The close approach of death has been described in various ways,

including, ‘in the suburbs of heaven’, ‘the gate of death’, and ‘the

honest hour’. These poetic labels should not be allowed to obscure

the starkness of the reality. We will all have such an encounter, on one

particular day, in one specific place. At that time-and-space juncture, we

will indeed be at the very edge of life. In their detail, these last hours will be

different for each of us, but some features will be common to most of us.

These are presented here to help us all, the dying and their families, gain a

better understanding of this most significant of all life’s closing

transactions.

25.1 The experience

Although a few of us will die unexpectedly and suddenly, nearly all of us

will die unsurprisingly and comparatively slowly, over days, even weeks.

This process of dying has often helpfully been divided into three stages of

experience. During the initial stage, or what has been called ‘facing the

threat’, the dying person may go through a spectrum of emotions,

including fear, anger, shock, denial, humour and hope. The chronic stage,

or ‘being ill’, may bring some understanding and resolution of those

emotions experienced during the initial stage. And this phase is often

characterized by a measure of depression. The final stage, or ‘acceptance’,

may be marked by acknowledgement of the inevitable, but not necessarily

so. These stages are not fixed points, but merely a generalized pattern—

some of us will die with quite different experiences.

Besides these emotional aspects, there is also a commonly-recognized

pattern of physical events. During the final days or hours, most people

experience some increasing weakness in their bodies as well as a general

immobility. They become disinterested in food and drink, they often have

difficulty in swallowing, and they can become drowsy. The dying person

may experience breathlessness, which can cause fear and anxiety for both

the patient and family—it can be overcome by various treatments, ranging

from the complexities of opioid administration, to oxygen therapy, to

simply repositioning the patient. Restlessness and confusion can often be

relieved by attending to the patient’s environment—soft lights, familiar

faces and quietness can all help. Drugs may also be required, but it may be

that the patient is undergoing some emotional or spiritual anguish for

which there is no drug alleviation. Nausea and vomiting are not common at

this stage, but if they do occur, they should be treated with antiemetics.

Emergency situations can arise. It is important that appropriate and

timely actions are taken, not only for the comfort of the patient, but also for

that of the relatives and carers, who can be unduly alarmed by such events.

Some emergencies are predictable, because of the patient’s medical history,

and some are preventable. Nevertheless, most emergencies in the last hours

are irreversible and palliative treatment should be directed towards the

urgent relief of distress.

For those who have suffered from a long-term incurable illness, these last

stages of dying can often be predicted and therefore anticipated well in

advance. For others, the end may be hastened by a more sudden and

unexpected deterioration. Whatever the details, death is truly imminent—

the patient is about to die, perhaps within a few days, or even hours. It is a

time for other changes. For example, nursing care and the control of the

patient’s symptoms no longer rely on aggressive clinical investigations and

treatments. It is that crossover time. What, a short while before, were

considered to be essential drugs, such as antidepressants and

corticosteroids, are often dispensed with, and other drugs, such as

analgesics and sedatives, become the required medicines if pain and

restlessness are present. Also, support for the family and carers assumes a

new priority. This is the time when anxieties, stress and emotions run high

for all concerned. The type and extent of care provided should be

frequently reviewed.

These are some of the common experiences of dying. And these

responses and treatments are the foundational patterns of good palliative

care. An understanding of them will contribute to the patient dying well and

the experience and memory of a good death by all the other people involved.

25.2 Support for the dying and the living
Involvement with dying people is not straightforward. It will, at first,
perhaps make us feel uneasy and awkward. It is said that the British attitude
towards the dying is six feet away and three feet above—in other words,
remote and detached. But if we need to do it, and want to do it well, then
reading a short book, like Living with Dying—A Guide to Palliative Care,
by Cicely Saunders et al. (1993) should help us considerably.

One of the keys to dying well is the availability of support. This consists,
needless to say, of support for the patient, but also for the family, and for
the carers, both lay and professional. Because of a distorted view of death,
these latter people can often resist it so strenuously that they can become
exhausted. It is a time when relatives can also become especially fatigued,
as well as perhaps perplexed and guilt-ridden. Carers need to be cared for
too because they can become resentful, and cross at the lack of success of
their efforts. In the midst of death, even doctors and nurses sometimes need
to be told that it is not their fault that the patient is dying. These carers can
already be doing a dozen and one things for the dying patient, and, as each
day goes by, there are additional chores and duties. Tempers can be frayed
and patience frazzled—such people really will need support. To be sure, at
the very edge of life can be a time and place of tension.

