dodie was born to eternal life. What could have been an unbearable loss became a joyous homecoming, and Dodie’s parents were able to say that their thirty-four-year-old daughter had a beautiful death.
I went to Dodie’s house with “head knowledge,” but I left with “heart knowledge.” Dodie’s death transformed me into an apprentice midwife. I am still an apprentice. Patients and families are my teachers, and I will not graduate from this school until my own death. So I will share what I know as one apprentice to another.
Even though I’m writing this book primarily for nurses, especially when beginning this work, I hope that those who want to serve as midwife for loved ones will also find it helpful.
To the countless hospice workers who shared their stories with me;
To the patients and families who allowed me to be a part of their stories;
And to my parents, for showing me what a family can be.
The Dignity of the Dying
I FELT CALLED TO HOSPICE WORK quite some time before I stopped whispering, “Wrong number!” Because of my hospital nursing experience, the thought of death conjured images of a slow, agonizing process, involving a helpless patient and a hopeless staff. It involved inflicting pain on already pain-racked bodies. I’m still haunted by memories of tying patients down to keep them from pulling out tubes, repeatedly sticking IVs into worn-out arms, and assisting with heroic resuscitative measures that we called the “million dollar send-off.”
When I provided this type of “care” for the dying, I had the same sick feeling as when I participated in the hospital “care” of women in childbirth. Even though I knew the academic and legal rationales for distasteful practices, it never felt right.
Many times families would tell me, “We want everything done for our mother.” I would shake my head, thinking, “They just don’t know what everything is.” Doctors have a tendency to think of death as a personal enemy, and that’s usually good. If I have an illness that can be cured, I want my doctor to wage all-out war against it. But once it becomes evident that treatment is not going to be successful, I want to spend my last days in comfort and peace.
I can understand why it’s hard for doctors to turn about-face at this point, but it hurts my heart to see patients put through the rigors of treatment, even such drastic measures as artificial ventilation, because the doctors hate to fail. My friend Dodie, for instance, was encouraged to start another round of chemotherapy three days before she died.
Fortunately, more and more doctors are referring their patients to hospice care when a cure is unattainable. And more and more families are asking for, even demanding, hospice care when that point is reached.
Hospitals are wonderful, necessary resources for the treatment of disease. But they are not the best places to die. Even if there are no painful treatments, the routine alone robs patients of control and peace. The focus is not directed to the comfort of the patient; it’s directed to the convenience of the staff and the overall efficiency of the operation.
Vital signs are taken every four hours, baths are given every morning, meals are served at predetermined times—and the patient has no control over this routine. Staff members come in the room throughout the day and night, carrying out a variety of tasks at their convenience. There is often some limit on visitors. And patients usually hurt, because doctors and nurses have been taught that pain cannot be eradicated, just made a little easier to bear.
In contrast, hospice care is focused on the control of symptoms instead of the cure of disease. Pain is unacceptable, not a necessary evil. And pain medicine is given in pain-free ways.
The patient is consulted and included when decisions are made regarding a care plan, and the family helps provide that care. Our tools are primarily our hearts and hands, instead of high-tech equipment. Death is neither hastened nor prolonged.
Hospice care is loving support for patients who are living their last days and for their families. This support is physical, psychological, and spiritual. The hospice team consists of nurses, doctors, social workers, home health aides, clergy, and volunteers, and their roles often overlap.
The first hospice in the United States began in 1974, but true hospice care is not new to this country. Care for the dying has traditionally been a function of the family, with generous community support. Nursing duties were the woman’s responsibility, and this art was passed down from mother to daughter. Hospitals were places for the homeless and the poor. It wasn’t until the 1930s and 1940s that medical advances made hospitalization an attractive alternative to home care for all illnesses.1
In the days when medical care was geographically inaccessible, however crude it might have been, families surely felt the helplessness of being unable to provide treatment for the dying. Today we have sophisticated and accessible treatment, but once those options have been exhausted, families are made to feel helpless in providing even basic comfort measures. Hospitals push families aside and, at best, treat them as guests. We are led to believe that death is a medical event best attended by experts.
The Death Event in a Fragmented Society
Probably the greatest cause of our perceived helplessness is the fragmentation of our families and communities. Because our families are scattered geographically, we no longer feel capable of caring for our own during a final illness. There is no Granny living around the corner who carries a lifetime of experience in her hands. There is no aunt nearby to share stories about sitting up with the dying. Frequent moves have left many of us without Church or community ties. Instead of a doctor who is almost a member of the family, we receive our health care from a multitude of specialists.
The hospice team can help fill these gaps, acting as a substitute for family wisdom and community support, giving families the courage to care for their loved ones at home. We can provide expertise, but must avoid assuming the superior role of experts.
I heard of one eighty-year-old gentleman who had been referred to professional counseling by some well-meaning person. He attended one session, came home, and said, “I think that’s for people who don’t have families.” I believe that in-patient care of the dying should be reserved for people who have no caregiver or home, or whose care simply cannot be managed at home.
Since so many people hold full-time jobs, providing around-the-clock care can be a formidable undertaking. But I have seen families find creative solutions and make heroic sacrifices to give their loved ones the opportunity to stay at home. Adult children often take turns providing care, using vacation days or even taking a leave of absence from their jobs. Sometimes a circle of friends will rotate care days. When a spouse is the care-giver, relatives and friends can assume weekend duty to provide a much needed rest. I’ve seen such novel solutions as employers and even divorced spouses stepping in to assume the patient’s care.
As the hospice movement grows, more and more people have come to experience firsthand the beauty of allowing the patient to live those last days surrounded by the comfort of home and family. And I’m seeing nurses with hospice hearts making the last hours better for patients and families in intensive care units, emergency rooms, and medical/surgical wards.
