Some of the hospice patients talk about their impending deaths, or about God. Most just talk about what people always talk about — unfinished business and unanswered questions: regrets over firing an employee 50 years ago; the pet no one has yet promised to adopt; feeling sick to death of being sick yet not ready to die. About Bach. "How did he dream up that music?" one woman asks.
Listening to final inquiries like these has long been the domain of a family priest or rabbi. But for a growing number of Americans who do not know a member of the clergy, that bedside auditor is increasingly likely to belong to an emerging professional class known in the hospice world as a pastoral counselor or chaplain, who may or may not be a clergy member.
The encounter with a chaplain can be profound and spiritual, and sometimes religious in a traditional way. More and more, though, ministering to the terminally ill in hospice care is likely to be nonsectarian, or even secular.
In the quarter-century since Medicare and some private insurers began picking up the bill for hospice care, it has become a common recourse for the terminally ill. With doctors, nurses, social workers and ample supplies of pain medication dispatched to their homes or nursing facilities in the final weeks and months, about 1.3-million Americans died last year in hospice care.
Spiritual counseling has always been an optional part of the service. But recently, the proportion of patients choosing to receive it, and the number of new chaplains entering the field to meet the need, have risen sharply.
Chaplain services in New York City have nearly doubled since 2004: About 65 percent of the city's 4,000 hospice patients accept visits from chaplains now, compared with about 35 percent four years ago, according to the two hospice providers, the Visiting Nurse Service of New York and Continuum Hospice Care.
Nationwide, a study released recently by the National Center for Health Statistics of the Centers for Disease Control set the proportion of patients accepting a chaplain's care at 72 percent in one sampling, as compared with the 59 percent another group found in 2000.
The new demand has contributed to a steep rise in the number of chaplains of all kinds, said Josephine Schrader, executive director of the Association for Professional Chaplains, the largest certification body in the country. The vast majority of recruits in the last 10 years — an estimated 3,000 chaplains, representing a 50 percent jump, she said — are working in hospice care.
They are in some ways a different breed. "The new chaplain culture is more professional and secular," Schrader said, and "more adaptable" in approach.
In the hospice idiom, the job of the chaplain is to make dying easier. In a way that perhaps only Americans would understand, some chaplains refer to what they do as fostering a more "successful" experience — by whatever definition of success can be negotiated in the final hours between a dying person and a compassionate stranger.
Health care and religion experts cite several reasons for the new pastoral model: a growing consensus in the medical world that spiritual care comforts terminal patients; the shortage of clergy, especially priests; a decline in traditional worship; and the apparently unchanged need most people have near the end of life to make sense of existence.
Some chaplains are ordained clerics, some not, though almost all undergo training in giving spiritual counsel to that growing segment of the population that describes itself in polls as feeling connected to a higher power but not an organized faith. "The ones with a family priest, they're not calling us," said Vincent Corso, the pastoral care director for the Visiting Nurse Service.
During the four months that a hospice chaplain has visited Dr. Bertram Schaffner, a 95-year-old psychiatrist, at his Central Park South apartment, the word "God" has come up only when discussing the doctor's collection of Hindu figurines of household deities. Schaffner told his chaplain, the Rev. Hajime Issan Koyama, a Buddhist monk, that he wanted help in understanding "why I'm still living at this age, and what I should be doing."
Karen Gilbert, a 56-year-old writer, mother of two and self-described polytheist, received help from the same chaplain, who is accommodating her wish that her body remain undisturbed after her death to allow for a period of protective prayers, in accordance with Buddhist principles of reincarnation.
Gilbert endured sometimes overwhelming pain from spreading colon cancer, and suffered the guilt many terminal patients feel about leaving their families. Yet she told the monk one warm September evening in her Lower East Side apartment that one of the hardest tasks in her final months was admitting to her circle of friends that "I pray to a god." She died on Sept. 29.
As a reporter accompanied five chaplains around New York over several weeks, they and their patients sometimes spoke in specifically religious terms, but more often employed the everyday language of pleasure and pain: about regrets, loneliness, conflicts unresolved with relatives living and dead; about dogs, movies and people they loved, the meaning of dreams, the TV show Dancing With the Stars.
Visiting one patient after another, 15 or 20 a week, the pastors usually seemed sure-footed in their improvised mission. Their interaction with mortality, often without the shield of sacramental ritual, frequently recalled the work of the town doctor in Camus' book The Plague, who defines the good man as "the man who has the fewest lapses of attention."
The chaplains listen, mainly; and sometimes, like jazz musicians, pick up themes and try to bring them to new levels.
"I talked to my mother yesterday," said Robert, an 83-year-old man with Alzheimer's, whose mother died in the 1960s.
"How was she?" said the chaplain, Tom Grannell. "You haven't talked to her in a while."
"Pretty good," Robert said. "She agrees with my father: I'm lying here too long. Time to get back to work."
"Your mother always believed in you," the chaplain said.
"Yes, she did," Robert said.
Because their services are aimed at a diverse population, and because of the federal dollars usually involved, hospice providers forbid counselors to proselytize, and require them to undergo training in accepting all patients' beliefs.
So, when Robert, who is Jewish, asked Grannell to pray with him the other day, Grannell, a former Roman Catholic priest, pulled from his pocket a pamphlet published by the Central Synagogue in Manhattan.
"I'm not Jewish, you know," he wryly noted as he turned the pages looking for his place. Then he read a prayer, "We praise you, oh God, healer of the sick," speaking in the phonetic Hebrew provided in the brochure.
Visits often seemed uneventful, with long minutes of silent hand-holding. But an ordinary conversation could suddenly turn sharp.
"How are you?" asked the Rev. Kei Okada, visiting a man in his 70s, a terminal cancer patient, in his downtown apartment.
The man removed the oxygen prong from his nostrils and replied slowly: "What do you mean by that? What is there to say? I am not well." He added, with a fist tightly clenched under his chin: "I am not getting well. I have no hope."
Okada did not speak, but maintained earnest eye contact with the man for many minutes. Outside, afterward, he said his patient's greatest challenge would be the "letting go of this cerebral concept of meaninglessness, of nothingness."
The silent partner in the visits is the underlying rage of many dying people. It sometimes issues from behind clenched teeth, or explodes in the sudden tearing away of intravenous tubes.
"It's been two years," said the distraught wife of a man who lay dying in the next room in an apartment near Canal Street one bright morning. "He fought so hard. He didn't tell his friends. He didn't want people feeling sorry for him." He was 59, and died the next day.
As Okada huddled inside with the man's doctor and nurse, the wife unspooled his last months: "He kept saying how sorry he was for leaving me and the kids, for the trips we would never take. He loved his life." After two years in and out of hospitals, he had refused to undergo more treatment.
An hour later, when the patient fell asleep under sedation, and his wife greeted a stream of relatives at the door, Okada left, on the way to his next appointment.
As he hurried along, checking phone messages, he was asked if the daily encounter with other people's deaths was ever too much. He paused, and said a chaplain's own distress and sense of vulnerability to death were, in a way, part of the job. "It is my first bond with my patient," he said.
In the best of worlds, he said, a relationship based on that helps a patient make peace.
"But many times, this never happens," he said. "We are there to be there. That is the point. It is my job to stay when there is no answer."