Nowadays, dying and death have become largely private, somewhat
embarrassing, and even sanitized, affairs. How different it was just a
generation or two ago when a whole village or neighbourhood would be
affected by the death of one of its residents. One mark of this change is the
decline of the custom of the wake, a mix of lament and celebration
attended by family, friends and the locals. Nowadays, it tends to be a
‘family only’ occasion.

The role of families in the dying and death of a person can be crucial. Yet
they can differ enormously in their intra-familial relationships. Two
extremes can be recognized. First, there is ‘the patient in the family’, which
is typically a warm and caring environment. Second, there is ‘the patient
and the family’, which is characterized by rather cold and distant
relationships. ‘You and yours’ probably fit somewhere between these two
ends of the range, but, hopefully, up towards the ‘warmer’ end.

Families are certainly assorted. Some are ‘synchronous’, that is, they
function admirably as long as their daily routine is maintained. Alter it,
such as when one member is dying, and that cohesive structure can come
unstuck and so, unexpectedly, can their ability to cope with the edge-of-life
experiences. For other families, dying and death can uncomfortably force
them together and that can rekindle past animosities and serve to highlight
their dysfunctional nature. Then again, some families, who are distant,
both socially and geographically, can be reunited by the dying and death of
one of their own relatives—thus, it can, even should, be a constructive,
reconciliatory time. Incidentally, these vast opportunities for fostering
personal maturity and family relationships are why hospice personnel are
generally opposed to denying patients access to the truth about their
condition, as well as any legislation that would encourage the hastening of
their death. These can be difficult, but also precious, times.

At these times, clear communication must be high on the agenda, not
only between family members, but also with doctors, carers and especially
towards the patient. State-of-the-art medicine has made personal
communication increasingly fragile. Therefore, encourage it. Become a
brick, not in that toe-curling, bumptious manner, but as the Lord Jesus
would do—gently, compassionately and genuinely. Our communication
must be sincere and realistic, and it includes both speaking and listening.
There must be questions and explanations about what is happening, what
will probably happen, what medicines are being used, what support is
available, and how the family can provide help for not only the carers but,
above all, for the dying one. There should also, when and where appropriate,
be prayer and Gospel communication from church leaders and others.

Such true communication is honest communication. There is some
debate about whether the dying patient should be told the truth. Should
information be withheld? The Christian rule must surely be, always tell the
patient the truth about what is happening. Truth, whether spiritual or
medical, does set you free. In twenty-first century parlance, this is
empowerment, enabling patients to exercise their intrinsic dignity. Of
course, care must be taken to tell the truth in a way that will not cause the
patient undue apprehension—bad news is best broken in small pieces,
rather than as a bombshell. The more frightened a person is, the less he is
likely to talk about his doubts and fears. Whatever the prognosis, the
patient can be assured that he is dying and that all is well—he can stop
struggling and relax.

Practical support that is insufficient is the main reason why many
patients have to leave their homes and be admitted to a hospital, or a
hospice. For some this move can be problematic because it can be
accompanied by a hastening deterioration, both physically and mentally.
Or, at least, it can often seem that way. However, such declines were
probably occurring anyway, and the new environment can simply make
them more obvious. Now read carefully, and remember this—this person,
your loved one, is never going to recover, he is dying, right? Perhaps he will
live for just a day, or a week, or even surprisingly for a month or longer, but
the end is now irreversibly in view. Such a move out of the family home is no
disgrace—it is not a failure on your part, whether you are the spouse, or a
member of the family, or caring team. Some dying people need 24/7 care,
and no husband, or wife, son, or daughter can give that for more than a few
days. So be sensible—there is already one patient, nobody wants two or
more!

Nevertheless, whether the patient is spending his last hours at home, or
in hospital, extra help is often needed. There is much that the Christian
fellowship can do at this time. But, be sensitive. Do not arrive
unannounced. Do not phone late at night. Do not outstay your welcome.
Perhaps one or two people could coordinate this extra assistance. And do
not forget that there will be a need to continue some aspects of this support
once the family has been bereaved. What can best summarize this type of
Christian response? Surely, it is the application of injunctions like those of 1
Timothy 6:18, ‘Command them to do good, to be rich in good deeds, and to
be generous and willing to share’ and Romans 12:15, ‘Rejoice with those
who rejoice; mourn with those who mourn.’

