Tia Jamir 

A Page from the ICU

One early summer morning around 2:30 am, one of the ICU nurse paged for the chaplain. I reached for the phone and called the ICU nurse. The nurse calmly stated, “Chaplain, we need you here. We are Withdrawing Life Support” (WOLS).” I did not think twice about the matter and rushed up to the floor. Nothing in the call suggested that this page was different to any other WOLS. Yes, these calls are always intense, profound, and challenging but routine nonetheless.

Once inside the room, I can immediately sense that not all is routine here. The nurse who quickly introduces me to the family appeared relieved to see me, more than normal. She quickly leaves the room, and I introduce myself again to the two ladies in the room: Jenny is 25 and Gena is 20. They looked poised, calm, and out of place. (The real names of these two people of all subsequently mentioned in this story have been substituted).

The patient, John, is their father. As it turns out, they have not seen their father in about 20 years. They are here because they are the legal next of kin and legally required to make final decisions for their long estranged Dad. Below is a sampling of our conversations. The visit lasted over 2 hours.

But first, a brief glance at the patient’s medical pathology and what our medical team was up against shows the seriousness of his medical condition.

The patient is a 48-year-old male and initially came to our ED after falling off a ladder. Imaging of the head and spine was negative for acute process. The patient was being held in the ED as he was intoxicated on alcohol and was being watched until he could sober up. He was initially discharged. The patient returned to triage some time later "feeling funny," began reporting feeling bad. The patient soon became apneic and collapsed. The patient was found to be pulseless. CPR was initiated. The patient was intubated and received a shock. Pulse regained and he was initiated on hypothermia protocol. The course was complicated by a witnessed V-fibrillation arrest. His course was complicated by acute respiratory failure with worsening chest x-ray findings as well as increasing oxygen requirements. Given his history of HIV and his immune compromised state, the patient was treated with initially broad-spectrum antibiotics, which were further broadened to IV steroids as well as IV Bactrim when his respiratory status declined further. Pulmonary as well as Infectious Disease followed the patient closely. He required pressor support for septic shock, which was accompanied by worsening renal failure. He was also found to have cirrhosis, likely in the setting of hepatitis C infection as well as chronic alcohol use that was confirmed by his family. He had transaminitis which was thought secondary to ischemic liver from his cardiac arrest.

Chaplain visits with patient’s two daughters:

Chaplain (C): Let me offer you condolences for your circumstances here and I want to assure you that I am here for you as long as you need me.

Jenny (J): Thanks for coming. They say he will not recover and we have some questions for you. And we need your advice.

[Gena nodded in agreement]

C: Sure. How can I help you?

J: This is our dad. We have not seen him for the last 20 years. He abandoned us. Two days ago, we received a call from the hospital informing us of his fatal illness. They were reaching out to us because we are the legal next of kin. And now we need to make his WOLS decision. [I can see the conflicting emotions in their eyes: Pain, sorrow, hope, and anger among other things].

C: Gosh! You two are put in a very tough situation. [They both agreed and nodded looking down at their feet].

J: (softly but with authority said) We want to know whether he can go to heaven or not?

C: I see. Can you tell me a bit about your faith background? What church do you attend?

Gena (G): We are non-denominational. We are Christian.

C: Good. Tell me a bit more about your hope and fear. And about your dad’s background.

J: I think he is a Christian, too!

For about half an hour they talked and I listened about their anger and frustrations. Their questions were simple and profound: “WHY” did he not love us and “abandon” us? “WHAT” did we do wrong? And more importantly they wanted to know, “WHERE” is he going after the WOLS? Heaven?

I find it difficult to discourse about theology and about “life” after life with patients and their families, if I don’t know anything about their background. This is especially true at 3:00 in the morning with two young girls facing this grim reality of death and abandonment, awash with confusion, anger and hope. Through my own discomfort, I managed to stay in fruitful dialog with them. It became clearer to me as I listened to them that they cannot and will not consent to WOLS until they have taken care of their dad’s spiritual needs, or rather his eternal rest was confirmed. I was deeply moved and touched. At the end of a troublesome and in some ways an ugly life, here lies a man with horrible diseases, who has at least two bright and lovely daughters that are genuinely concerned about his eternal destiny. Now, they are looking for some sort of spiritual guidance from the minister, who is practically a stranger. However, this morning, no amount of strangeness or ugliness was going to stop these siblings/daughters from trying to get their estranged dad “saved.”

Gena said, “Do you think he has the ability to confess even now?”

Before, I can answer, Jenny jumped in quickly, saying, “They tell us that they have revived him multiple times. We are hoping and choosing to believe that he saw the other side (meaning heaven and hell). And that Jesus is giving him another opportunity to confess. Do you think he has done that?”

G: We have been praying for him to receive Jesus before we initiate the WOLS.

