Spiritual Aspects of Palliative Care for HIV Positive

Hegumen Methodius (Kondratjev)

"…the one aim of those who practice philosophy
in the proper manner is to practice for dying and death".
Socrates

Unlike the secular medicine, the Church has always seen the hopeless, the sick without the future, to the very threshold of death. Until recently doctors limited their care about the doomed to pain killers and whenever they could they would return such patients to the care of their relatives. No spiritual care or at least warm-heartedness was included on the list of responsibilities of medical workers. In many cases the patients going through the most difficult final segment of their lives saw no human concern or support from their part. What doctors would try to do is to maintain a false hope on recovery; they would conceal the verdict and play a sly game that humiliated all its participants. Man has the right to face death, to summon his courage to encounter it rather then be abducted by it unprepared.

The Church traditionally pays much attention to the very last days of man on the earth. It is not only because it believes in life after death and eternal existence or because of compassion to those who suffer, which is natural for human beings. The last days, sometimes even hours, determine the person's eternal fate to a very high degree. The way the person died may help to make conclusions about his afterlife lot. Not always though, but to great extent. The choice man does at the very last moment of his life can cover all sins of a wicked person or devalue the multitude of good deeds of a righteous person. "Therefore, son of man, say to your countryman, 'The righteousness of the righteous man will not save him when he disobeys, and the wickedness of the wicked man will not cause him fall when he turns from it. The righteous man, if he sins, will not be allowed to live because of his former righteousness'. It I tell the righteous man that he will surely live, but then he trusts his righteousness and does evil, none of the righteous things he has done will be remembered; he will die for the evil he has done. And if I say to the wicked man, 'You will surely die', but he then turns away from his sin and does what is just and right - …follows the decrees that give life, and does no evil, he will surely live; he will not die. None of the sins he has committed will be remembered against him. He has done what is just and right; he will surely live" (Eze 33:12-16). These verses from the book of prophet Ezekiel speak naturally about the spiritual life and spiritual death of man. The spiritual state, which man finds himself in at the end, becomes his eternal property.

The death of man is a great mystery. It requires a substantial preparation. Before the end man experiences an outmost psychophysical tension; the awareness that he is coming to the very last limit of his life also causes a great strain of all his spiritual forces. A correct attitude of people around to the departing fellow facilitates his demise and helps him to pass the supreme test with dignity. It is difficult to overestimate the significance of the last preparations to death when it is encroaching. Christian ascetics who always had the grace of mortal memory, considered it a great blessing to be informed from above about the coming end, about the day of their passing away. They knew the price of such a notice and what they should do, unlike careless sons of this age who lead a fast life. The other church people, priests in particular, did not forget about their duties to the dying men either. It is a great blessing to approach the end being surrounded by true communicants of the Church.

I shall share one example of the level of ecclesiastic care about the dying. The instruction for parochial priests indicates only four blessed reasons to adjourn the Devine Liturgy it is has not reached the Great Entrance yet: attack by enemies, collapse of the church building, a complete exhaustion of the priest who has suddenly fallen ill, and need to hear to confession and give communion to a Christian dying in the neighbourhood. In the latter case, the parishioners must wait for the priest to return from his duties and meanwhile read prayers or homilies. Having returned the priest will proceed with the worship, but has he to stay long with the dying, the Liturgy will be postponed till the next day. From this we should conclude that the price of time of the passing away person exceeds the aggregate value of time of all other parishioners, according to the Church; the situation of the dying person is more significant than that of the living.

Currently medicine is developing a special field, palliative aid to hopeless patients. This started in the West, we caught it up here. Palliative care is care that improves the quality of life of patients and their families facing life-threatening illness. Particular attention is given to the prevention, assessment, and treatment of pain and other symptoms, and to the provision of psychological, emotional and spiritual support, according to the World Health Organisation's definition. Church experience of servicing those who suffer from incurable diseases turned out to be of demand; medical institutions invite church people, both the clergy and the laity, to contribute to palliative care.

Time has come to explain who is writing this article, why and for whom. The author of the article - an Orthodox spiritual father - wants to share his thoughts about palliative care for the HIV positive at the last terminal stage of their disease with the laity who begin to care for such patients at hospices and hospitals. I have served as priest to the dying, I have experience of communication and communal life with HIV-positive young people at the parish, although I have never attended the demise of people dying of AIDS; there are few people in our country yet who have got such experience.