25.3 Religious concerns
The elderly and the dying need to be assured of comfort, both physical and
spiritual, and that their current life is neither meaningless, nor useless. As
many will know, visiting the dying Christian can frequently result in the
visitor receiving more counsel, spiritual and otherwise, than the visited.
Even so, the dying can have religious concerns and fears—these too need to
be addressed. Asking a minister to visit a dying person can have useful,
therapeutic outcomes. It can also precipitate a ‘crisis of faith’. This book is
not the place to rehearse the duties and privileges of the Christian pastor or
minister, but they should not be minimized. This is, after all, the last time
for the dying, unbelieving person to accept Christ as Lord and Saviour. Can
there ever be a more critical time of ministry?

There is the reality of the deathbed conversion, and we should never
underplay it. Nor should we necessarily be downcast if we do not observe
it. Who knows what occurs during the last hours of a person’s life?
Searching for God, recalling earlier-heard truths, memories of Christian
teaching and testimony, who knows? The dying thief is our exemplar (Luke
23:43). But we should also beware of creating false hopes in ourselves and
others. We do not always know how God works, except that it is forever in
love, according to his purposes and sovereignly. Conversion is not our
business, it is God’s. It is he who has said, ‘I will have mercy on whom I will
have mercy, and I will have compassion on whom I will have compassion’
(Exodus 33:19). Our task is to be true and faithful. Nevertheless, the death
of someone with uncertain saving faith and undecided eternal destiny
should cause us to, ‘Seek the LORD while he may be found; call on him
while he is near’ (Isaiah 55:6) and prompt others to do the same. But can we
doubt that we are going to be astonished by some we meet in heaven?

25.4 Earlier preparations
None of us can predict when, where, or how we will die. Some may want to
go unannounced by way of a sudden and massive heart attack. Most of us
probably want to go quickly. For what it is worth, I would like to go
coherently, at home, with my family around my bed. I would like my last
meal to be lobster followed by profiteroles, cooked by my wife, though I
acknowledge it may have to be just lobster bisque and chocolate sauce! I
would want my pastor to have read to us, my favourite Bible book,
Colossians, and then prayed with us all. I would encourage my family to
follow the Faith, and then say my farewells. Then I would go to sleep, die
peacefully, and go to be with my Lord. Maybe it will, maybe it will not, be
like that for me. But have you ever thought honestly about your great event?
Have you thought about, or better still written, your obituary notice, and
your funeral service, have you chosen the hymns and the Bible readings?
How is it that we can spend long hours planning a holiday, or so
meticulously prepare to redecorate the dining room, but think so little about
making the arrangements for our last and most certain event of this life?
Think about those last days and hours—it will do you good. They lead to
death and eternity. There are no subjects in the whole, wide world about
which men and women ought to be more interested. None of us has had any
previous, personal experience of it. In many ways, death is that great
unknown. But, the wise will learn from those who have gone before. And,
above all others, there is One to learn from. He is the One who has already
experienced death. He is the One who has already conquered death and
experienced resurrection, and has told us about them both. Is there an
afterlife? Can you doubt it? Do you doubt it? Then, read John 14:1–4. The
second person of the Trinity has promised to make a new home for all his
people and to take us there. I cannot speak for you, but that promise is good
enough for me.

And it was also good enough for many of our believing predecessors.
They knew how to prepare for death. We have largely forgotten how to, and
that is our loss. Most of us are too busy living to consider dying. Now, while
we are in good health and strength, is the time to start preparing ourselves.
Such a momentous event deserves extensive and thorough preparation. To
wait until we are on our deathbeds would seem to be too late, almost like
after the event.

Such preparation includes reading and contemplating. Pride of place
must, of course, go to the greatest book on life and death, the Bible—it is
peerless. There are other books too. One of the best is that nineteenth-century
golden oldie, Archibald Alexander’s Thoughts on Religious Experience (1967).
Musing on Psalm 71, he so wisely wrote, (p. 250), ‘Let the aged then tell to
those that come after them, the works of divine grace which they have witnessed
or which their fathers have told them. Let them be active as long as they
can, and when bodily strength fails, let them wield the pen; or if unable to
write for the edification of the church, let them exhibit consistent and shining
example of the Christian temper, in kindness and good will to all; in uncomplaining
patience; in contented poverty; in cheerful submission to painful providences;
and in mute resignation to the loss of their dearest friends. And when death
comes, let them not be afraid or dismayed; then will be the time to honour God
by implicitly and confidently trusting in His promises. Let them “against hope
believe in hope”.’

