Aged Care Ministry: 3 Challenges and 5 Responses
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I have been a Presbyterian pastor for twenty-five years, the last three of which I was privileged to serve as an aged-care chaplain. I ministered in three Presbyterian nursing homes with a community of 220 residents, some 400 staff, and hundreds of family members. As I wrap up this ministry to return to parish, I want to share both some of the challenges I experienced and some of the solutions to these challenges that became apparent to me over those brief three years.
This is not intended to be a professional or academic paper: I do not engage here with scholarly literature, nor do I intend to tie my thoughts to doctrinal studies. These are simply “lessons learned”—lessons that I hope may assist others who labor in the same ministry.
I lost count over the past three years of how many Christians said to me: “Those old people must be very open to the gospel, as close to death as they are.” It’s a plausible idea, but not at all true to my experience. I did not at all find nursing home residents more open to the gospel, but generally less so than those younger in years with more years of life ahead of them. I begin by describing three challenges to bringing the gospel to the frail elderly, and five possible responses to those challenges. I conclude with a word about how all people serve God, no matter how frail and incapacitated they are.
Challenge One: Fading Senses
Nursing home dining rooms are surprisingly hushed. You might expect to hear happy chatter over a meal, something like the buzz and hum of a college cafeteria. In fact the only people talking are staff serving the meals. This is because the frail elderly find communication challenging and exhausting even in a quiet and cosy tête-à-tête, let alone amidst the din of a bustling dining room.
The first challenge to sharing the gospel with nursing home residents is their damaged communication receptors. A recent study found that:
Eighty percent of eighty-year-olds are hard of hearing. This usually affects their ability to understand what people are saying more than the range of tones they can hear, and they can hear low frequencies better than high frequencies. That’s why people with age-related hearing loss find it particularly difficult to follow conversations in noisy environments.[1]
Eyesight also begins to fail. Many residents are legally blind and almost all find it difficult to read without glasses, or difficult to read the words on a page at all. Even if a resident’s eyesight is strong, they may not have the strength to hold up a book for any length of time.
In any case, it requires energy to take in and comprehend what a person or book is saying; and aged-care residents do not have much energy.
These are the kind of physical hindrances to taking in information that are described in Ecclesiastes 12:
Remember also your Creator in the days of your youth, before the evil days come and the years draw near of which you will say, “I have no pleasure in them”; before the sun and the light and the moon and the stars are darkened and the clouds return after the rain, in the day when the keepers of the house tremble, and the strong men are bent [loss of limb strength], and the grinders cease because they are few [loss of teeth], and those who look through the windows are dimmed [loss of sight], and the doors on the street are shut—when the sound of the grinding is low, and one rises up at the sound of a bird, and all the daughters of song are brought low [loss of hearing]. (Eccl. 12:1-4)
Solomon suggests that we should come to God before our bodies and communication receptors deteriorate and break with age. The fading of the senses is the first challenge to be overcome in aged-care chaplaincy.
Challenge Two: Stoic Adaption
As people age their abilities and functions decrease and their aches and pains increase.
Eyes grow dimmer, ears grow duller, teeth grow fewer. Necks and backs weaken, knee and shoulder joints wear out and need replacing. The digestive system becomes less robust, and people are more susceptible to diarrhea or constipation. Bladder and bowel functions fail, and sanitary pads are required. Swallowing becomes more difficult, and food and drink must be mashed or thickened lest it go down “the wrong way,” causing infection in the lungs. Hearts beat less sturdily, brain function clouds and darkens.
What I have observed, as the parts of people’s bodies begin to weaken and break, is that people adapt. I have watched people adapt from walking sticks to walking frames, and then to wheelchairs, and then to reclining chairs, and then fulltime to their beds. I have watched people adapt from solid food to pureed food to liquid food. People adapt from leaky bladders to complete loss of function. People adapt from having all of their teeth to some teeth to no teeth at all. People adapt to losing their speech, or the loss of control or movement on one side of the body after a stroke. As the body conks out people don’t naturally cry out to God; we just adapt. And the same happens with pain. We learn to cope with the new pain in our neck, back, knees, shoulders, or teeth. We don’t often cry out in prayer. We just take more medication and learn to cope.
The impression I have is that death itself is just one more stage of deterioration to cope with and perhaps not the worst because “you are not there to feel it.” And if people have a vague idea that they will face God and judgment and perhaps even hell, then they expect to adapt and deal with that as well.