C: I am really amazed at the two of you. I don’t know how I would respond, if I was in your shoes. [At this, they both smiled].

J: Well, we have two older brothers. One of them wants to come but can’t because of military duty and the other one does not want anything to do with him.

[This was a beautiful moment filled with hope and wonder].

C: I see. And if I am hearing you right, you dad’s repentance is important to you. I don’t have the power to do anything but we can pray together. I do believe in the power of prayer. But before we pray, both of you can speak into your dad’s ears about your wish, comfort, and Jesus. They tell us that “hearing” is the last thing to go from us when we are dying.

At this they both quickly get up and with tears whisper words of forgiveness, and urgings to believe in Jesus. In this intense moment, they were forgiving their father for what he has done to them (abandonment) and in turn interceding for him and begging for forgiveness from the Lord. This moment eclipsed the ugliness of abandonment by the beauty of a place beyond this earthly place, for the daughters.

As requested, we prayed together for God’s mercies and restorative hope for the afterlife. After this, we informed the physician to initiate the WOLS. 

Believing in seeing beauty

In this paper through the case study above, the focus on believing has grown out of the author’s wrestling with the notion of vision and beauty. A holistic perception of patients-as-human beings requires us to embrace such notions as part of treatment. Before wrestling with vision, I confess and see that Christ is the most beautiful thing in the human realm, but it is difficult to perceive this. I often contrast my situation to that situation of the Amish community In particular to the ugly tragedy that transpired on October 2, 2006 in Nickel Mines, Pennsylvania, US. On this fateful day, a Gunman came into an Amish one-room schoolhouse, where he shot and killed five children before committing suicide. This created an ugly scene for the peace loving community and captured the American public attention and worldwide news. The ugliness of the slaughter of the innocent children was transcended by the community’s ability to forgive, almost instantaneously. It appears that the Amish community as a whole seems considerably less susceptible to ugly incidents that scar them because they were accustomed to perceiving beauty and this enabled them both to perceive and to interpret Christianity with grace. They clearly demonstrated the beautiful living.

As a Health Care Chaplain, I am painfully but fruitfully integrating a theological vision, that is, the vision of the beautiful, the vision of the true and the good. Beauty, or in the more sonorous Latin term pulchrum, is the manner in which God’s goodness gives itself and is expressed by God and understood by humanity as the truth. Deprived of beauty, the good is no longer attractive, and so we are not motivated to pursue it. This perceived loss of beauty is ultimately a loss of primal wonder. We no longer respond either to humanity or to the created universe with a sense of awe, and this leads us to embrace matter as a universal metaphysical principle, which ruins our taste for love. Having embraced materialism, humanity becomes sick, inevitably begins regarding each other as mere matter. Spirituality is dropped off by the way side in our pursuit of false beauties. There is a real and imminent danger here. The ethical value of all persons—their inherent dignity—is thereby diminished. This illness implies that aesthetics and ethics are related in important ways: first on the level of moral motivation (we are motivated to purse the good only when it appears to us as beautiful), and second, on the level of moral discernment (the appearance of beauty in a being is a manifestation of its true value and ethical worth). The figure becomes valuable—worthy of being loved—because of its great radiance from within. Most of the time, this beauty becomes visible in some concrete deed or event – say, perhaps, an act of forgiveness, like in the Amish community, or in lives of two daughters where they had confront the ugliness of abandonment. In both of the instances, they mustered a profound sense of gentleness. This is something otherworldly, a sort of a beautiful agony, where the ugliness is peeled away by the beauty of forgiveness. Perhaps, in some ways this is akin to God the Father’s agony in watching his Son slip away at the Cross. 

Re-Visioning: Beauty as transformation

Vision as a discourse inevitably deals with negotiation, communication, and transformation. S. Brent Plate succinctly states that a study of vision has to do with the desire for transformation, for a connection between “how we see and how we live,” and that this is “part of what drives visual culture studies.”[1] Elsewhere, Margaret Miles stipulate that vision is valued “because of its power to move, to focus the senses and mind, and to offer a mnemonic aid that gathers the worshipper’s strongest and most fundamental idea, emotions, and memories in an enriched present.”[2]

In the same way, vision theorists such as John Elkins, have successfully argued that, “Ultimately, seeing alters the thing that is seen and transforms the seer. Seeing is metamorphosis, not mechanism.”[3] Similarly, Hal Foster says, “Although vision suggests sight as a physical operation, and visuality as a social fact, the two are not opposed as nature to culture: vision is social and historical too, and visuality involves the body and the psyche.”[4] Thus, seeing has an active component, and understanding it as such enables one to hear and see their involvement in the creation of identity. Margaret Miles describing such a seeing (religious seeing) says, “Religion is a way of seeing not merely in the figurative sense. Religious “seeing” implies perceiving a quality of the sensible world, a luminosity, a “certain slant of light,” in which other human beings, the natural world, and objects appear in their full beauty, transformed.”[5]