But I see a danger in hospice care in the United States—a danger that seems to be related to our society’s devotion to and dependence on experts. There is the temptation to put our hospital-based, paternalistic model of care into practice even in hospice care programs. There is also the tendency to focus solely on the body while ignoring the spirit. This could easily lead to a hospice system that is only a notch or two above the expert-controlled, disease-focused hospital care of the dying—a care system that is often spiritually bankrupt.
Midwifery for Souls: Birthing to Eternal Life
Hospice care in the context of midwifery for souls is closely aligned to traditional midwifery in childbirth: a natural, gentle approach to an intimate and life-changing family event, with careful attention throughout the process to the body, mind, and spirit of the patient as well as to the family.
I have a friend who is a midwife, and I accompanied her on prenatal visits and home births from time to time because the symmetry between natural birth and natural death fascinated me. From beginning to end, the physical, psychological, and spiritual similarities are striking.
First, there’s the shock of diagnosis. Even when a woman is trying to get pregnant, the news is unbelievable. And even though we all know that we must someday die, we really don’t expect it to happen to us.
The next step is to consult professionals, seeking a good outcome. The pregnant woman absorbs information from veteran mothers, searching for the best way to make this journey. The terminally ill person reads articles and consults survivors, searching for an angle the doctors might have missed.
The last several weeks are a time of spiritual searching and life review. The pregnant mother works on relinquishing her pre-baby life, and the dying person detaches from this world.
The pregnant mother nests. She gathers all the things she’ll need for the baby and prepares her home for the new arrival. The dying person carries out a reverse nesting, giving away belongings, putting business in order, and perhaps making funeral arrangements.
The pregnant mother wonders how she’ll make room in her heart for someone else to love. The dying person wonders how to let go of loved ones.
The pregnant mother may feel out of control, as if her body has a mind of its own. The dying person may see the body as the enemy.
As the time of birth approaches, the mother worries about the actual birthing. Will it hurt? Will I have the people I want around me? What will it really be like? The dying person has the same questions.
Giving birth is something the body knows how to do, and usually does quite well if interventions are kept to a minimum. In the dying process, the changes in the body are self-protective. Medical interference prolongs the dying and diminishes both comfort and peace.
The goal of midwifery in childbirth is a healthy mother, a safe birth for mother and child, and a healthy baby. In midwifery for souls, the goal is a comfortable body, a peaceful passage, and a triumphant soul. The family’s active involvement and loving presence greatly assist in the achievement of these goals.
Confusion, dissension, and any form of negativity interfere with birthing and dying, and tend to generate complications. Above all else, fear is the greatest enemy. Both birth and death take great effort, and the labor is easier to endure with eyes focused on the reward.
Family: The Basic Unit of Care
THERE ARE NOT MANY HARD and fast rules in this work, but I have identified a few from my own experiences in dealing with families. You certainly don’t have to follow them, but I would like to share them with you.
Of course, patients are our top priority, but everything that happens to them takes place in the context of their family—even if they’re alone.
Wounds and Battle Scars
Most patients and their families are battle-scarred by the time their journey leads them to hospice. Most cancer patients have endured some combination of surgery, chemotherapy, and radiation. Regardless of diagnosis, patients and family members alike have probably had their hopes dashed time and time again. They’ve had little control over their fate, and they’ve had their fill of hospitals and medical professionals. They are wounded, battered, and very tired.
As their hospice midwife, you are entering their lives at a vulnerable time. You must be respectful, humble, and peaceful. You may be an expert, but this is their Daddy. They know what he likes and what he doesn’t like. Often, they’ve been doing the hands-on care for some time. Listen well to what they say and what they don’t say. Take your cues from them. If they are emotionally bankrupt, you will need to step in and steer them through the immediate decisions that must be made.
Symptom control must be achieved as soon as possible. I always tell the patient and family that we are “comfort experts.” Trust is quickly earned when we are able to alleviate the nausea or pain and the patient is finally comfortable, sometimes for the first time in months.
Watching a loved one suffer is excruciating, so when comfort is achieved for the patient, it is also achieved to some degree for the family. Trying to work on anything else before the patient has reached some level of comfort is futile.
The family often has many fears. You need to find ways to talk to them away from the patient. I’ve found it best to meet these fears head-on because what we imagine is usually worse than reality. Always look down the road a bit and help them prepare for the next step.
When family members come to trust you, they will share their worries. Often these are related to elimination. What happens when he can’t get up to go to the bathroom anymore? How will we possibly manage bedpans and, even worse, incontinence? Many families worry about the patient’s modesty, but this usually takes care of itself. As the patient approaches death there is a process of detachment; some things just don’t matter anymore.
As this detachment develops, the bulk of your care is turned toward the family. They are dealing with the emotionally and physically draining task of caring for their loved one. In addition to the physical care, there’s the sadness of watching their loved one deteriorate in body and detach from them in spirit. As the patient loses bodily function and interest in things that used to bring pleasure, the family loses a bit of the person they love. One man said, “I miss Dad already, and he’s still here.” They need a great deal of love, compassion, and encouragement from the midwife.
A Privileged Guest on the Journey
Even if you develop a beautiful relationship with the patient and family, you are still looking at a snapshot. You are seeing a moment in the life of this family. The album will grow, and you’ll learn more and more about them, but you are not a member of the club.
Every family is unique, having its own set of unspoken rules, family rituals, and shared history. Sometimes not knowing what went on before is a blessing, because you only see patients as they are right now. Illness often softens people. They shed their masks and become authentic and lovable in a new way.
It’s easy to be judgmental of a family, asking questions like, “How can those children turn their back on such a sweet old man during his last days?” But you don’t always know the whole story.
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