At our annual reunions, my brother and sisters and I often joked that we flew home every year because “this might be Grandpa’s last.” We wanted to be sure to say one final goodbye. The odd thing was, we had been saying this for twenty years. Grandpa just didn’t seem to die. And as the clock ticked on, one of us would occasionally take the gamble and skip a year. It didn’t seem to matter; he was always alive the next.
Norman Alois Ulrich, my mother’s father, was the family patriarch—a tall, opinionated man with an arch sense of humor. He was the son of a cook and a sign painter. A World War II bomber pilot, he belonged to that generation that permitted men to rule their homes with strong fists. But his sternness was always coupled with witty limericks and practical jokes. It made him impossible not to love.
When I was small, a visit to my grandparents in the Chicago suburbs meant two delicacies my parents denied me: Dunkin’ Donuts and television. Grandpa and Grandma spoiled us in other, better ways, too. Grandma encouraged love of God, languages, and travel. Grandpa, an accomplished artist, provided us with an endless supply of paper and paints. And he let us help tend their small garden plot of tomatoes and peonies. Once he bit the flower off a peony to make a point, although I have forgotten what it was. This was the stuff of childhood.
As I grew older and left home, I began to learn more about this magnanimous man. While he was in flight school, his plane malfunctioned during takeoff and was rear-ended by another plane. His instructor, in the back seat, was beheaded. Grandpa, unconscious for nearly four days, sustained a crushed pelvis, fractured back, and head injuries requiring a hundred stitches and seven new teeth. After three and a half months in the infirmary, he was to be discharged home, but he requested to return to flight training. Permission granted, Grandpa was awarded the rank of second lieutenant, put in command of a Boeing B-17 Flying Fortress, and received his Pilot Wings. The crew called him “Sir.” He was twenty-two years old.
The stories hinted that Grandpa would never die. In May of 1944, while he was flying over Germany with the 334th Squadron of the 95th Bombardment Group, a German fighter strafed his aircraft. Bullets disabled the instruments, damaged one engine, and blew up the left waist gunner’s weapon. With two crew members unconscious, they collectively decided not to bail. As Grandpa attempted to pilot the plane to a neutral territory, he was approached by two German fighters. He lowered his landing gear to signal surrender and the fighter pilots, instead of killing ten men, allowed him to land in a potato field in Packebusch, Germany. Pilot and crew survived, only to be taken as prisoners of war.
Grandpa continued to thwart death while imprisoned at Stalag Luft III, a camp southeast of Berlin, in what is now Poland. It was the same camp from which seventy-six men had successfully escaped just two months prior, made famous by the film The Great Escape. At the camp, tensions were high and treatment severe. Despite being nominated as cook—best known for a breakfast cereal he concocted out of otherwise inedible bread crusts—Grandpa, and his comrades, often went hungry for lack of food.
During the early months of 1945, reportedly the coldest winter on record, the prisoners were forcibly marched from the camp, across Poland and Germany. Their Red Cross parcels intercepted, the soldiers grew hungry, cold, and sick. Grandpa’s flight jacket had been a trophy for the Germans who had shot him down. He survived that winter by huddling with a small, hand built cookstove, which he carried with him on the marches. Frostbite would affect him for years to come.
Grandpa was liberated by General George S. Patton on April 29, 1945, and returned to Chicago to marry my grandmother and build a career as a commercial artist and graphic designer. The war had scarred his body, though, and as the decades passed, his physical pain intensified. The pain medications caused constipation. The constipation caused a different kind of discomfort. And his seven replacement teeth never seemed to stay in his mouth.
If my siblings and I perceived my grandfather to be dying for twenty years, he certainly was not languishing. If anything, he seemed to experience healing even as he was dying. How could this be? The answer depends, in part, on what is meant by healing and what is meant by dying.
Generally speaking, dying is not an acute event. There are, of course, some exceptions. A convict facing the guillotine is not dying. He is alive and living until the split second when the blade passes through his neck. Then he is dead. It makes little sense to speak of such a person as “dying.” In most circumstances, however, people die over a period of time, from minutes to years. Grandpa was dying over decades. He hadn’t received a feared and fatal diagnosis. Rather, he had accumulated several lifetimes’ worth of insults to his body, and these caused such suffering that physical decline always meant a decline unto death. The frankness with which he spoke about his “dying” led us grandchildren to think he was actively dying—for a long, long time.
In contrast, healing, as I will use it, can refer to the physical and to the metaphysical. The Oxford English Dictionary defines it as the “restoration to health.” In turn, “health” can mean “soundness of body” as well as “spiritual, moral, or mental soundness or well-being.” Thus, healing can be understood as the restoration of physical, spiritual, moral, or mental well-being.