Interestingly, the issues of vision also surface at the crossroads of several current discussions in contemporary moral philosophy. Neo-Aristotelians such as Martha Nussbaum argue that the consequences of discernment and perception in the moral life give life its meaning.[6] However, they fall short in expressing a consensus on how vision is formed and focused and in how a depth of vision is developed. Without this emphasis, an ability to distinguish moral from immoral vision and to discriminate eyes that behold from eyes that devour vanishes. In such a scenario, humanity encounters difficulty discerning what to look at and, more importantly, what to look for. Insightfully, Margaret Miles says, “Theoria, contemplation in which one is lifted out of one’s familiar world and into the living presences of the spiritual world—begins with physical vision, with a trained and concentrated seeing that overcomes conceptual barriers between the visual and the spiritual worlds.”[7] Perhaps, it is helpful to perceive that seeing is associated with the “power to move” to the ones seeing because the act of seeing has transformative power. Specifically, the transformation of sight presupposes a moral purification and begins in the present state when one learns to see Christ through the sick and the broken.

Hospital Chaplaincy and Vision Correction

Ministering to patients has enabled me to see and to begin to restore my vision. Aesthetics and ethics, beauty and goodness, are intimately linked. More importantly, the total dimension of the beautiful always calls for moral decision. Genuine aesthetic apprehension does not end in mystical self-loss; it demands an ethical task. Ultimately, this ethical task is God’s work of creative form, with which human beings concur and assist. In this particular context, assisting humans-as-patients and their loved ones or families inevitably means restoring relationship or forging a new sense of being-in-relationship. As this case demonstrated, by the two daughters through the grace in believe they envisioned healing by means of eternal rest. There was no sign or dramatic event after the daughters spoke but silence from the dying father as well as from the chaplain and the daughters, for a while. The space provided by silence was not out of defeat much less despair but born out of a deep affirmation of life, hope, and stillness in the face of a power actualized through reconciliation and forgiveness.

How can one cultivate such a vision? In the Phaedrus, Plato makes some interesting claims. First, rhetoric should be considered the same as medicine. Second, it is not possible to understand the soul without considering it as a whole, and third, we cannot understand the body without considering the whole.[8] Put a bit differently, just as philosophy only emerges out of dialogue, the same is true of medicine, and that just as philosophy must be holistic, so must medicine. To trace Plato a bit further, he is suggesting that medicine must be soul medicine. Science alone cannot know the whole person. Medicine rightfully belongs to the caring enterprise and this creates a healthy belief system in the value of all human lives. Theologically, silence is the space where God relates to his beloved Christ, in his hour of dire need.

Visualizing the Silence of God in the Hour of Death

As I labor in the house of healing, I am seeing death’s power (or lack of power) in action. For many, death is an unwelcome event. Unfortunately, it appears that medicine reflects this collective notion of death and dying. Perhaps, this is because our social compass does not point to the ancient concept of a good death. As a result death threatens us, since it represents our absolute loneliness, helplessness, and more importantly powerlessness.

Loss and pain, like birth and death are part of life, necessitating care. I am fortunate to be ministering in a house of healing, where “care” is fundamental. What happens is not as important as how one responds to it: resentfully or gracefully. Knowledge of what happens during pain or suffering is provided by both soft and hard sciences, such as psychology or neuroscience. As a confessing believer and as a practicing professional chaplain, I believe in a distinctive perspective of spirituality. This may seem unsettling and archaic but suffering or ugliness does not take the challenge away from attempting to discover God’s Spirit at work and to choose life even in times of trial. When Jesus asks his audience to take up our cross and follow him (Mark 8:34) we are invited to reach out far beyond our broken and sick condition and give shape to a life that animates the great things that are prepared for us. Reflecting on the significance of pastoral care in the face of sickness and suffering draws my mind toward an aspect of the Cross that often goes unnoticed: the silence of God and the crying of Christ. This is not an excuse but the silence of God serves as a deep metaphor of spirituality in the face of grave illness, abandonment, ugliness, brokenness, despair and hope. The crying of Christ serves as a catalyst for our hope and belief. It appears ugliness and beauty is conjoined demanding a response from the seer.

In the final moments of John’s passing, just like so many other deaths, there usually comes a time when I find myself looking to the Cross and in solidarity with the family inevitably cry out to God for help. Visualizing the Cross and in particular, the dying of the healer brings the entire belief into some sort of chaotic calm. For Christians, the Cross is a constant paradox. In the act of perfect obedience to God, Jesus also perplexing experienced the absolute distance and separation from God. Likewise, the nearer we come to God, the more we become “similar” to him, but we also mysteriously see the infinite dissimilarity, as well. Hence, the more we know him, the less we know him. Jesus is at once a creature cursed at the Cross and simultaneously his greatest obedience. Creation curse him, God curses him. He looks to God to counter all the curses, but there is only silence. At Golgotha, at death’s hour, God is silent. How can this be? What kind of a vision this creates? The vital thing, the painful thing, is that there is no answer from the One to whom Christ calls/cries out in the darkness.  “My God, my God, why have you forsaken me?” There is no answer. Perhaps there is no answer because the grief and ugliness is unbearable at the sight (vision) of his beloved son’s final moments. Restoration and forgiveness is painful and priceless.

