Editorial Note: When Steve Krueger wrote these reflections, in the season of Pentecost 2006, he was serving as a chaplain for LifePath Hospice and Palliative Care, the largest not-for-profit hospice program in the United States. LifePath Hospice currently serves almost 2,300 patients in the counties of Hillsborough, Polk, Highlands and Hardee, Florida. The listed counties are in the Tampa area.
Steve was the prime organizer and host for the First Daystar Conference in 2000. He served as the president of the Daystar Association and as editor of the Daystar Journal. Pr. Krueger died on January 5, 2010. To read other writings of his beyond those he contributed to the Daystar Journal, go to: https://www.crossings.org/stephen-c-krueger-in-memoriam/
Hospice Reflections on John 11
Stephen C. Krueger
Shortly before his death, Dietrich Bonhoeffer wrote a brief poem from Tegel Prison in Berlin. It’s titled “Christians and Pagans.” It seems to be Bonhoeffer’s mature thoughts about who cries out to God for help in their need.
Men go to God when they are sore bestead,
Pray to him for succour, for his peace, for bread,
For mercy for them sick, sinning, or dead;
All men do so, Christian and unbelieving.
Men go to God when he is sore bestead,
Find him poor and scorned, without shelter or bread,
Whelmed under the weight of the wicked, the weak, the dead;
Christians stand by God in his hour of grieving.
God goes to every man when sore bestead,
Feeds body and spirit with his bread;
For Christians, pagans alive he hangs dead,
And both alike forgiving.
This essay is about death as we experience dying in hospice care in America today and the Promise. Its thesis is that while hospice care offers an extraordinary set of medical, psychological and even spiritual supports to help the dying to die, linking the terminally ill and their care-givers to the Promise still is the needed ministry from the confessing Christian community. In recognizing that, hospice is important new ground for the church’s mission but a ministry that can only be done with compassion, sensitivity, insight and care.
In order better to discuss the thesis, I will try to enlist the Fourth Evangelist’s story of Jesus’ encounter with his friend Lazarus whose problem goes far beyond the help requested of the Lord. The problem requires a Promise of something utterly new.
- The Summons
So the sister sent a message to Jesus, “Lord, he whom you love is ill” (John 11:3).
It has been my experience in ministry in hospice care that the summons that goes out to surround the dying with care doesn’t normally begin that way. The summons usually goes out first as a summons to cure.
Mary sends word to Jesus to come in order to cure. More than likely, had Mary and Martha lived in our time, they not only would have called for Jesus to come but would have summoned the vast resources of modern medicine with its many promises to provide treatment, medications and procedures that have cure as the goal. Certainly in an illness, healing and cure are what everyone wants from the medical community and from God. We have long known that the Latin root of the word for “salvation,” salus,has far less to do with one’s eternal destiny than it does with “healing, wholeness,” the very thing we pray for when we lift up our sick to the Lord in prayer.
What makes the Lazarus story unique, however, in the Gospel of John is that it is not about illness as the core problem. Jesus has successfully cured the ill as a lame man walks (John 5:1–18) and a blind man’s sight is restored (John 9:1–41). That Jesus can cure illness is not the issue. What Jesus is going to do about dying is the issue. Extending a summons to Jesus to cure the sick is quite different than crying out to the Lord to break the hold of death.
In 1948 a British nurse named Cicely Saunders, in noticing how helpless modern western medicine seemed to be in caring for the dying, began a movement that we know today as hospice. Saunders saw the medical community operate with a model that made curative hospital care the only alternative for the terminally ill, much to the defeat and the agony of the dying. Under the medical model death was seen as an enemy to be conquered through resolve, better science and cure. Thus physicians treating the dying would withhold medications such as morphine because they were seen as too addictive and too defeating of curative treatments. Patients would be kept alive at all costs even if it meant being kept alive in great pain and discomfort. It appeared as if the collective ego of modern western medicine were on the line in its treatment of the terminally ill.
Saunders eventually was able to convince enough people in the medical community that it needed to accept the reality of dying and that other palliative procedures for the humane treatment of the terminally ill were ethically and medically necessary. Thus in 1967 St. Christopher Hospice was founded in London with an entirely different approach for the care, not cure, of those at the end of life. Included in this approach was the control over one’s own treatment for the patient.
