Betty was in her early 80s, admitted for a bleeding mass in her esophagus that seemed likely to prove malignant and inoperable. She’d requested a chaplain visit overnight, so I made her my first priority that morning.

“Greetings, Betty, I’m Chaplain Greg. Thanks for inviting me to be with you.”

“I’m so happy to see you. I’m doing well this morning. I have been blessed to know Jesus Christ as my Lord and savior since I was a little girl.”

“What a joy that is! I’m happy for you!”

Betty proceeds unprompted with “life review,” sharing about her 60-year marriage to her husband, a retired pastor with several chronic medical conditions, and their children and grandchildren, who continue to play an active, supportive role in their lives.

“Now it seems my time may be coming … I’m excited to finally meet Jesus face-to-face, though I worry a bit about my husband. We’ve always talked that he’d be the first to go, given his health, but now it looks like I may be. Still, I trust God to care for him as He always has, and our children will be there for him, too. And it won’t be much longer until we are together in heaven.”

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My friend John asked me at dinner recently, “What percentage of the people you see nearing end of life are at peace with their situation? What factors seem to make the difference?” I am under no illusion that I have definitive answers to these questions, but I’ve seen enough to offer a few thoughts.

My answer to John’s first question was, “Maybe 60%, maybe more.” Betty is just one example among several since our dinner. I will continue to keep this question in mind over the coming months as I go about my rounds, but it feels right, at least for the population I see in the hospital where I work. John’s second question—“What factors seem to make the difference?”—is harder.

Religious faith is an important source of peace for many facing death, but it’s no guarantee—for some, their faith can elicit a sense of having fallen short of what was expected of them in life, and fear of the consequences. And I’ve seen plenty of patients with no active religion, or even explicit atheism, who seem fully at peace with their imminent deaths (Clark, The Science Teacher, is one example).

One factor uniting Christian Betty with atheist Clark is a sense of wonderment about the source of their existence and the universe we inhabit, as well as deep gratitude for the life that this source provided. Gratitude is a theme that runs through so many of the patients I see who are at peace, even (or perhaps especially) in those whose lives have been remarkably difficult (for example, Dean in From The Ashes).

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Lucy, in her 50s, was a new admission to the oncology unit but no stranger to cancer. Her lung cancer, diagnosed 10 years earlier, had been managed with surgery and chemotherapy, but after recent headaches and dizziness she was re-evaluated and found to have tumors throughout her brain. She made a request for a chaplain visit the night she was admitted.

Lucy greets me warmly as I arrive, guessing correctly from my attire that I’m the chaplain she’d requested. She gets right down to business.

“It looks like this is it,” she begins. “I’ve had a good run and gotten a lot of extra years, but I’ve always known this day would come and now it’s here.”

“I’m sorry, Lucy—that’s difficult news, even if you are prepared for it. How’s that sitting with you this morning?”

“I’m mostly OK. I’ve got my affairs in order, and I’ve discussed this possibility with my kids for years, so they’re as prepared as they can be.” Her voice trails off but her eyes remain engaged. I wait for more.

“What I really wanted to talk to you about is my sister, who I haven’t spoken to in years. We got along well enough growing up, but as an adult she became really mean and cruel to me.” Lucy relates an escalating series of events, culminating in an act of betrayal that led Lucy to cut off communications between them.

“That’s heartbreaking, Lucy,” I reply, “but I can understand why you felt you needed to set that boundary in order to protect yourself.”

“I don’t regret it, but I realize I’m still angry about the way she treated me. I don’t want to die angry. I wanted to talk with you about how I can forgive her—I think I need to find a way to do that in order to die in peace.”

So we talk about how forgiving another person is something one can do on one’s own. It doesn’t require anything of the person being forgiven, no matter how much one might wish for an apology or just an acknowledgement of hurt. It doesn’t even need to be communicated to the other person. Forgiveness is something one can offer for the sole purpose of putting one’s own heart at rest.

“I never thought about it that way at all, but now that you say it, it makes perfect sense. I think I’m ready to start writing down what I want to say. I’ll figure out later if I actually want to send it to her.”

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Every time we chart a spiritual care encounter, we are prompted to assess the patient/family regarding “Forgiveness/Peace.” At one end of the scale, 1 = “Sense of reconciliation” and 2 = “Still have some things to reconcile.” In this context, reconciliation means “Is the patient/family reconciled with and at peace with their situation?” It doesn’t necessarily mean “Have they reconciled with the important people in their lives?” but it certainly can. In fact, the other end of the scale is 4 = “Distanced from others” and 5 = “Alienated from others,” reflecting the importance of relationships in finding peace.

Betty and Clark are good examples of “1” but I’d say the “2” I gave Lucy is more common, especially in the early days of a hospitalization. Most of us have some Unfinished Business (to cite yet another post) that we need to take care of, and a medical crisis can prompt us to take steps to heal relationships that we may have long been putting off. One of the most important things we can do as chaplains is to serve as a sounding board to help others identify the unfinished business in their lives so they can begin to move forward toward peace.

That night at dinner, I told John I thought one of the biggest factors impacting a patient’s sense of peace is having enough time to prepare for end of life. I would now frame that differently: it’s having very little unfinished business—especially unreconciled relationships that need to be set right in order to be at peace. It’s a helpful reminder that it’s never too soon to begin that work …