We have annual statistics on the number of young people infected with the immunodeficiency virus, we know how the disease develops, for these reasons soon we should expect a growing number of patients close to the terminal stage and should think what kind of help these young people leaving this life will need. Before one begins to work with patients dying of AIDS, he/she should understand that there is nothing new about this, that this is not an unparalleled event. Simply something that used to happen very rarely will begin to occur more often. Nearly every case will be a combination of three factors: the dying person is young or very young, s/he has a very eclectic and crippled worldview, and s/he is under the pressure of stigmatization and rejection. I shall consider them one by one starting with the latter.

It is no secret that HIV/AIDS in this country spreads primarily among drug addicts, among men of non-traditional sexual orientation and people with random intimate relationships. There are very few cases when people got infected in a different way. For the time being the general public is becoming indulgent only to the dissoluteness of the young under the pressure of the mass media; drug addiction and homosexuality is still unambiguously rejected by the overwhelming majority of people. Church people regard both drug addiction and all kinds of whoredom as a deadly sin. Can you imagine how difficult it must be for a young person to disclose his/her HIV-positive status, especially with the account of groundless fears and numerous stories on the level of contagiosity of the disease? No wonder that even some parents are not aware that their child is infected with HIV. There have been instances when fathers or mothers, having learnt about their children's disease, closed their door to them. The infected people are fully aware of their situation, confined their bitter secret in a limited number of very trusted people, even losing some of these few, and experience strong psychological pressure.

A few HIV infected begin to attend church, churching gradually. The Church teaches not to disdain repenting sinners. The sin that was left in the past and lamented gives no ground for the others to treat the person with animosity or reject him. The Church Tradition teaches us to treat people enthralled by a sinful habit with mercy. However the reality is that the attitude of church people is quite negative even to those HIV-positive who seek God; it does not differ much from the attitude these people get in a non-church environment. The process of relaxing stigmatization is very slow.

What can be done to improve the attitude of church people to people with HIV/AIDS? It is the HIV-positive who should initiate the process. I may advise them to inform the priest about their disease during a confession. First, it is safe, since spiritual fathers are mainly wise men and are obliged to keep the confidentiality of the confession. Second, this knowledge will help the priest to assess more objectively the penitent's life situation and give a more precise piece of advice, if necessary. Third, the spiritual father thus learns that there is an HIV-positive among his parishioners. When the priest hears such confession for a second or third time, he will realize that time has come to create an atmosphere of a sympathetic attitude to the HIV-positive in his parish, that problems of these people are becoming part of his life and the life of his flock. From now on he cannot think that such people are of no direct concern to him. The Gospel teaches us a merciful treatment of the neighbour, so it will not be difficult for the priest to correct his flock's erroneous opinion on people with HIV/AIDS, if he discovers it.

The HIV-infected with a living faith will be a rare phenomenon in a hospital or hospice. It is clear what will constitute medical, psychological and spiritual help for them rendered by church people with medical education. This kind of patients and medical workers worship one God, 'speak one language' and follow one system of moral values. It is easy for them to understand each other and communicate. The causes, that had lead the patient to infection, were left in the past and lamented. Problems with unchurched patients will be qualitatively different. Often they are atheists, with little education, socially rejected, spiritually 'educated' within youth sub-culture (anti-Christian in its nature) or in a criminal milieu; they are unrepentant and angry with the whole world. People like this will make up the majority of HIV positive patients that need medical care. In early years the infected people came nearly exclusively from the midst of drag takers (it has been only lately that the share of sexually infected patients began to grow). These 'former' drug addicts (who usually have failed to give up drugs) have a whole bunch of diseases against the background of fading away immunity; their parents or relatives who have had a lot of trouble with them will try to place them under doctors' care so that the latter see these wretched off to the grave.

The problem starts with mutual disliking and aversion. Patients with a long record of drug addiction have learnt to look at others from the point of whether this person can be helpful in providing money for another dose or not. Their attitude to the rest of the world is quite aggressive, distrustful and quite often ironical (cynical), and always tend to use people. HIV has only aggravated their alienation from people. They are very unattractive as people. Medical workers can be prone to alienation for some other reasons. For instance, they can be under the influence of a widely spread stereotype about drug addicts, which represents the lovers of getting high in the worst possible light. The temptation is to immediately share the opinion of their family who have got tired of them, 'Let God take the freak away the sooner the better' (as if they had a seat booked for them in the Heavens). However medical code of ethics, say nothing about Christian ethics, forbids to hurry anybody to go hence into the other world.

