A Practical Approach to End-of-Life Issues: Practical Matters in Counseling on Death
A Practical Approach to End-of-Life Issues
Presented by Rev. Robert R. Fleischmann
IX. Practical Matters In Counseling on Death
I have outlined for you some of the basic principles that have helped me address death with fellow Christians. I believe strongly that it is these principles that must be the most remembered words to fall from my lips. But I cannot ignore that there are attending secular concerns which must be considered and upon which we are asked to comment. I will try to address the more common ones briefly.
During my seminary days, I remember being taught that when you work with some cults they will use the same words as you do but mean something different by them. The same holds true in dealing with medical issues. Be aware of how some of the terminologies have changed over time or how it is used to imply different things. Following are some common examples:
- Christian ethics: the only value system in which motive is the first determination of right and wrong
- Divine autonomy: God reserves for Himself alone the right to begin and end life
- Time of grace: the length of time God lovingly gives each person to come to faith in Jesus Christ and to share that faith with others
- Christian self-image: how a Christian sees himself through faith: an evaluation of self-worth based, not on position, appearance, race, or wealth, but on the righteousness of Christ which God has assigned to us.
- Quality of life: humanistic view of self-worth based on worldly, subjective factors which ask, “Am I getting out of life what I want?”
- Quantity of life: the Christian view of self-worth based on acknowledging life, whatever its quality, to be a quantitative valued gift from God.
- Christian medical-ethical decision making: a way of approaching tough decisions with the question: “Is God still holding out the gift of life, or is he taking it away?” Christian ethics reject decisions made on the basis of the question: “Do I like the life God is giving me?”
- Euthanasia: The active or passive, voluntary or involuntary, application or withdrawal of medical treatment in an effort to hasten death: murder.
- Imminent: Two doctors agree that regardless of the application or withdrawal of medical treatment, death is likely to occur within days.
- Imminent Death Care: The application or withdrawal of medical treatment which acknowledges that God himself is taking the life with a specific focus on making the final moments of life as comfortable as possible.
- Terminal: Used with such words as cancer, condition, or illness to indicate that in a physician’s best medical judgment an identified malady will cause death. The term “terminal” does not presuppose a time factor for death to come. It simply indicates a condition has been identified which will most likely be the cause of death.
- Active Euthanasia: The termination of life by direct intervention (i.e. lethal injection).
- Passive Euthanasia: Hastening death by the withdrawal of life-sustaining treatment. This can range from taking a terminally ill patient off of a respirator to denying him food and water with the specific intent to shorten his or her life.
- Voluntary Euthanasia: The killing of a patient in accordance with his or her wishes. This is broader than suicide because it involves a second party in bringing about death. Also referred to as assisted-suicide, or, where medical assistance is involved, physician-assisted suicide.
Involuntary Euthanasia: The killing of an incompetent or comatose patient without his or her consent, justified as merciful or humane.
- Definition of Death: The complete cessation of all circulatory and respiratory functions in the body accompanied by the absence of any neurological activity in the cerebral cortex and brain stem.
- Brain Death: The absence of any neurological activity in the cerebral cortex or the brain stem. Some have referred to this as whole-brain death. Some physicians have identified a lack of measurable neurological activity in the cerebral cortex as brain death, even though brain stem activity is sustaining basic bodily functions. Using this limited definition of brain death essentially is a qualitative argument for terminating life.
We pastors are often looped into the family circle in this arena once the family has received some sort of diagnosis implying a terminal condition. When considering a diagnosis it is important to remember that they don’t call it a medical practice for nothing. A diagnosis is, at best, an educated guess based on a number of known indicators and speculating on some unknown ones.
Addressing the topic of accuracy in diagnosis Dr. Joseph Stanton, affiliated with the Human Life Center, shared the following information in an April 6, 1988, public debate with Derek Humphry on assisted-suicide:
A study at Harvard Medical School at Peter Ben Brigham’s [?] Hospital is enlightening. Lohmann[?], with five other authors, in a paper entitled “The Value of the Autopsy in Three Medical Eras” in the New England Journal of Medicine, 1983, Volume 308, pages 1000-1004. They took the three different eras, 1960, 1970, and 1980, and they studied 100 autopsies in each of those years.
Now there were tremendous advances in diagnostic technology during that period. The startling finding reported were, “Ten percent of the autopsies in each era revealed a major diagnosis, that if known before death, it might have led to a change in therapy and prolong survival. Another twelve percent showed a clinically missed major diagnosis for which treatment would not have been changed.”
So the clinical diagnosis at death was faulty in twenty-two percent of the cases in one of the leading American medical institutions.