The hospice movement required a realistic and fresh look at death and dying. It was widely received although not without substantial criticism. By 1974 in the wake of an invitation for Dame Saunders to teach at Yale the movement was transplanted into the United States through the organizing of the first American hospice program, Connecticut Hospice. Today one in three Americans dies in accredited hospice care, enabled by legislation Congress enacted in 1982 to make hospice care part of the benefits of Medicare.
Still, in the Lazarus story Jesus is initially summoned to Bethany probably before Mary and Martha checked out Lazarus’s Medicare options for hospice. No doubt the expectation was for Jesus to cure in the same way we seek out help from the medical industry today. Our culture probably is, if Ernest Becker is right, even less ready to deal with dying than most others, so insulated from it we have become. Cure from a promising medical community is still the prevailing operative word. Even today the hospice option, which requires accepting the reality of death for the individual patient, remains difficult for the medical community and for the general population to embrace. Hospice requires an uncommon care far beyond customary expectations to cure.
- The Consultation
After saying this, he told them, “Our friend Lazarus has fallen asleep, but I am going there to awaken him.” The disciples said to him, “Lord, if he has fallen asleep, he will be all right” (John 11:11–12).
After the summons to come and deal with the terminally ill often comes the consultation among the dying and their family and friends that will try to make some sense out of it all. The human species is like that. We all need to believe that life is not an arbitrary series of events that ultimately do not matter but that there is a plan somehow, somewhere to make what happens to us meaningful. Confronting death is no exception.
When a patient enters a hospice program, the staff is prepared to assist the patient and care-givers in a variety of ways. The most important way is that the patient is led to acknowledge that he will no longer seek curative treatment and wishes instead the palliative, holistic care hospice can provide. If the patient is eligible for Medicare, and if his primary physician agrees that his life-limiting illness will bring about his demise within six months or less, the patient can invoke his Medicare hospice benefits for two 90-day periods, renewable after recertification at 60-day intervals thereafter.
To accept all that is quite an emotional jump for a patient and his family. Even with a sensitive hospice staff consisting of physicians, hospice nurses, social workers, chaplains, bereavement counselors, home health aides, hospice homemakers and trained volunteers, a terminally ill patient and those who love him still face all the confusing, disheveling emotions that accompany anticipatory grief and separation. Unlike the strict medical model that has as its goal to cure, hospice care shifts its goal to a plan of palliative care that stresses the quality of life until the patient’s death. Yet lingering is the underlying meaning of death itself.
The hospice staff will do a great deal of consulting with the patient and his family as a patient is admitted into hospice care. The progression of the illness will be discussed by hospice physicians and nurses. The patient will be given choices about pain medication. He will decide how lucid he wishes to remain at various stages of his illness progression. He will be monitored closely for comfort issues, including side issues that result from his environment (like bed sores, personal hygiene, etc.). He will have a choice of whether to be resuscitated or not. He will be helped through the host of end of life decisions about wills, funerals, living wills and the like. Further, most accredited hospice programs will come to him, whether he is living at home or in a nursing home or assisted living facility or comes to a hospice house where his family will always be welcome.
In spite of the excellence of modern hospice care, however, the persistent issue of “why death at all” is something that hospice, even with its required chaplaincy, may not be able satisfactorily to address. Chaplains are mandated to be part of America’s accredited hospice programs. Their purpose is, to be sure, a valuable one. They are asked to explore with a willing patient his own interior self and his feelings about dying. Chaplains will further seek sensitively to enter the spiritual reality of the patient and to enable the patient himself to enlist his own spiritual resources to face what he is experiencing. Further, chaplains are available to help connect a patient with the faith community of the patient’s choosing, even and especially if the patient has lost touch over the years. Nevertheless, the chaplain is obligated never to impose his/her own religious views on a patient, although, if asked (which not infrequently happens in a trusting relationship), the chaplain may share his/her faith if so invited.
