The Reality of Age in Hospice Spiritual Care

While age plays a big part in grief, we have to be careful not to minimize the impact of the loss to the bereaved.


Dr. Saul Ebema.

What thoughts, feelings, or images do you experience when you hear that a 90 year old man has died in a nursing home? What about the death of a 45 year old man who died of cancer at home in the presence of his wife and young children? What about the death of a young adult just graduating from college? What thoughts and emotions do you experience when you hear a young 8 year old boy has died? The context of age is a major social factor in determining reactions to death and dying. It is safe to say that every age group has specific therapeutic issues that ministers counseling the dying and the bereaved will encounter during the counseling process.

The Elderly

One morning in December, I received a call that the patient I was scheduled to visit that day had just died. I was in the middle of a visit with another patient but decided to shorten the visit and went to comfort the family who had just lost their loved one. This patient was 93 years old when he died. The family seemed at peace with the death. The common theme that came out of the family members when I offered my condolences was that, “He had lived a long life and nothing to be sad about.” Some said, “He had a good life and it was time to go.” Although they were sad that he died, the death was acceptable as a natural progression of life. Through my work as a hospice chaplain, I have noticed many reactions to death and some of the reactions are activated by the age of the deceased. Contemporary American culture considers death at an advanced age as normal and acceptable. “The families and friends of the elderly dying person tend to view death as less tragic and less threatening than in the case of a child or young adult.”[1] This is probably because of the marginal economic and social roles the elderly play in the society.[2]

It is to be noted that although the death of an elderly person is less tragic than the death of a child, it would be incorrect to minimize the intensity of a mourner’s grief merely because his or her loved one was elderly. “It makes little difference to a man of 90 that his 85 year old wife has died and that she should constitute a low grief loss. In this case, age is irrelevant to him because he has lost his life’s companion.”[3] For ministers providing spiritual support with the terminally ill in this age group, several important age-specific problems arise. The combined effects of terminal illness and old age can produce extreme physical challenges which are both painful and emotionally distressing. “The loss of physical control over one’s body is a frustrating, embarrassing, and depressing experience.  Given a marginal social role and terminal illness, the elderly person can easily experience a sense of uselessness and unimportance in the final months of life.”[4]

During counseling sessions with the elderly, ministers can alleviate some of their concerns by encouraging them to be active participants in the counseling process.

Most elderly patients have issues to address such as forgiveness, unresolved problems, broken relationships, and unfinished business. All these psychosocial issues may lead to spiritual pain as they near death. Ministers “counseling people with these issues can offer opportunities to examine their unfinished business, to work toward resolutions where possible, and to accept failures where necessary.”[5]

Middle Aged Adults

Dying persons in this age group present counseling challenges that defer from the elderly. The middle aged adult with family and work responsibilities who is stricken with terminal illness and the elderly in a nursing home face their deaths with different concerns due to their perceived age differences and social responsibilities. “The sense of loss, injustice, and anger is often more intense in the person at this middle stage of life.”[6]The major psychosocial concerns in this age group are the loss of identity, work, family and the reality of not being able to support their families or not being able to raise their children.  When compared to the death of an elderly person, the family members and friends of a dying person in this age group have intense psychosocial issues. Kubler-Ross gave a great example regarding this issue:

The first example is Mrs. W., a twenty-eight year old mother of three small preschool children. She had liver disease and because of her liver disease, she slipped in and out of hepatic coma, disorientation, and psychotic episodes. She was a young woman who felt that she was too young to die. She never really had the time to be with her children. During these times of confusion she was totally disoriented. She went in and out of the hospital; her husband took out a loan to pay for the hospital and doctor bills. He had babysitting problems, and he finally asked his mother to come into the household and take care of children. The mother-in-law did not tolerate the daughter-in-law well. She would have liked to get it over with as soon as possible.The young father was in great distress because of his financial problems and the whole mixed-up state of the household. One day he came home from work tired and desperate, and he blurted out to his dying wife, “It would be better if you would live and function as housewife and mother for one single day than drag out this misery any longer.” This young mother sensed that her husband counted the days; the three children did not make it any easier, but they made her feel guilty for dying on them.[7]

Middle aged terminally ill patients with young children are often worried about their children and the effects of death on them. They have concerns about financial issues of the family, and being a burden on family members; they experience guilt, and a sense of abandonment. They also struggle with unfinished business.

Effective ministry to a dying person in the middle age group is a difficult duty. The starting point is to analyze yourself as a pastoral counselor. It begins with coming to terms with death personally, spiritually and theologically. The Pastoral counselor needs to put themselves in the patient’s place and not expect instant resolution of problems. They need to be good listeners to the patient’s narrative. In the process, the counselor can help them cope with the fear, anger and anxiety associated with dying.

Youth, Children and Infants

There is an implied though not plainly expressed expectation in our culture that the parent will die before the child. The orderliness of the universe seems to be undermined when this expectation is unmet. The unnaturalness is not determined by the age of the child, but by the fact that the child dies out of turn with the parent.