Like Camus’ version of Sisyphus, we scrounge meaning in the heroic acceptance of life’s pains and absurd meaninglessness. Back of all lurks groundless hope. Shattered men hope to return to home and work; lonely women hope that families will come and visit; everyone hopes that life after death “will work out, somehow.”
Perhaps if we plunged directly from full health to massive deterioration—such as is experienced in a catastrophic accident—then we might be shocked into crying out. Instead, most people experience creeping normality. We allow the camel of pain to poke his nose into the tent, then his head, then his neck and shoulders, until the whole obnoxious beast is in the tent and we can’t get rid of it. So we just learn to live with bodily disintegration.
When we presume that nursing home residents must be more open to the gospel, we might think that this is because as they begin to lose function, and as they begin to accumulate bodily pains, and as they draw closer to the final breakdown of death, that they will turn more keenly to God for his help in overcoming these disabilities—in some small measure in the short term, and completely at the end of time. But if the Spirit does not move us to repentance, then we just stoically adapt to each downward step of deterioration.
Challenge Three: Hard Hearts
Aging is both distilling and concreting. People seem to grow into more concentrated versions of themselves, and harder versions. As a rule, lewd men grow lewder, crankier women grow crankier. Gentlemen grow more gallant, ladies more considerate. Those who have lived for money, or their ego, or their family, or for widows and orphans, die with the same obsessions.
With the thief of the cross we are shown one deathbed conversion. One deathbed conversion so as not to lose hope, but only one so as not to presume. As a rule, people who have lived without God die without God.
This hardening applies to the realm of ideas. As we age it becomes more difficult to understand a new idea, more difficult still to analyze it, and almost impossible to accept it. Old dogs don’t learn new tricks. A vintage car cannot, like a Tesla, follow satnav directions. A vintage TV cannot display a movie in technicolor and surround sound. Vintage minds and hearts struggle to assimilate and love new ideas. Even if we were religiously and morally neutral it would be extremely difficult to understand—let alone to embrace—something so stupendous and spiritual and counterintuitive as the gospel of grace.
But we are not neutral. Our spirits are as crooked as a medieval alleyway; our hearts are as hostile to God as a Jack Russell Terrier to a shadowy stranger. “The heart is deceitful above all things, and desperately sick; who can understand it?” (Jer. 17:9). We are “futile in our thinking and our foolish hearts are darkened” (Rom. 1:21). We would rather bow before a block of painted wood than to our living Creator. In fact, our hearts are dead to God: we are as capable of responding to God’s voice as a buried corpse to birdsongs in the cemetery garden.
Even if every other gateway—those of hearing, sight, energy, mental capacity, and a willingness and ability to learn new ideas—lay open, our God-hating hearts, dead in our sins and transgressions, seal us off from God like the grave from the living. This for aged-care residents is the third, greatest, and—by nature—invincible barrier to receiving Christ as Savior.
How might a nursing home chaplain respond to challenges such as these?
Response One: Exaggerated Communication
If ears are dull, then we must speak more loudly, slowly, and deliberately. Prior to the twentieth century, actors, politicians, and preachers, lacking public address technology, had to learn to speak from their diaphragms (not their throats), to project, and to enunciate every consonant and vowel. Public speakers had to be loud and powerful, had to cultivate resonant and sonorous tones. (Echoes persist with our present-day Shakespearean actors and archbishops of Canterbury.) We must borrow at least some of these old public-speaking techniques if we are going to be heard by the very elderly.
And if we give the frail-aged things to read, then we must use very large fonts with serifs, which clarify the letters and make it easy for the eye to track across the page. Handouts must be light enough to hold and easy to handle. I produced weekly twelve-page church handout booklets in 24-point Times New Roman font, with distinct pictures on each opening that I could use to help people find their place: “Please turn to page 5; if you can see a kangaroo paw then you know you’re on the right page.”
Similarly, when I play hymns, I play them fortissimo. If the songs sound a little inappropriately loud for the setting, then it is probably about right.
Physical materials must be exaggeratedly loud and clear; but so must the matter. The frail-aged do not have the energy for long addresses, so sermons must be concise. Abstractions are similarly wearying, so sermons must be concrete. Grey and muted tones will be neither seen nor heard: everything must be colorful, vivid, bold, and loud. More Berlioz than Debussy; more Norman Rockwell than Monet. In short, the aged-care chaplain must draw on all the techniques of the classic children’s talk: short, sharp, pointed, vivid, memorable, and never without an object lesson or two.