How are we to avoid the temptation? The Holy Scriptures read, "Prepare yourself and be not confused". What did the person expect, when s/he took the decision to attend the dying? Was it that every dying person will be a fine-looking righteous man? The righteous die surrounded by relatives, friends or disciples; it is the most whimsical, disobedient, resentful and unmanageable patients that relatives try to leave at hospitals. This is what we should prepare ourselves for. In this regard the HIV positive do not differ much from the rest. The terrifying tall tale about drug addicts does not reflect the whole reality. The general public sees them as villains, but most often it is they who have become pitiful victims of true villains that have made a handsome fortune on their drama. These poor young people come to the end with crippled bodies, hearts and spirit. They have ruined their temporary life and are losing the last chance to enter the eternal life. The majority of them regret the first, but very few of them every think about the second, which is more important. They sowed chaos and destruction, and have harvested the bitterest fruit for themselves. So we should extinguish anger against them with compassion and should cover aversion with mercy, with God's help. And we would better make up our minds to this in advance.

Christian attitude to death is not simple. St Basil the Great and other Christian thinkers of the antiquity echoed with Plato who believed that 'the contemplation of death' is the climax of true human philosophy. Death is the worst curse of humanity. It is the limit of alienation from God and the extreme level of humility and disfiguration of a human being. Death is the true measure and the last test not only for man himself, but also for all his deeds and virtues. The awareness of death and mortality leaves its mark on the whole system of human values: everything and anything that sooner or later will fall a prey to death, insatiable and voracious, is senseless. However strange it may be, but this horrifying image of death has the other side. We may perceive the expression of God's love of mankind in death. Having allowed death, God stops life in perishability and stagnation; He aims the sting of death at perishability and at its cause, i.e. sin, thus limiting decay and sin. God allowed death so that 'evil did not become immortal', according to St Gregory the Theologian. A temporary human death abolishes an eternal death, a poison becomes a remedy, a wound - the source of healing. Death rocks to the foundation all human values and thus awakes the quest for true values, eternal Truth and unquenchable light. Thus death educates and what is more important makes us vigilant and wakes us up from 'deep slumber' (metropolitan Amphilochius (Radovich), Educational Meaning of Death).

The lack of a holistic, deep and tradition based worldview is another characteristic feature of the HIV-positive. The coming of the end makes them realize the situation: it is impossible to laugh the problem off and ignore it light-heartedly, like it was possible quite recently; death makes them think about itself. How do we bring these young people to the thesaurus of the religious wisdom? How do we help them to accept the answers received through Devine vision? How do we encourage their reconciliation with the Saviour? It has become unnecessary already to analyze or criticize their system of values: it fails to respond to the challenge posed by suffering and death.

And here we may yield to the temptation to 'propagandize' Orthodoxy among those who are about to depart from this life. The motivation is quite clear: these people risk losing their eternal life together with their temporary one if they stay outside Church till the very end. A believer cannot stay indifferent to the ultimate lot of his neighbour. Unfortunately attempts to solve the problem in a straightforward manner do not lead to expected results. What are the peculiarities of missionary work among hopeless patients at a hospice or hospital? First, these patients are and will be to the very end at the mercy of medical workers who begin to preach their own worldview to them. This evangelistic effort is not quite testimony among free and independent people. The patients may perceive it as pressure (and they will not be quite wrong), and pressure in the issues of conscience, worldview and choice of faith usually cause negative reaction: the person begins to resist the pressure as it is without any desire to understand what s/he is being told. The rejection of 'the form' leads to the rejection of 'the content'. What is worse, the patient may begin to play the hypocrite eager to stay in good relations with the staff, he echoes, takes books and may even agree to see a priest, but deep in his heart he experiences additional discomfort because of his cowardice. It is a known fact that grace always considers the person's free self-determination unlike unreasonably zealous preachers and stays idle in hypocrites. Second, these people have a long record of drug addiction. Looking for drugs they have flawlessly learnt to identify those whom they can milk for cash for a dose, they have become perfect liars and hypocrites. As soon as the patients see that they will be able to get some 'benefits' or a more sympathetic attitude of the staff for the imitation of churching, they will have no second thought about using this opportunity. This is so, especially if they see a potential possibility to cadge an additional dose of a soporific or a bigger dose of a narcotic analgesic. The staff should not fall into this trap. Third, on the threshold of death man begins to live more through his heart, everything around him becomes of no interest, everything that is directly related to him is felt very deeply. For this reason the Good News should come to that man through his heart rather than through his mind which keeps losing its command over the person. I should elaborate on this idea.