It is curious that healing means restoration. Restoration implies the return of a preexisting state of wholeness. Is a baby “healed” of a congenital hole in the heart if he had never known a prior state without such a hole? We might say that the baby is healed, not because he once had a hole-less heart, but because the baby belongs to a kind (that is, human beings) whose healthy hearts do not have such holes. The non-pathological human heart offers a standard for health against which we may assess the baby’s congenital hole.
Attempting to define standards for spiritual or mental health is trickier. Imagine, for example, sitting around a conference table with a group of colleagues at work. Which of them is mentally healthy, and why? This can be a delicate question in the workplace. Who is spiritually healthy, and what does this mean? Is the mentally healthiest also the spiritually healthiest? Does it make any difference if, instead of a conference table at work, the scenario is a church Bible study? Articulating a standard for optimal physical health seems feasible, but setting a standard for mental or spiritual health is, at the least, a lot more complex.
The story of the Garden of Eden describes how defining such standards became complicated. Things start out just fine—the planet was teeming with life. Adam found a companion. Disease did not exist. But then a devilish snake comes along and tempts Eve with Godlike power. She takes the bait and Adam follows. This act leads to the Fall of Man. Different Christian churches nuance this doctrine in different ways, but to take the risk of summarizing broadly, the Fall rendered the human race hopeless—some say “totally depraved.” Its consequence was physical, spiritual, moral, and mental brokenness for all people everywhere.
Only God could heal humanity of such pervasive brokenness. Such a healer had to be God, because no mere mortal could fix the mess initiated in the Garden. But if such a healer were fully and only God, the healer would not understand what it is like to be human. Thus a healer, at once fully God and fully human, is needed to cure people of the disease that plagues all of humanity.
If we are honest with ourselves, we can each identify physical, spiritual, moral, or mental dysfunction in our lives that we can’t seem to fix. All of us have something wrong, whether due to genetics or circumstance. Healing means restoration to well-being, and we are part of a kind—that is, the race of Adam—that did, once upon a time, know physical, spiritual, moral, and mental flourishing. Thus the God-Man Healer—that archetype of the most robust sense of health—suggests that there is hope for us. The question is whether modern medicine leaves room for him.
Conventional Western medical practice does not dwell much on paradox. We physicians pride ourselves on evidence-based guidelines and data-driven treatments. Our patients expect precision, and our technology delivers it. The language we use to describe our aims and successes conjures up images of a military commander, resolutely conquering the enemy. In medicine, death is the ultimate enemy, and we expend much effort to stave it off. This is why we attempt to resuscitate the newly dead and the undeniably dead, why we put everyone on life support the moment any organ begins to fail, and why we offer chemotherapy to patients dying of widely metastatic cancer. Doctors know it’s nearly impossible to resuscitate the definitively dead, that life support cannot finally triumph over death, and that chemotherapy is of no use in advanced, end-stage cancer. But these are the only tricks in the doctor’s tool bag for healing the dying. And they aspire to healing defined solely as physical restoration.
Yet healing is more than physical. It is spiritual, moral, and mental restoration, too. In recent years, hospitals and clinics have acknowledged this, and although the selection of tools in the doctor’s bag hasn’t necessarily expanded in response, healthcare administrators have added mental health counselors, social workers, and chaplains to the healthcare team.
The problem, however, is that mental and spiritual healers face such constraints in their practice that it is nearly impossible to see patients through to spiritual or mental healing. Chaplains, for example, are often beholden to high productivity goals. Because their services do not generate dollars for healthcare facilities, one chaplain can be responsible for an impossible number of patients. In many large hospitals, “spiritual care” amounts to brief daily visits with each of 30 patients in one’s assigned ward. The chaplain might be secretly relieved when a patient is away at a procedure or fast asleep; such occurrences enable the chaplain to keep on schedule. Furthermore, in order to justify their non-revenue-generating presence, chaplains have to document the “care” they provide, which adds a significant administrative burden.
As with other aspects of medicine, chaplain training has become professionalized and standardized. Core competencies must be demonstrated and professional affiliations maintained. I have spoken with chaplains whose jobs were threatened because they acted too much like “priests” and not enough like “professional hospital chaplains.” I have also spoken with chaplains who feel that modern hospitals permit them to offer little more than a superficial, professionally packaged form of generic spiritual care—a far cry from the rigorous work that might lead to spiritual restoration. Mental health and social workers tell similar stories about how the structures of modern medicine limit the depth of work needed to bring about mental and moral healing.