Response Two: Familiar Texts
Given how difficult it is for the frail elderly to take in and accept new information, it is vital to bring them texts that are well known. People with dementia may not remember what they had for lunch, but they may very well remember a song or poem or reading from the 1940s. We must lean hard on those old familiar texts.
The Lord’s Prayer is first among these. I prayed it many times every day and very often the person with whom I prayed spontaneously joined me in this prayer. I found the most familiar text to be the Traditional Ecumenical Version, which uses the words “trespasses” instead of “debts,” and “temptation” instead of “trial.” I had to remember that Roman Catholics do not end the prayer with the doxology: “For thine be the kingdom.…”
The Lord’s Prayer is also a launchpad for invaluable pastoral counsel: including the importance of relying on the Lord for daily provision of help and strength; the importance of seeking and extending forgiveness; and our ultimate hope that he will deliver us from evil—both personal evil and the ravages of sin—and will deliver us to a new heaven and earth without injustice, pain, tears, and death.
The twenty-third Psalm is another familiar and very precious text. I have read it innumerable times and drawn attention to Jesus as our Good Shepherd, who loves his sheep and laid down his life for his sheep, and who is present with his sheep with help and comfort even in “the valley of the shadow of death” (Ps. 23:4).
John 3:16 is also quite well known and is of course a very moving and powerful summation of the gospel. I quoted it often in my sermons, prayers, and one-on-one conversations.
When it comes to content, as hymn writer Kate Hankey urged:
Tell me the old, old story
Of unseen things above,
Of Jesus and His glory,
Of Jesus and His love.
Tell me the story simply,
As to a little child;
For I am weak and weary,
And helpless and defiled. (“Tell Me the Old, Old Story”)
Response Three: Repetition
I was led, early in my adult Christian life, to disdain the use of the Anglican Prayer book as archaic, dull, and heartlessly repetitious. How could anyone say something with meaning if they have to say it every week? I have since learned that it is possible to say the same things or different things with either meaning or empty formalism, or with something on the spectrum between these two poles. Successful engagement with liturgy depends less upon novelty or familiarity than upon the preparation of the heart and mind.
Without doubt there is power in repetition for those near the beginning and end of their lives. Rote learning is necessary for the young, and a comforting reinforcement for the old. Having seen the value of liturgical repetition, I intend to use much more of it when I return to parish.
Thus I settled on a simple weekly liturgy drawing from a limited number of texts: a Call to Worship (Psalm 34:1-3 or Psalm 100), a hymn, the weekly reading, a prayer of confession (the same every week), a second hymn, a message, a response by praying the Lord’s Prayer or reciting the Apostles’ Creed, a final hymn, and then the benediction (2 Cor. 13:14).
I also found myself drawing from a pool of only about ten hymns: “What a Friend We Have in Jesus”; “This is My Father’s World”; “When I Survey the Wondrous Cross”; “All Things Bright and Beautiful”; “The Lord’s My Shepherd”; “Leaning on the Everlasting Arms”; “There is a Fountain”; “Jesus Loves Me This I Know”; “How Great Thou Art”; and, of course, “Amazing Grace.”
No one ever complained, “Not that one again!” People were delighted to sing these great old songs over and over, and I believe that the wonderful message of these hymns sank in more deeply through repetition. (Chris Rice’s marvellous CD, Untitled Hymn: A Collection of Hymns, was a great help to me here. His versions are bright, clear, very singable, and uplifting.)
I aimed to bring short (five-to-seven minute), sharp, and concrete messages from whatever reading I had chosen for the week but found myself saying over and again, like a tolling church bell on Sunday morning, that “We must put ourselves in the loving arms of the Good Shepherd,” and that “Jesus Christ died on the cross for the forgiveness of our sins, and rose from the grave to give us everlasting life.”
Response Four: Participation
Many years ago a well-known Anglican writer—on holiday at the time—visited our church in Hobart. Months later he published an article recording his impressions of his church visits. While he commended the faithful preaching of the churches he had attended, he lamented the lack of congregational participation. Presbyterian congregations, deprived of the call and response of The Book of Common Prayer, seemed far too passive to him. I have come to think that he is right.
In an effort to rouse the elderly congregants from their weariness of body, mind, and spirit, I began inviting them to join with me in reading out the Prayer of Confession, and then the Call to Worship, and finally the Benediction too. In fact our penchant for reading silently is a late invention. The ancients typically read and prayed out loud, which engages far more of the mind and spirit than passive listening and silent mental recitation. As a result you are brought closer to understanding the meaning of the text and then, hopefully, to owning the meaning. Between the hymn singing and out-loud Scripture readings and prayers, my little congregations had very little opportunity to zone out and doze off.