The mismatch of man's spiritual forces, his mind, will and heart, is one of the consequences of the Fall. Our mind tends to isolate itself in itself though it cannot get completely detached from our heart. The mind and the heart have different functions: the mind states and the heart assesses. In an everyday life of an ordinary man his mind lives its own life according to the rules established by the academic education system and constantly justifies the existing social norms; his heart lives its own life guided by a different logic. Suffering makes the mind and the heart reunite and restore the lost integrity of the cognition process where the intellectual ability to see and the illumination of the heart are equally important. The majority of people find God through suffering for exactly this reason. The suffering person leaves the rational academic type of cognition implanted in us through education, but not peculiar to us originally, and returns to the personal type of cognition. Man, being a person, as if enters a personal dialogue with nature personified by him and with other human persons (be that with love or hatred); he begins to talk with God. Like beck in his childhood, man may begin to talk with dolls (it is a known fact that some hospices use doll therapy). The dying man suffers in all aspects, physically, psychically and spiritually.

Those who preach a man loving God should show the person who suffers, that there is kindness and love of men, and they should begin from themselves. The infirm are like children in their perception of people around. Children pay more attention to what their parents do, rather than to what their parents say since they do not quite follow the adults' speech. Both the infirm and children are very responsive to kindness and attention and they refuse to conceive what angry men and women tell them. To reach the conscience of a suffering man you should first reach his heart.

Here is an example from a priest's experience. Following the blessing of her spiritual father a Christian woman Alexandra came to visit a young hieromonk from the neighbouring region. Three days after her arrival she had cerebral haemorrhage. Her state after the stroke was not bad, but she was strictly to observe confinement to bed. She stayed in a separate room in the priest's house; some parishioners took care of her round the clock. The woman asked not to inform her daughter about the incident, especially because she was not a church person and reacted quite aggressively to her mother's ecclesiastic life. Since it was not her first long pilgrimage, her daughter's family supposedly should not have got worried by her long absence. Unfortunately the sick woman did not want to burden her nurses with requests and violated rest cure. She felt a bit better and decided to go to toilet on her own. As a result she had another stroke, a fatal one. Soon after that she lost conscience and remained like that for eight days, till her death. The parishioners continued to take care of Alexandra; her daughter was urgently called for. One hour after her arrival all the women came up to the priest and said that they considered themselves free of the duty since the daughter had come. All of them looked hurt. The daughter said nothing to the priest, but the very first minute the women stayed with her they heard what she thought about her silly mother, crazy believers, about priests and God who had permitted all that. The priest said he would not accept that resignation and asked the women to be understanding since that are also daughters of Eve and they know how unjust a woman can be when she is embittered by grief. He reminded that they were Christians, hence should overlook the offence, and that they should continue taking care of helpless Alexandra and her poor daughter and give them every possible kindness and compassion. So the women proceeded with their care. A day after the daughter was no longer angry with them and began to talk normally; in three or four days she treated them as relatives. The mother died. The women undertook to draw all necessary documents, find a coffin and a car to take the daughter and her mother's body to their native town. The daughter was quiet; she had dramatically changed in the atmosphere of compassionate love. At the farewell dinner on the eve of the departure she said smiling, "I feel so well here. I don't even remember when I felt so happy for the last time". Her eyes proved her sincerity. The coffin with her mother's body was in the room next door. Just before her mother died and up until her departure she began to ask for instruction in prayer, ask about going to the church, about fasts and Sacraments. She accepted everything with trust. The priest saw that that was the best way of coming to Church.

Such an approach to churching is the most acceptable for ministry at a hospice. The person should try to open his own heart when he tries to make way to the patient's heart. Communication at the heart level does not accept any slyness, or a hint of hypocrisy, or a white lie. Beware that 'a small lie produces great distrust', while the staff, on the contrary, should gain the patient's genuine trust for his own sake. If you fail to find proper words or cannot say the truth in reply to the question, you would better say nothing. When people begin to perceive others sincerely they become unusually sagacious and capable of perceiving the slightest moves of the other man's heart when he is opening it. Suffering makes this ability more acute. Any insincerity becomes evident.

What topics may raise during confiding conversations and which of them are most important? About death. About the sense of life and suffering. About different objects of faith, i.e. the beyond, God, way to salvation, importance of church life to man, etc. The patient may tell about his religious experience, usually very little one, and ask to interpret it. He may tell what precluded him from faith. He may ask about repentance, its meaning and how to get prepared for it. About prayer, etc. It is advisable not only to understand the question asked and know the topic, but be clear why the patient has raised this issue and why it is important for him.