When Jesus in the Lazarus story tells his disciples that Lazarus has fallen asleep, his meaning is obviously not to sound glib about his friend’s death. Obviously, Jesus is beginning to talk about a new reality where death is defeated and has lost its power to hold. The disciples, on the other hand, are ready for the simple, glib solution to Lazarus’s illness. “So, Jesus,” they say, “what’s the problem here then?” And indeed, glibness is not unusual in the hospice setting either. It frequently is part of the consultation of family and friends between themselves to deal with the beloved’s terminal illness by keeping it at a safe distance, especially when they know in hospice care that the patient’s physical suffering is being kept in bounds. Yet such “making light of” does not come close to the meaningful and important business to be done with the terminally ill. There frequently are relationships that need reconciling, sins to be forgiven, hopes to be shared and love to be put into words that had never found adequate expression before. Death calls out the urgency of making true what should have been true all along.
Even more important is the matter of making sense out of death itself.
- The Anxious, Hard Reality
Then Jesus told them plainly, “Lazarus is dead” (John 11:14).
At some point the reality of dying descends from the head into the heart. Bereavement counselors refer to this as anticipatory grief. For the terminally ill and her loved ones, grieving begins when the meaning of the loss begins to hit home emotionally and death becomes far more real than just an intellectual concept.
In hospice care the process of grieving that accompanies the acceptance of death is seen as therapeutic, normal, natural and good. While more discredited today than it was when it was the rage among grief counselors several decades back , Elizabeth Kuebler-Ross’s On Death and Dying still is something of the operating model with her delineation of the stages of the grieving process.
Nevertheless, if death is talked about, as it often is in hospice care, as a natural part of life, something merely to be accepted as part of the created order, then something precious in the Biblical faith has been lost. The question remains unanswered, “Why does God give us life only to take it back again?” The problem is compounded when a sanitized view of death as natural fails to cry out for a Promise where death and its meaning is ultimately defeated.
Paul Tillich insisted that there is an honest anxiety that must accompany the realization of one’s death. The problem ultimately is that death implies judgment (something the modern age eschews) and thus loss of ultimate meaning to one’s life because death means “estrangement” not only from life itself but from life’s ultimate Ground of Being, God.
Estranged from the ultimate power of being, man is determined by his finitude. He is given over to his natural fate. He came from nothing, and he returns to nothing. He is under the domination of death and is driven by the anxiety of having to die.
In my experience with hospice care, it is here that the hospice model must yield to something more. While providing an excellent way to support the process of dying, it cannot minister to this essential anxiety about the meaning of death itself.
Perhaps this dose of reality was what Jesus had in mind for his disciples when, after discussing the significance of Lazarus having fallen asleep, Jesus reinterpreted what he meant and said, “Lazarus is dead.” Death moves the human dilemma beyond the sphere of cure and even benign acceptance. It requires something new in which to believe.
Martha said to Jesus, “Lord if you had been here, my brother would not have died. But even now I know that God will give you whatever you ask of him.” Jesus said to her, “Your brother will rise again.” Martha said to him, “I know that he will rise again in the resurrection on the last day.” Jesus said to her, “I am the resurrection and the life. Those who believe in me, even though they die, will live, and everyone who lives and believes in me will never die. Do you believe this?” (John 11:21–26).
As one trains for chaplaincy in the American hospice setting, there is a customary hard and fast distinction that is drawn between religion and spirituality. Modern hospice programs have a need to distinguish, as do their post-modern counterparts, between religious bias on the one hand and the more authentic interior life of human spirituality on the other.
In my opinion the distinction is not particularly a brilliant one in that it fails to notice that the word “religion” is really an innocuous word, not necessarily laden with all the divisive connotation often associated with religion. “Religion” comes from the same root that the word “ligament” does and merely means that which holds a body together. In the case of religion, one’s “religion” is that set of symbols, beliefs and values that seek to form a coherent whole and allow its adherent to interpret life. Still, it is thought to be a great insight by some to extricate one’s spirituality from one’s religious bias.
So, okay. Those are the rules when you interact in the hospice setting, and they do in fact make a point. Religion can be a problem in the pluralistic American setting where the personhood of each is to be respected. Manipulating toward someone else’s religious bias through proselytizing and the like can defeat therapeutic spiritual care. Hospice chaplaincy has as its goal to explore deeply with the patient his own interior life, feelings and values so that the patient can enlist those as resources to confront his dying. That having been said, the question is “Where exactly does that leave us?”