Congregational participation is something else that I intend to bring much more into parish ministry.
Response Five: Kindness and Consideration
What drew vast crowds around our Lord? Yes, his arresting and authoritative teaching. Yes, his acts of power. Yes, the prospect of bread. Yet the gospels also speak again and again about his compassion—literally his “bowels of compassion”—his manifest love welling up from the core of his being.
The frail elderly have typically endured some ninety years in an often cold and jagged world. Many have lived through poverty and war. Too many have had to bury a child. Many have endured disappointment, betrayal, tragedy, and injury to the body and spirit. All of us have inflicted others with some measure of these evils.
To such curse-ravaged souls the chaplain can and must bring the love and compassion of Christ. This cannot be fabricated. Even the dullest eyes see instinctively through the mask of the play-acting hypokritēs. We must learn to look at these ancient and ruined bodies and souls through the eyes of Christ: as made in the imago dei, as fallen in Adam, as culpable rebels receiving their just punishment for sin and equally as victims suffering from the disease of sin, and as slaves suffering under the chains of sin. We must be moved to tears also for the fate of those who will die in their sin, without the saving white robe of Christ’s righteousness.
Although the barriers to the gospel are many and high, we begin to break down these barriers when we come with the compassion of Christ.
But loving sentiments must be backed up with loving practicalities. “Suppose a brother or a sister is without clothes and daily food. If one of you says to them, ‘Go in peace; keep warm and well fed,’ but does nothing about their physical needs, what good is it?” (James 2:15-16). Let us bring the clothes of patient listening and the daily food of reliability—of being there week-in and week-out, at the times we say we are going to be there. There is a man, not a Christian, who waits all week for his twenty-five-minute chat with me before church on Thursday morning. After two months of these chats he began to come to church. This has happened time and again—routine patient conversations turning into church attendance. Who knows what God does in the hearts of these people who come under his Word?
Love also means putting aside our native embarrassment or squeamishness when ministering to people. At first, I would stop praying or reading with a person when a caregiver came into the room. I soon realized that I would get very little done if I paused every encounter for every interruption. Later I realized how powerful these encounters could be for the caring staff, most of whom are not Christians. Your out-loud prayer and Bible reading is likely the only prayer and Scripture that they have yet heard. Your prayerful references to sin, atonement, divine forgiveness, heaven, hell, the cross, resurrection, Heavenly Father, Holy Spirit, and Jesus Christ, are likely the only time these people ever hear a word about these divine truths and titles. “You are the light of the world.” You bring the Spirit and presence of Christ. You are, I say with reverence, the nearest incarnation of the Incarnate Christ that many of these people will ever experience.
It is essential to nurture good relationships with nursing home staff, not only for their sake but also for the sake of your chaplaincy work. Very few residents can get to church if the staff do not help them up in the morning and feed and wash and dress them on time. Most often you need the staff to physically help people, bound to their reclining beds and wheelchairs, to church services. Staff can either hobble your ministry or help to make it flourish. So be kind and respectful to them, encourage them and thank them for their work, and assist them when appropriate to help move and feed people. I pray for them and their families out loud in our weekly services: “Lord, thank you for the good people who work here; for the cooks, cleaners, nurses, carers, managers, and others who work so hard to care for our residents. May you give them strength and skill and love in their hearts. Bless them and their families, as they are a blessing to our residents.”
It is widely known that nursing homes are crushingly lonely places. Of the two-hundred-plus residents I cared for, only a handful had daily or every-other-day visits. Only a third had regular visitors. Dozens had no visitors at all. There were many reasons for this neglect: some had families who lived away; some had harmed their families in times past; and every family of a resident was busy with other things. Chaplains and volunteers bring the most precious gift of all: the gift of a listening ear, of someone who cares, of presence. When Christ agonized in the Garden of Gethsemane, an angel appeared from heaven, “strengthening him” (Luke 22:43). May we, like visiting angels come to strengthen the struggling, win the hearts of residents and their care-givers and families.
If the ultimate blockage to the gospel is spiritual, then of course the most powerful thing we can do for those to whom we minister is to pray for them: that the Lord will take away hearts of stone, and that he will give them hearts of flesh. That he will make the dry bones live. That he will open blind eyes to see Christ.