Now a little bit on the sense of life. The Scriptures read that God "chose us in Him before the creation of the world" (Eph. 1:4). He had a special ideal and a special dream about each of us. Earthly parents also dream about their children, but their dreams are often quite groundless. We cannot say this about God's plans, for potentially man is provided with everything necessary to implement the Creator's dream about him with God's help, so that the man 'comes about': being created in the image he would turn in the likeness. Unfortunately the error of the first human couple distorted the cosmos, the image of man's birth and being changed, and suffering and death came into this world. However God's ultimate plan about each person born to this world has remained unchanged. The accomplishment of God's eternal dream about any son or daughter of man is the reason why they came into life, and the ultimate sense of life for them. No person can imagine anything more sublime or deeper about himself and for himself. Since God's plan about each man is special and unique, each person has his own the sense of life and own vocation. Naturally, ascension to ultimate perfection will continue in the eternity of the Heavenly Kingdom, but some initial steps that determine the very possibility of entering this Kingdom should be taken by man within the boundaries of this dramatically spoilt world, doomed for destruction. God grants initial conditions of existence for each man in this fallen world, and these conditions determine man's fate to a great extent: we are born at a certain time, in a certain country and to certain parents. This is the starting point for our self-actualization.

Perhaps it is not unnecessary to warn those who tend to fall into the thick of philosophy when talking to a patient. A conversation with the patient who is close to transiting from this life to the next should not be limited to theorizing: it is not the strength of mind and clear reasoning that are necessary here, but heartfelt tactfulness and compassionate attention. Whenever the patient begins to talk about the sense of life you should switch to a talk about his life and not the sense of life in general. The man who has just a few months left wants us to help him assess his life, tries to find sense in his fate and attempts to penetrate the concealed meaning of what has happened to him. The man shows you enormous trust when he invites you to this conversation. I shall repeat that each person has his own sense of life, which he does not make up but comprehends with a more or less degree of sagacity. It is only he himself who can truly comprehend it. Others may be not more than his assistants in this quest. It helps if his assistants think about their own sense of existence.

Any activity which meaning is not clear for the person is difficult for him. It is much more distressing to suffer without understanding its purpose. Even minor hardships may cause grumble and complain. However if the sufferer discovers sense in his sorrows then he will be able to astonish others by his firmness and patience. Christianity give an irrefragable answer to the meaning and purpose of suffering; but it is not always easy to accept it: good news about the cross seems cruel to the sons of this age, who were brought up by European hedonistic civilization. It nay be easier to understand the ecclesiastic answer rather than resign to it and accept. Those who have humbled themselves receive help (strength) from above - they penetrate into the mystery of suffering and consciously accept their cross; this fortifies the man spiritually during the time of 'sorrowful visit' and helps him pass the test with dignity. For this reason it is more important to help the patient conceive his suffering than supply him with good analgesics (which the Church has nothing against). Any conversation about suffering should develop very cautiously with close observation of the interlocutor's emotions. It is easy to hurt the neighbour even in the attempt to help him. The cross is a spiritual weapon, and any weapon should be treated with care. Better give examples if you feel that you are not in full command of the topic. Specific examples are always necessary. It is not advisable to take them from the lives of saints, because even heroes look quite weak against the background of ascetics and martyrs, and deeds of saints will hardly inspire patients who are a feeble spirit. Listening to a story about saints people will simply think, "well, they are saints, they are totally different from us, they are not us". And there will be some who will perceive the stories about saints as fairy tales and will tell nothing to the story-teller not to offend him. Without any comment I shall share three testimonies about endured suffering. I shall retell the first one in my own words.