Still, it’s true: Religion today is thought to be more of a problem than a solution and not without good reason. The interaction at the death of Lazarus between Jesus and Martha is something of an encounter between Jesus and someone with all the stock pious answers that can stand as a roadblock in entering into the deep reality of the grieving. Martha begins by challenging Jesus authentically, perhaps with anger. “Lord, if you had been here, my brother would not have died.” Yet rather than let the honesty stand, Martha quickly glosses it over with something suspiciously overly pious, “But even now I know that God will give you whatever you ask of him.” Surely Jesus must have had his reasons for failing his friend and her brother. “It is God’s will. God must have wanted your child for himself in heaven to be one of his angels. It is really a blessing in disguise.” Those stock religious answers to the overwhelming questions of the grieving are in fact singularly unhelpful and even destructive for those who are in active bereavement.
As the confessing Christian community enters the hospice setting, it needs to be sensitive both to the biases against religion it will encounter and also to its own religious biases. It will need to ask, “Just whose needs do we hope to meet here, ours or theirs?” If there is a meaningful Promise to be articulated, it will have to be out of the deepest interior questions the grieving trust to reveal in themselves. In the Lazarus story, even as Martha, perhaps the quintessential religionist, responds to Jesus’ promise, “Your brother will rise again,” with “Yes, sure, I know … there is that doctrine going around about resurrections,” she yet in her own grief needs to hear the Lord’s new Promising offer, “I am the resurrection and the life.” Even then it remains debatable whether Martha truly hears a Promise and makes it her own. “Yes, Lord, I believe that you are the Messiah, the Son of God, the one coming into the world,” may be as much about doctrinal agreement with Jesus as anything else.
- The Honest Encounter
When Mary came where Jesus was and saw him, she knelt at his feet and said to him, “Lord, if you had been here, my brother would not have died” (John 11:32).
In the Lazarus story I picture Mary out of her relationship of trust in Jesus and out of her high expectations of one who would be in every way her Lord to be the honest one. Kneeling at Jesus’ feet, the sign of her absolute regard and trust, she pushes her Lord with the core question of all. “Why were you absent? If you had been here after we had sent for you, my brother, your friend, would still be alive today.”
The reality of death is finally about somebody’s failure, as there is something elemental in our bones that knows that death is not natural at all. Who ought to take the rap for our dying? Who holds the responsibility for not showing up when we cry out to him to save us?
Of course, while seemingly irreverent, almost blasphemous in fact, to ask such questions of God, they would stand alongside of the very same questions as they emerge from the pages of the Bible itself. Certainly it was not a strange question for Jesus either. It was his own from the cross, as the words of Psalm 22:1, “My God, my God, why have you forsaken me?” come from Jesus’ own lips. Is it an angry question? Perhaps. Does it describe the true unmasked reality of death and dying? Yes. What else is death, really, except utter forsakenness by God, or with Tillich, estrangement from the Ground of our being?
There is probably another time and place in caring for the dying to ask, “Why is this all so?” Of course, we know death is the “wages of sin” and all that. Nevertheless, its underlying sting is very real, and to experience death’s meaning at its core is as honest as it gets.
What is striking, however, in the Lazarus story is that Mary does not shrink from asking Jesus the question, “Why were you absent when we needed you?” From her there is no glossing over the seriousness of the honest encounter.
In all spiritual care of the dying it is the question many persons of faith spend their lifetimes preparing to answer, and sometimes the best answer is born in patient, quiet listening, refusing to fill in easier answers before awesome questions have yet had their full say.
- The First Answer: Divine Solidarity
Jesus began to weep (John 11:35).
There are, as most readers know, thousands of words in recent literature written about those who are most beneficial to the grieving and the dying. They are those who enter into solidarity with those who mourn and share in their experience of pain and sorrow. From Rabbi Harold Kushner’s When Bad Things Happen to Good People to many other salutary works about human caring, it bears repeating that the most meaningful helping comes in the form of genuine empathy.
What is less common, although it too is a theme in contemporary theological literature, is the portrayal of God who weeps with those who mourn. Juergen Moltmann’s The Crucified God has become something of a classic study of the tradition known as the theology of the cross among other great works on the subject.
Nevertheless, the view of God as one who suffers our pain and our dying with us is an incredible insight and one that is born in the words from the shortest verse in the Bible: “Jesus wept.”