Finally: Service and the Widow’s Mite
I sit with a man born during World War Two. Now deep in his eighties, he is laid quite low by an incurable disease. When his body was fit and strong he delighted to serve God and others. Now with every passing day others must do more and more for him: showering and dressing him, cooking and cleaning for him. Soon caregivers will have to lift him from bed to chair and his food and drink to his lips.
He implores me, eyes wide, hands open, a cloud on his brow: “How can I serve God now?”
How precious to him—and to others whose hearts are rent by a sense of uselessness—is the history of the Widow’s Mites, of the woman who gave only a tiny fraction of what the rich merchants were giving to the Temple treasury. Jesus said,
“Truly, I say to you, this poor widow has put in more than all those who are contributing to the offering box. For they all contributed out of their abundance, but she out of her poverty has put in everything she had, all she had to live on.” (Mark 12:43-44)
Jesus could not be clearer. When it comes to serving God, it is not the amount of money, muscle power, or mental ability that counts. What counts is the posture of the heart. In God’s balance the widow’s mites outweighed the merchants’ bulging bags of silver and gold. They gave a part of their surplus; they made no sacrifice to self. But the widow sacrificed everything for others.
This is how Jesus served us on the cross. He gave all of his heart, mind, and body. He gave up his dignity and lifeblood. Like the widow, he “put in everything.”
Those who have by faith received Jesus’ sacrifice—whose sins are forgiven and whose eternal life has already begun—will long to serve God and others in the same way. Has God blessed you with physical strength? Education? A trade? Professional skills? Oratory? Teaching ability? Leadership? Property? Money? Thoughtfulness? The ability to encourage? Kind words and deeds? Prayerfulness? Just as Christ has given his all for you, you will learn to give your all to him and to others.
And never forget this: God will use us to serve him and others, no matter our abilities or disabilities, our capacities or incapacities, our wealth or our destitution.
Yes, God uses the exhausted, the sick, the crippled, victims of dementia, and the dying to serve himself and others. He even uses our dead body for his service, as a memento mori (a reminder of our mortality), and by drawing out the loving service of those who bury our remains.
That is one reason why, until Jesus returns, “the poor you will always have with you” (Matt. 26:11). There will always be those who give and those who receive, and both will serve God in their complementary ways. The sick and disabled and poor will be God’s beautiful instruments, through whom God will teach others to love.
As the great French preacher Adolphe Monod taught from his own deathbed, from his own agony and helplessness:
You would think that the suffering would be excluded from the privilege of glorifying God, absorbed as they are by the sadnesses and pains of life. Not at all! These are the ones who are especially called to glorify God. They find in their sufferings, as they found in their atoned sins, the greatest way of giving glory to the One who has taught us to say: “When I am weak, then I am strong” (2Co 12:10).
What consolation for those who suffer, to be able to say: I can by my sufferings—that I bear patiently and peacefully, while waiting for that which will be joyful and glorious—I can, by these sufferings, give to God a glory that I could not have otherwise given to him. What infinite sweetness the suffering find in this thought!
It is above all because of this that suffering becomes privilege. Yes, to suffer is a privilege for the Christian. To suffer a lot is a special privilege.[2]
We live in a society deeply infected with Darwinism. The doctrine of “survival of the fittest” makes us think that the vigorous are more valuable, more worthy of surviving, than the weak. In a godless world, it is, as Nietzsche taught, “the will to power” that matters. The most valuable are those who most assert their will and strength upon others.
How wonderful, by contrast to this cold and cruel calculus, is the true Christian mindset: that we all, bearing the imago dei, are invested with incalculable honor and glory, no matter what our physical or mental condition.
We offer our mites to him. And he will take our frail, aging, and dying bodies, our weak and declining minds, our disability, our dementia, our final breaths—and even our lifeless bodies—and he will use them to love and to serve others, and to bring glory to his name.
And then in heaven—with renewed bodies and abundant life—we will serve him and one another perfectly, and with perfect joy, forever.
May we love Christ in the persons of the very aged with this spirit and with this hope.
Related Articles:
Recommended:
Christian Suffering: A new translation of the 1857 classic, Les Adieux d’Adolphe Monod à ses Amis et à l’Église by Adolphe Monod
Notes:
[1] National Library of Medicine. “Hearing loss and deafness: Normal hearing and impaired hearing.” Created: May 15, 2008; Last Update: November 30, 2017. ncbi.nlm.nih.gov/books/NBK390300.
[2] Adolphe Monod, Christian Suffering: A new translation of the 1857 classic, Les Adieux d’Adolphe Monod à ses Amis et à l’Église (1857; trans. Campbell Markham, Hobart, 2007), 26.