The death of a child is considered to be a greater loss in our culture because the child has not had the opportunity to live a full life compared to the adult or the elderly. The emotional and spiritual needs of dying children vary greatly with age and intellectual ability. According to Eason’s studies of dying children, “Infants’ response to dying is solely influenced by the physical distress of the illness. The child as an infant is not fully aware of the people or the environment around he/herself. Therefore, infants need great physical comfort.”[8]

Considerable pastoral counsel may be needed for the family during this time as they struggle with their real sense of helplessness. Toddlers take clues from the significant relationships around them on how to respond to death and dying. The feelings and responses of their parents often become that of the toddlers. The feelings of the parents and the family are communicated to the child and become the child’s feelings also. The task of dying may thus become much more burdensome for the young child because he also bears this load of his/her parents’ feelings. Young children will respond with fear as they die, not because they can appreciate the fearfulness of death but rather because their parents are upset and fearful.[9] Pastoral counseling in this age group should focus on minimizing the child’s and parents’ fears and anxieties.

Older Preschool Children

Older Preschool children are more self-sufficient from their parents. They enjoy making decisions, expressing themselves. Within this age group, everything is viewed in terms of black or white, good or bad. For this age group, a diagnosis of a terminal illness may be viewed as a punishment for something they might have done. Guilt and feelings of rejection are common.

Pastoral counseling for terminally ill preschool children may include, assuring the child that his/her illness is not a punishment. Honest and rational education on illness should be given. The minister can encourage family members to avoid any kind of separation from the dying child and keep changes within the home or family to a minimum. Outlets for normal childhood emotions- like video games or other kind of activities should be provided to help the child normalize the dying process.

Grade School Children

Grade School Children have a clearer awareness of separation from others. In most cases they have greater sense of independence, self- confidence and awareness of individuality. The reality of impending death brings feelings of vulnerability and concern over non- existence. As the illness progresses in the child, the body which had provided to most self- identity and control now becomes weak and disabled by the illness. This reality makes the child feel angry, resentful, and depressed. As the child at this age in more capable of understanding what is happening to them, there is a need for truthful and open communication about the illness. The pastoral counselor can offer supportive presence, individual and family counseling sessions for the patient and family members to help process their grief.

Youth and Adolescents

            The responses and needs of terminally ill adolescents do not differ much from those of adults. The developmental stage of adolescence makes their responses to death more intense than those of adults. The fear of pain and physical disability emerge as central concerns. “A related problem that is most apparent in teenaged patients involves the association between body-image and identity, and the feelings of shame and disgrace over their physical conditions. For the terminally ill adolescent there is an acute sense of the injustice of death.”[10] Dying adolescents rightly see themselves as being cheated out of a future and this is hard to accept. “Hostility and aggressive behavior is not unusual for terminally ill teens, and these feelings certainly need to be addressed.”[11]

Due to depression, adolescents with terminal illness may attempt to commit suicide. Sometimes their close friends empathize with them so much that the potential for a suicide pact is common and high. Therefore, terminally ill adolescents and their friends may have to be monitored for suicide. For ministers counseling children of any age, counseling techniques must be adjusted to the developmental level of each dying child. In general the task of ministers in these situations is to provide information, support, and solace for the dying child.

To assist both child and family, the minister can also employ family therapy sessions. In a family therapy approach both the dying child and others in the family learn to communicate openly with one another. “Parents often need be helped to manage their feelings of anger, guilt, and helplessness, as they learn to help their child.[12]

Sources Sited

[1]George W Rebok and William J. Hoyer, “Clients nearing death: Behavioral treatment perspectives.” Journal of Death and Dying 10 (1980).

 [2] Joseph Culkin, “Psychotherapy with the dying person.” http://www2.sunysuffolk.edu/pecorip/SCCCWEB/ETEXTS/DeathandDying_TEXT/Culkin.htm (accessed February 20, 2015).

[3] Rando, Grief, Dying and Death.

[4] Richard A. Husain, Geriatric psychology: A behavioral perspective (New York: Van Nostrand Reinhold, 1981).

 [5]Culkin, Psychotherapy with the dying person.

[6]Arthur C. Carr et al., Psychosocial aspects of terminal care (New York: Columbia University Press. 1972).

[7] Elizabeth Kubler-Ross, Living with death and dying (New York: Macmillan.1981).

[8] Mark W. Eason, The Dying Child: The Movement of the child or adolescent who is dying (Springfield, IL. Charles C Thomas, 1970).

[9] Ibid.

[10] Culkin, Psychotherapy with the dying person.

 [11]John E. Schowalter, The child’s reaction to his own terminal illness (New York: Columbia University Press. 1970), 92.

[12]Susan Blake and Karen Paulsen, “Therapeutic intervention with terminally ill children: A review.” Journal of Professional Psychology 12 (1981):


Everyone knows that the task of being a Hospice chaplain is harder than any field in professional chaplaincy. Our goal is to train chaplains and prepare them for competent service within the Hospice industry.

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