The story from Eugenie Poselianin's book Heavenly Flowers of the Russian Land tells about an ascetic of the 19th century. It was a pious woman who followed the evangelic commandment and visited prisoners. She talked with them on soul saving topics, read and handed out books, helped with things and sometimes fulfilled their requests outside the prison. There was one man among the prisoners who was convicted for a murder. He never participated in conversation: every time the woman would come, he would turn on his bed to face the wall and would stay like this until she left. He was chained to the wall with irons to limit his movements even in the ward. After the death verdict the man was transferred to a solitary cell till the time of execution. That woman came to him some time after on his request. He confessed that had pretended he had not been listening to her; in fact he had been very attentive to everything she had been saying. She had inspired sincere trust in him. Then he asked to explain a dream, which had impressed him. He saw himself sitting in a forest swamp, looking horrible, all in rags; he was black all over except for his feet, which were white and clean. The convict thought that the dream was sent to him from above and that was some message for him, which he could not understand. He was sure the woman could interpret it. The righteous woman was aware of the responsibility and answered what she felt by her heart. Following the truth of God the murderer was to be excommunicated forever and sent for eternal suffering for his sins; only his white feet were to avoid that lot because put in irons they had suffered more than any other part of his body. Having thought for a while the man said that it had been suggested that he should appeal for pardon and there was much certainty that his death sentence would be altered. But he would not forward the petition: he would be freed of eternal suffering through his voluntary acceptance of death. The woman decided against talking him out of that, though she wished he stayed alive with all her heart.

Another story is from Psychotherapeutic Experiences in a Concentration Camp by Victor Frankl. Frankl spent several years in Nazi camps. He mentions his friend in the book who "concluded a 'covenant' with the heavens at the very beginning of his life in the concentration camp: let all his sufferings and his death become the price he paid so that the death of his beloved person be instant and painless. His suffering and death stopped being senseless to him, they were filled with deep sense. It is true, he did not want to suffer and die for in vain. None of us wants this!"

The last story comes from Alexander Solzhenitsyn's Archipelago GULAG. Osorgin "was denounced, cast into a punishment cell and condemned to death. On that very day his young wife (he himself was under forty) came to the quayside at Solovki. Osorgin pleaded with his jailers: don't spoil my wife's meeting with me! He promised that he would not let her stay for more than three days, and immediately she left they could kill him. They agreed. For three days he was with his wife, and, exercising supreme self-control, did not let her guess what awaited him. Not by a word, not even by the tone of his voice. And not by the expression of his eyes. Only once (his wife is alive and recalls it now), when they were walking along Holy Lake, she turned and saw her husband clutching his head in torment. 'What's the matter with you?' 'It's nothing,' he immediately explained. She could still stay, but he asked her to leave. The time came to part. <…> When the steamer left the quayside, Osorgin let his head fall. Ten minutes later he had already put on other clothes for the shooting".

Here are some more thoughts on a correct attitude to pain. Let us remember the Orthodox icon of Our Lord's Transfiguration. We the chosen apostles in it who are down of the ground; their faces are clearly twisted with strong pain. Along with that we hear a commentary to this situation from the Gospel, "Peter said to Jesus, "Lord, it is good for us to be here" (Matt. 17:4). How should we understand this? Should we not believe our own eyes? Let us read the beatitudes then applying our common everyday sense. What do they assert? Blessed are those who have realized their complete spiritual failure; blessed are those who mourn from morning till night; blessed are those who decided not to stand up for themselves; blessed are those who hunger and thirst for righteousness; blessed are those who cannot turn a blind eye on another man's sorrow; blessed are the pure in heart when everyone around wrap themselves in lies; blessed are those who put an end to the fight between intimate friends; blessed are those who are persecuted because of righteousness; blessed are those who are tortured and killed for their faithfulness to God. Felicity of these people is comprehensible to very few of those to whom the mystery of the cross has been opened, but it is clear to everybody and anybody that the beatitudes - from the first to the last one - are filled with pain. There are very few who would wish such happiness for themselves. However there are those who wish this. "I have come to love suffering", said sainted hierarch, surgeon Luke Voino-Yasenetsky. This is not a confession of a masochist, but the testimony of the person who has found the true way.

Let us read through the beatitudes once again, but with different 'inner' eyes. A zealot has realized his complete spiritual failure. It is very painful to see clearly one's own moral poverty, it is torturous to remain in such a state. However when the man plunges in this pain, he immediately begins to feel the touch of God. The coming of God, his felt proximity is an EVENT for any person. The relationship between the creature and the Creator becomes qualitatively different. However no sooner the man has lost his blessed pain and accepted the idea of being no worse than others (or maybe even better since he was granted a 'meeting' with the Lord), when he feels deserted until this pain returns and another meeting with the Saviour takes place. "Blessed are the poor in spirit, for theirs is the Kingdom of Heaven" (Matt. 5:3). To have this access to God the zealot aspires to make this pain of spiritual poverty persistent. This is what the great ascetic culture is about. To clarify the point I shall give an example. The staretz archimandrite Sophrony (Sakharov) with some monks from his monastery visited a man dying of cancer. The man was not a believer, but he had agreed to his relatives' request to see a priest. Father Sophrony said to him, "We know you have no faith. We demand nothing. We shall lay our hands on your head and pray about your recovery and we shall ask God for you. But we are not wonderworkers, we can promise nothing". When the fathers took off their hands after a long prayer everyone saw that the man was crying. The staretz began to comfort him, "We all understand that you are suffering and that you are afraid of death…" But the man stopped him saying, "I'm crying because of a completely different reason. I have felt God for the first time in my life. Pain and death have become insignificant".