Conclusion

Context never has a specific meaning. Yet the meaning of a communication is always dependent upon the context. In this pastoral visit, the two daughters, despite early childhood tragic and ugly memories of their biological father, they still were not ready to let him go. At least, not without doing everything they could for his eternal rest. The pathological history of the patient does not simply define the two daughters’ relationship with their dad. Put differently, they are being in relationship with their father. Perhaps, disease is a disruption in right relationship but in this context, this disruption ushered in a right relationship for the daughters. In fact, this disruption surpassed past pain and countered their ugly past with the beauty of forgiveness. This may have been the greatest gift the daughters received from their biological father, as he was passing away. He provided an opportunity for the daughters (and the chaplain) to witness life lived in light of beauty and grace in the grim face of ugliness. Furthermore, healing, as it was in the olden days is still about the restoration-reconciliation of right relationship. The two daughters experienced this ancient and ever important life-affirming gift. To repeat, the terminally ill father/patient played a crucial role in teaching and experiencing hope for restoration even when he was unresponsive and unproductive.

As this case study demonstrated, even when cure is no longer possible, healing (both for the daughters and their dad) is still possible for different reason and outcomes. Both the actors—patient and the daughters—are a healing agent, both consciously and unconsciously.  No matter what the patient’s spiritual and social history shaped by the daughters’ memory of abandonment, terminal illness raised questions about the value and meaning of his life and post-mortem life. These questions are of upmost importance. They are about the stuff of life: meaning, value, and relationship.[9] In his silence, the patient was bestowing a meaningful reflection for the daughters to confront and make peace with their collective ugly past.

Health care seems to be enamored with data. Many well-intentioned people are developing all sorts of scales to measure spirituality and religion in health care. Some of these are useful and have a purpose and a place in the continuum of care. However things get tricky, when one moves into issues of forgiveness, reconciliation, or hope. These are hard to quantify. Despite all the data, measurements, and outcomes upheld efficiently by technological progress, medicine still stands accused of having failed to address itself to the needs of whole persons and preferring to limit its attention to the finitude of human bodies.[10] Yet, when we treat the whole person by including the belief system, we are nurturing our patient and providing them with healing when cure is not possible. Furthermore, this in turn nurtures the provider as well.

In the end, it is in the echo of the silence and crying, I believe that I am firmly in solidarity with my patients in their suffering, chaos, and illness. The two daughters demonstrated that the overwhelming narrative threat is not that of abandonment and ugly memories that brings renewed pain and suffering, but it is in the power of restoration and forgiveness undergirded by a profound belief in the life after death. They were creating and imagining a reality that eclipsed the medical history and perhaps even their troubled social history in the name of their “belief” in resurrection. This is a vision of beauty.

The author’s has a MA in New Testament, along with an MDiv, and a STM in Historical Theology. He is currently completed a PhD in Theological Studies. His interest empowers his passion to serve and care for the patients, clients, staff, stakeholders, and in particular under-represented social groups. He is chaplain at Baylor Health Care System.

[1] S. Brent Plate, Religion, Art, and Visual Culture, New York, Palgrave, 2002, p.9.

[2] Margaret Miles, Image as Insight: Visual Understanding in Western Christianity and Secular Culture, Boston, Beacon Press, 1985, p.9.

[3] James Elkins, The Object Stares Back: On the Nature of Seeing, New York, Simon & Schuster, 1996, p.11-12.

[4] Hal Foster, Vision and Visuality, Seattle, WA, Bay Press, 1988, p.9.

[5] Miles, Image as Insight, p.2.

[6] Martha Nussbaum, Love’s Knowledge: Essays on Philosophy and Literature, New York, Oxford University Press, 1990, p.54-105; 195-219.

[7] Miles, Image as Insight, p.150.

[8] Plato, Phaedrus 270-71.

[9] Daniel P. Sulmasy, “At Wit’s End: Dignity, Forgiveness, and the Care of the Dying,” Journal of General Internal Medicine 16 (2001), p.335-38.

[10] Daniel P. Sulmasy, “Finitude, Freedom, and Suffering,” in Pain Seeking Understanding: Suffering, Medicine, and Faith, ed. Mark J. Hanson and Margaret Mohrman, Cleveland: Pilgrim Press, 1999, p.83-102.