Even if healthcare administrators recognize a role for healing that goes beyond the physical, their adoption of consumer-culture language further impedes the work of healing. As members of the healthcare team, chaplains and social workers have become “providers.” They do not aim to heal patients who suffer spiritually or morally; instead, they provide social and spiritual services to their consumer patients.
Similarly, nurses and doctors are increasingly referred to as “providers.” My patients routinely call me their “PCP” or primary care provider, a gross misrepresentation of my work. I do not strive to provide care to my patients, as if care were a packaged deliverable. I aim to care for them, to suffer alongside them, to heal them. When I am successful in this approach (regardless of outcome), my patients understand me to be a healer. The reality of modern practice is that productivity metrics, professional competencies, and consumer language diminish the supply of healers even as patient demand for healers increases.
Because healthcare systems today wield so much power, healing the dying is only possible with valiant effort. This valiant effort can be on anyone’s part—clinician, patient, or patient’s family or friends. But someone in proximity to the patient must advocate this robust sort of healing. Someone must insist on physical healing when possible, and spiritual, moral, and emotional restoration always.
Furthermore, there must not be any force opposing the work of healing. The most common limiting factor is cultural. Many patients and family members have put all their faith in the medical apparatus as a source for eternal life. They believe that medicine can fix all physical ailments. All too often, physicians think the same way. They have difficulty admitting defeat and surrendering their technology. Often, they find it easier to continue with life support than to inform a patient’s family that the patient is near death. Some doctors avoid talking about death, because they have yet to work out their own beliefs. The result is prolonged suffering and reduced healing.
There are at least three ways that patients, their families, and clinicians can work to heal the dying. The first is to recognize when the offerings of modern medicine are unlikely to help and are more likely to hurt. During the half dozen or so years before my grandfather died, he was periodically rushed to his local hospital after passing out. As the only medical doctor in the family, I suspected that either his blood pressure went too low, or that he had an episodically abnormal heart rhythm. Regardless of the cause, he would always rebound, and I would insist that my grandfather be discharged. The doctors were always reasonable. They recognized that a man in his late eighties was unlikely to benefit from an extensive workup. Discerning the limits of technology takes some knowledge, but motivated family members can certainly engage a patient’s physicians on this point. Doctors often want to have these conversations with patients and their families but are reticent to broach the subject of limiting medical interventions.
A second way to bring healing to the dying is to acknowledge human finitude. It is no secret that all will die. Yet Americans live as though it will not happen. When I became the healthcare decision maker for my grandfather, I had a frank conversation with him and his children about the blessings and burdens of cardiac resuscitation and life-extending technology. I warned them that the hospital was no place for the sick—an elderly person is often likely to become sicker—and that visiting the emergency room for every bout of constipation or lightheadedness would do little to improve the quality (or quantity) of his life. In short, we spoke of finitude—both human and technological. And eventually we decided not to have my grandfather transported to the hospital ever again.
Dying should be a community affair. This is a third way to bring healing to the dying. The community may include immediate family members, neighbors, colleagues, church members, or even members of the healthcare team. The point is that a deeper sort of healing occurs within the confines of community.
If my grandfather was truly dying for twenty years, he experienced healing because he was embraced by a community that hoped for his physical restoration, but even more strongly desired his spiritual, moral, and mental restoration. And in the presence of a community—religious, social, familial—that shared this aim, Norman Ulrich experienced healing that only the Healer could give.
As the years wore on, we all noticed that Grandpa’s bark quieted. His demands became less demanding. I remember my uncle commenting on the conference that he and my grandfather had attended which seemed to have signaled the immense softening of his rough edges. My grandmother later confided, “If it took your grandfather fifty years to become the man he became, it was worth the wait.”
On January 14, 2016, the staff at his senior living home summoned Grandpa’s oldest daughter to his bedside. At the age of ninety-five, after two decades of dying, he had begun breathing like a man who would soon be dead. My aunt phoned her siblings who immediately began to gather. Her own daughter and grandchildren had been visiting, so within the hour, four generations of family had gathered around my grandfather’s bed. The pastor just happened to be in the neighborhood, and he led the family in prayer and song. All of us had long anticipated this day. And as the family lifted their voices in song, my grandmother, his wife of seventy years, held my grandfather’s hand as he sighed contentedly and breathed his last earthly breath.
Lydia Dugdale is a physician at the Yale School of Medicine and editor of the book Dying in the Twenty-First Century: Toward a New Ethical Framework for the Art of Dying Well.