You can go to confession for five, ten or thirty years and confess one and the same sins with no subsequent improvement. This will go till once you get pierced with pain for your spiritual deformity and feel shame for your ugly life. This will become the starting point for a real reform, for the purification of your soul from dirt and for the transfiguration of your life. If pain disappears - transfiguration will come to a holt. "O, Lord! Grant me pain about my sins!" We should accept that this pain is a locomotive that drives us in the eternal life. "We must go through many hardships to enter the Kingdom of God" (Act 14:22). We should stop fearing pain; we should fear that we may not reach the destination.

What should we avoid in conversations with terminally ill patients? We should not continuously hint on a possibility of his miraculous healing if he develops faith to God and after some rites have been churched on him. This is strong a bait for the patient, but a very crude move from the missionary point of view. It does not matter for the man who wants to live and who has no religious convictions, who will be invited to him - a priest or a shaman - given a chance to survive. Nominally he will do everything anything he is asked to do, and this will look quite presentable. However the desire to live longer is not the desire to live eternally. The yearn for a miracle (especially the miracle of own recovery) is not the yearn for God. There will be no miracle, both the missioner and the 'converted' patient will feel a bit awkward and ashamed - one for the tempting hint (not promise!), the other for cowardice (and it will be even worse if he does not feel ashamed). Such 'faith' will vanish before the patient dies. Thoughtful observers will be very disappointed, especially in the Orthodox people. If they ever decide to become reconciled with God, they will do this most probably without their mediation and without Church.

What should we do if the patient has not opened himself in spite of all our care, if he has given no chance of an intimate talk about God and died without repentance? Well, that has been his choice, his free self-determination. Even God yields to man's freedom. We should learn to treat this greatest gift of the Creator with seriousness both in ourselves and in our neighbours. We can only take console in the fact that some patients will develop more trust in the Orthodox staff of the hospital if they see that the Christians unselfishly care for unrepentant patients till their last breath. The staff themselves will succeed in mercy.

Let us hope, nevertheless, that open-hearted relations will develop. Should we hint on something very important to the patient in this case? Regarding what he must do, for instance. I believe, yes. He must properly say good-bye to those who stay. How? We find the answer in Fyodor Dostoyevsky's Idiot. Hippolyte is an intelligent youth of seventeen dying of consumption. He is angry with the entire world and cannot accept his lot. It is Hippolyte's last conversation with prince Myshkin in private. The prince is about to merry Aglaya Epanchina whom Hippolyte is in love with without reciprocity. At the end of his talk with the prince Hippolyte challenges him asking, "Look here - before you go, just give me your opinion: how do you think I ought to die, now? I mean--the best, the most virtuous way? Tell me!" "You should pass us by and forgive us our happiness," said the prince in a low voice" (Idiot by Fyodor Dostoyevsky. Translation by Eva Martin). Hippolyte laughed in return, though the prince's answer is very deep and precise. It is Dostoyevsky's answer.

A fatally ill person's kin have resigned themselves to the fact of his departure while is fading away. This happens nearly always, no matter what kind of person he has been, even a righteous man. If an incorrigible sinner is dying, his relatives, having forgiven him all his former mean tricks, are usually looking for the earliest possible end, without saying this aloud. They sigh if death is slow to come (Hippolyte was right when he perceived that but was wrong in his reaction: he felt angry). When leaving we should leave quietly with the understanding that our source of life has dried up whereas life continues for the rest, people want to live and be happy. Without us. We are not part of their future plans. We should not only forgive them their happiness, but bless them from the bottom of our hearts to be happy. Let this not happen against the will of the dying man, since this will happen in any case. When the dying fears 'they will not survive my death', why does not anybody try to convince him to the contrary? It is not difficult to do this. However he does not want to accept this. His visitors feel that the more they will try to prove the contrary the less they will comfort the patient. It is distressful to visit the patient who remains captured by egoism till the last moment.