Yet as comforting as the notion is that even Jesus shared our human fate of grieving and joined the rest of the human race as an empathic friend, it still leaves us in our tears and sorrows and as yet without hope. It is not so strange that in response to Jesus’ own tears in the Lazarus story, his critics still complained, “Could not he who opened the eyes of the blind man have kept this man from dying?” (11:37).
- The Second Answer: Death’s Defeat
“Take away the stone” (John 11:39).
Of course, in the confessing Christian community Jesus’ ability to take away gravestones goes right to the core of our Easter faith. What is often overlooked among us is the Lenten solidarity with a broken and dying world that gives Jesus the authority to call out the dead to life again. That is why simplistic Easter proclamation to the dying and the grieving without having gone the distance of being fully present with those who mourn can readily fall on deaf ears.
Still, the Easter Promise, when it is compassionately administered, is precisely the Promise needed, and there is no way, even under the conditions of hospice care, that Christians can ignore the grand acclamation, “I am the resurrection and the life. Those who believe in me, even though they die, will live, and everyone who lives and believes in me will never die” (John 11:25).
What is so powerful about the Easter faith is that it is precisely because it sounds a Promise that hefty—death has been defeated in Christ—that confessing Christians are able to go the distance with compassionate care for those who mourn.
Robert Bertram’s poem, “Pardon My Dying: A Sequel to Ash Wednesday” captures why, with a Promise as strong as is Easter’s, Christians can enter the nighttime of their dying and their grieving as boldly as they do. The exchange in the poem is between a husband and a wife, both beloved to the other, where the last things that need to get said are getting said. The wife asks one more favor of her husband, that he pardon her of her dying:
“All right,” said he, “you win. What is there to forgive?”
“Forgive my dying. Pardon this damned mortality.”
“Your dying? Pardon that? But girl,” said he, “that’s something you can’t help. Dying is … only natural.”
“No, it’s not natural at all,” she said. “Life wasn’t meant to die. Neither were we. We both know that. We’ve known that ever since we’ve known of Easter. Death isn’t natural at all. It’s a downright dirty, dastardly, demeaning defeat. We’re not meant to ‘accept’ it, not even with dignity. We’re meant to trump it, as we shall.”
“But then,” said he, “if death is conquered anyway, if we outlast it (and we shall), why do you still think dying needs forgiving?”
“Does that,” she asked, “disturb you so, for me to say that death is what we’ve brought upon ourselves, what we’ve got coming to us? Does that strike you as morbid, despite the fact that I’m not afraid? Despite the fact that it’s my hope and not my fear which frees me to admit the shame of dying, do you see that as merely clinical escape? Come, Adam, can’t you deal with that? I believe you can?”
“I wouldn’t say,” said he, “that it is morbid. Still, it does seem—how shall I say?—a bit too self-important for us to take credit for so vast a thing as death. Are we, for all our guilt, really that influential?”
“That does seem hard to believe,” she said, “unless we manage first to believe that God is interested enough to judge because he’s still more interested in resurrecting and forgiving. For him to let us die is judgment, not contempt. And there’s a difference. Ignore us? That he never does. But deal with us he does. That important are we all.”
“But then,” said Adam, “why do you ask now to be forgiven by me? Forgiveness, yes. But why from me? I’m not the one who judges you.”
“But you’re the one I hurt. For, Adam, dear, I do hurt you by dying. You know I do. It hurts me, too, of course. Death hurts even my vanity. Death isn’t pretty and, as you know, I’ve always liked being pretty. But worse than that by far, it hurts to have to liquidate the fondest love affair that any wife could want. It’s for that, for interrupting that, that I do say I’m sorry.”
When death’s defeated in the Promise, the things between us that need to happen most can be entered into without fear. Reconciliation, forgiveness, restoration all presuppose Easter because with ultimate hope all things matter.
- The Third Answer: Death’s Defeat through a Death
Christ the Life of all the living,
Christ the Death of death, our foe.
It was over a decade ago when my brother and his family were involved in a fatal car accident outside Buffalo, New York, where they were headed for vacation. My niece, ten years old at the time, was killed. My brother, his wife and my nephew were terribly injured but survived. As I entered my brother’s hospital room, all I could say was, “I don’t have the words. All we have is a God who had a child who died, too.”