Dying can be a difficult time. Yet the Christian has numerous
consolations. Foremost among these must be one of Christ’s promises,
spoken, seemingly out of place, at the very end of the Great Commission. It
is, ‘And surely I will be with you always, to the very end of the age’
(Matthew 28:20). He will be there—Christ will warm our deathbed—he
will be our amicus mortis, our friend during dying, and then at death. It is
like a ricochet from Psalm 23:4, ‘Even though I walk through the valley of
the shadow of death, I will fear no evil, for you are with me …’ This is the
God who has promised to be with and to comfort his people. This is the
God who has said throughout the ages, from Deuteronomy 31:6 to
Hebrews 13:5, ‘Never will I leave you; never will I forsake you.’ Whatever
the distress, however strong the pain, despite the discomfort, God has
promised to be with you. Can there be a greater Comforter, or better
comfort? To go through dying with him, is going to be infinitely more
comfortable than without him. And this divine comfort is not just for the
dying. That in itself would be sufficient, and more than we deserve, but
God’s comfort also extends to those left behind. ‘Blessed are those who
mourn, for they will be comforted’ (Matthew 5:4). Some will deride all this
as ‘pie in the sky’—I call it ‘the blessings of God’

25.5 The prospect of heaven
This should be the best and the richest section of the whole book, though I
fear it will not be. The topic is beyond compare, and certainly beyond my
literary capabilities. I know that I can never do it justice, however many
times I rewrite these words. My consolation is that heaven will be far more
astonishingly better than I can ever describe. To contemplate the aftermath
of death for the Christian is like trying to explain to a blind man the
brilliance of the stars, or a rainbow. Alexander does a much better job than
I, when reflecting on the great transition (p. 187), ‘… from the state of
imprisonment in this clay tenement to an unknown state of existence,
would be overwhelming ... That the scene will be new and sublime, beyond
all conception, cannot be doubted; but what our susceptibilities and
feelings will be, when separated from the body, we cannot tell.’ But of this
we can be sure—it will be excellent, at least as good as life was in the
original Garden of Eden.

Such contemplations must not lead us to bicker about the minutiae of
heaven—what will my body be like, what will I wear and eat, what
language will I speak? Such questions are from the realm of idle curiosity
and time-wasting speculation. The antidote to any such squabblings is
1 John 3:2, ‘… and what we will be has not yet been made known.’ Such
details are not given to us in the Bible, and anyway, we do not need to know
these pleasures yet, they are, for the present time, unknowable. One day we
will know, because we will see, hear, touch, smell and taste them. But of
some things we can be certain. Again, let me borrow the words of
Alexander (p. 253), ‘… one of the first feelings of the departed saint will be
a lively sense of complete deliverance from all evil, natural and moral. The
pains of death will be the last pangs ever experienced. When these are over,
the soul will enjoy the feelings of complete salvation from every distress.
What a new and delightful sensation will it be, to feel safe from every future
danger, as well as saved from all past trouble.’

And, above all, he will be there. He who rescued us while on earth, he
who died in our place, he who transferred us from the dominion of
darkness into the kingdom of light. Now, it can hardly be imagined, then, it
will be the real thing. Though we are blessed now, then we will know newer,
better, greater heights. Therefore, now, while here on earth, we should be
living in happy expectation of such an eternal life. Corruption, tears, pain,
dishonour and weakness will give way to incorruption, smiles, joy, honour
and strength. Ah! How wonderful!

Finally, think about dying, death, resurrection and heaven in one of the
ways that the Bible does. It employs the analogy of seeds. 1 Corinthians
15:37 states, ‘When you sow, you do not plant the body that will be, but just
a seed, perhaps of wheat or of something else.’ No gardener can fail to be
amazed at the transformation when she surveys the wizened, brown seeds
in the palm of her hand, and then a couple of months later, the glorious,
multicoloured flowers, or the succulent vegetables. This encapsulates the
Christian hope. ‘So will it be with the resurrection of the dead. The body
that is sown is perishable, it is raised imperishable; it is sown in dishonour,
it is raised in glory; it is sown in weakness, it is raised in power; it is sown a
natural body, it is raised a spiritual body’ (1 Corinthians 15:42–44).

The big question is, are you ready? Ready for your last days and hours?
Ready for your last journey? Here are your three-fold biblical travel
instructions. First, make sure that your place is confirmed, ‘Therefore, my
brothers, be all the more eager to make your calling and election sure’
(2 Peter 1:10). Second, think about your destination, ‘Let us fix our eyes on
Jesus, the author and perfecter of our faith … sat down at the right hand of
the throne of God’ (Hebrews 12:2). Third, prepare to emigrate, ‘… I desire
to depart and be with Christ, which is better by far …’ (Philippians 1:23).

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