Why do we ask God's blessing through a priest? This means that we are not going to implement our plan against God's will for us, that we do not try to settle everything in secret from Him, but on the contrary, we ask for His supervision at all stages, for His immediate involvement and help. God enters our life through the blessing without limiting out freedom; He partakes in it. A priest's blessing binds us and God together, according to the power 'to bind and loose' given by God Himself to the clergy. "I tell you the truth, whatever you bind on earth will be bound in heaven, an d whatever you loose on earth will be loosed in heaven" (Matt. 18:18). Success of our plan is not the main thing, though if God agreed to help us the chances of a favourable outcome become much higher. Sometimes, however, God decides to impede our plans, for our own good. No matter what happens then, what matters is that God is with us. This is the purpose of getting a blessing.

He who blesses remains in the life of the one he blessed, even if he if not God. The Creator has planned for and made it possible for people to stay together at a much deeper level than it is commonly believed. Love and blessing create this togetherness, hate and curse destroy it. Even death cannot break the link that unites those who love each other. On the other hand, even God Himself cannot help those who have broken with the rest. Why is there no remembrance of those who died in animosity to God? Why are people not allowed to partake in the Sacraments if they justify their hatred to others? It is not because God and the Church wish them bad, but because they will not be able to accept help anyway since they have disconnected themselves from everybody. It is impossible to help them. Their choice terrifies by its despair. There is hope to alter the situation before death; there is no hope for this after death, there is no repentance after death. Those who entered the beyond in peace and repentance continue to live in those whom they used to love. For this reason, when the living gives alms and work good deeds in his memory, the dead person mysteriously participates in these acts of charity and benefits from them.

Believers know all this. It is only necessary to find a way of prompting to a fatally ill person how to bless life and happiness of those who stay behind. This is much more important for him than for those who stay. They will manage to arrange their life even without his blessing, but what will that person experience in afterlife if he withdraws into himself? Dostoyevsky described a blessed end of a young man in the Karamazov Brothers. The staretz Zosima tells about the death of his elder brother Markel to his disciples on the last day of his life. Markel, like Hippolyte, is seventeen and has contracted consumption. Markel has lost his faith after he talked to an exiled free-thinker. He spends the first stage of his galloping disease in anger and without faith. Faith will return to him later, but he will not be getting up by that time. "That's how I remember him sitting, sweet and gentle, smiling, his face bright and joyous, in spite of his illness. A marvellous change passed over him, his spirit seemed transformed". Then the elder remembered Markel's words addressed to his mother, "Don't cry, mother, life is paradise, and we are all in paradise, but we won't see it; if we would, we should have heaven on earth the next day." Everyone wondered at his words, he spoke so strangely and positively; we were all touched and wept. "Mother, little heart of mine," he said "my joy, believe me, everyone is really responsible to all men for all men and for everything. I don't know how to explain it to you, but I feel it is so, painfully even." So he would get up every day, more and more sweet and joyous and full of love". Zosima also remembers the blessing his elder brother had given him, "It was a bright evening, the sun was setting, and the whole room was lighted up. He beckoned me, and I went up to him. He put his hands on my shoulders and looked into my face tenderly, lovingly; he said nothing for a minute, only looked at me like that. "Well," he said, "run and play now, enjoy life for me too." I went out then and ran to play. And many times in my life afterwards I remembered even with tears how he told me to enjoy life for him too. <…> He died the third week after Easter. He was fully conscious though he could not talk; up to his last hour he did not change. He looked happy, his eyes beamed and sought us, he smiled at us, beckoned us. There was a great deal of talk even in the town about his death". (The Karamazov Brothers by Fyodor Dostoyevsky. Translation by Constance Garnett).

In conclusion I would like to say a couple of words about those who have decided to minister to the hopelessly infirm. I have already said that the whole matter may be presented differently by those who are observers and by those who perceive the situation from within. Observers would regard the care for terminal patients abandoned by their kin as a feat of self-denial and a high ministry. But the opinion may change when you consider the situation from within. When you are continuously with people who suffer, who are on the verge of life and death, who cast their farewell glance on their course of life and prepare themselves for their last exam and the main meeting, you begin to realise that it is you whom a great favour has been done to, and you are allowed into the sanctuary. We experience compassion to these people, our hearts converge, and in the final effect we are granted an opportunity to look at the world through their eyes. This is a precious gift. Those who have decided to minister to the dying have found the main pearl in their lives.

Top of the page