As the Christian community seeks to minister to the dying and those who grieve around them, it is important to remember what we have. Words are often far too feeble a thing to bear the reality of what is going on. All we have is a God who had a child who died, too.
Yes, of course the Father does something about it. He doesn’t abide his child’s death. Instead, God pulls off Easter, for his child and for all found in that child. But Easter does not come cheaply or easily. It is born in tears.
As I began this essay, I used a poem by Dietrich Bonhoeffer that has always struck me as what Christians have among all the human family. Yes, it presupposes that God’s love and forgiveness are meant to reach all for the sake of God’s Son. The divine love’s universal embrace stands for me in the realm of a mystery, the mystery of redemption, and none of us has the wisdom to play God in the face of the vastness of death and new life. What is striking about the poem, even in its meaning for those who were Bonhoeffer’s enemies, is that there is only one distinction between Christians and all others, as all finally call upon God. Christians are those who stand by God in the hour of his grieving, as if the Body of Christ in the world is composed of those who join God as God empties himself in the person of his Son, who gives up his life redemptively for the salvation of the world.
It is a good picture to keep in mind as Christians seek to enter the world of hospice with its dying and its grieving: that God is already there in the person of his Son, bearing up the tears and sorrow and pain and the dying we find around us.
It is likely that hospice care will become the preferred context for the nation’s dying. As noted above, it already embraces in its care one in three Americans today with its numbers growing steadily.
Accredited hospice care is what it is: society’s answer to better approaches in caring for the terminally ill. In more classic Lutheran language, it is with all its ambiguities a “kingdom on the left” phenomenon. In that sense it is part of God’s creative, continuing care for God’s fallen-but-yet-still-loved creation. Hospice brings to bear some of the best palliative care for the dying the secular has to offer.
Yet even with its spiritual overtones, hospice in itself is not a conveyor of the Promise. That witness needs to come from the outside, from among the confessing Christian community. As discussed above, however, Christians must be prepared to enter the hospice context humbly, with compassion and a willingness to listen actively and with a caring heart that discerns deeply the time for the Promise.
Hospice can provide a new context for the church’s mission today. Indeed, it ought to. There are few opportunities better suited for the Promise to be administered than with those at the end of their lives. But the calling will be for an uncommon sensitivity to the needs of the dying and the grieving. Establishing relationships of trust will be the watchword for effective ministry.
Typically hospices will be open to the Christian community as long as trust is won. The religious who come to hospice with hidden agendas will not last long. Patients who experience manipulation rather than someone truly interested in their personhoods will not abide false friends for very long. Time is of the essence for them. There is an urgency felt by the dying for whom illusions of immortality have long past. Still, inherent in the human soul is a hunger for hope found only in God. Augustine’s observation still applies: “Thou hast made us for Thyself, O Lord, and our hearts are restless until they rest in Thee.”
Churches can approach hospice in a variety of ways. Chaplains are always interested in connecting patients in their care with the pastoral care structures of a patient’s faith community. Oftentimes that means welcoming back the many who had fallen through the cracks over the years. Now is the time. Accredited hospice programs are extremely eager to find volunteers willing to be trained to bring their many gifts to the side of the dying. Hospice volunteering takes a special breed of people. Persons who are secure in their Christian faith make excellent hospice volunteers. The blessing, of course, is that those volunteers will bring back to their faith communities a wisdom and a growth that will only strengthen their local churches, having lived the questions of the dying and sought to minister to them.
Hospice ministry is among the new shapes of the culture. If anybody ought to be there, the confessing Christian community in intentional mission to the terminally ill needs to be at the top of the list.
 Dietrich Bonhoeffer, Letters and Papers from Prison, ed., Eberhard Bethge. (New York: Macmillan, 1971), pp. 348–49.
 Ernest Becker, The Denial of Death (New York, The Free Press, 1973).
 Paul Tillich, Systematic Theology (Chicago: The University of Chicago, 1957), 2:66.
 Harold S. Kushner, When Bad Things Happen to Good People (New York, Schocken Books, 1981).
 Juergen Moltmann, The Crucified God (New York: Harper & Row, 1973).
 Robert W. Bertram, “Pardon My Dying: A Sequel to Ash Wednesday” (St. Louis: The Crossings Community, 1972).