I have not seen any serious indication that there has been any improvement in these types of statistics. In the September 8, 1995 issue of the Rocky Mountain News was a story on unexpected deaths in Colorado hospitals. The story noted that in the past five years there have been more than 660 unexpected deaths in Colorado hospitals. While a very small fraction of these is related to mistakes made by the staff in patient care, the remainder represents simply the unexpected death of a patient because of a misdiagnosis.
Unless the evidence is incredibly obvious and compelling I counsel families to get a second opinion. I encourage this not just to offer a glimmer of hope in the face of a dismal prognosis but also to help a family feel as though they have done all that is reasonably possible to assure they are doing what they can to protect and preserve life.
Do Not Resuscitate (DNR) Orders
Resuscitation is an aggressive procedure designed primarily to restart a heart by external means which has stopped unexpectedly. It is not uncommon for some patients to suffer broken ribs and bruising during this procedure.
A successful resuscitation is intimately tied to the health of the patient at the time of the arrest. Statistics indicate that elderly patients, generally 70 years of age and older, who undergo a resuscitation in a nursing home have very little chance of surviving more than a few additional days.
When a family is asked whether they wish a DNR order upon a family member admitted to a nursing home or hospital they should consider the age and general health of that patient. A discussion with the attending physician will prove helpful in determining whether or not to authorize a DNR. The motive for not authorizing it would be an acknowledgment that when the heart stops it is perhaps the final attendant medical circumstance to arriving at the conclusion God is bringing death for this person. Other circumstances preceding the heart arrest might be advancing dementia, inoperable cancer or tumors, advanced age, and a frail body.
Breathing machines generally refer to ventilators or respirators. Most often patients are placed on these machines as a temporary measure to help them through some medical trauma. The intent is that in a short period of time they can be weaned from the machine and assume normal breathing.
The challenge of using these machines enters in when anticipated recovery does not happen. What was intended to be remedial now becomes a necessary artificial means to preserve life. Eventually, the doctor must approach family members seeking permission to remove a patient from such a machine. This becomes a very difficult matter for the family to wrestle with. These are also some of the most difficult situations you will encounter as a pastor, should the family seek your counsel.
When addressing this circumstance I generally ask “why” questions. I want to know why they would keep the patient on the machine or why they want to stop it. I listen carefully to see if I hear selfish or quality of life arguments for stopping the care. I listen with equal concern to any notions that by keeping the machine going they somehow feel they are challenging God in sustaining a life that is apparently going or gone.
If the decision is made to remove the machine I always request medical staff to wean the patient from the machine. Weaning is a process where the use of the equipment is slowly scaled back to allow the patient adequate opportunity to take over breathing. I have encountered instances where the patient does indeed take over breathing on his own for a few days or longer before finally dying.
Medical Directive Statements
The 1990 Patient Self-Determination Act passed by Congress requires health care facilities that receive federal money to inquire whether or not patients have advance medical directives. A patient is not required to have such a directive, though many who have faced the question think it is a requirement for admittance.
Initially, the model document presented to patients was a living will modeled after one drafted by the Society for the Right to Die and adapted by states to meet certain statutory requirements. In most cases, a Christian would not feel comfortable with the pro-death bias in these documents and our office regularly counseled that you were better off with no document than with the state living will. When no such medical directive statement existed most medical institutions worked with the presumption that the patient wanted to live and therefore administered care accordingly.
At Christian Life Resources we saw how strongly people felt about having their own medical directive statement, even though one was not required. To meet that concern we first drafted a document entitled “My Christian Declaration on Life” to serve as a Christian medical directive statement. It was well received with over 15,000 in distribution. To our knowledge, they have never been disputed when they were consulted by family members and hospital staff.
Two developments took place simultaneously, however, which dramatically affected the role of medical directives and the position of our office. On one front medical institutions were abandoning their “presumption to live” position and were exchanging it for a more liberalized policy which allowed wider latitude for the staff to make determinations based on a subjective evaluation of the quality of life.
On another front, it was becoming apparent that when living wills were consulted they were far too generic to provide any sort of real direction for the medical staff. This spawned the development of a document generally referred to as a Durable Power of Attorney for Health Care. It was like the Power of Attorney document commonly used for estate concerns. This one, however, is an entirely separate document that allowed two important things: 1) the delineation of specific medical care wishes; and 2) the designation of a health care surrogate or decision-maker in the event the patient was unable to make a decision on his or her own. These documents are by far the more favored of medical directive statements.
Because of the change of positions on the part of medical institutions, and with this directive statement, Christian Life Resources now encourages the use of such a document and has its own customized version of it.
This Christian version of the Power of Attorney for Health Care document was initially drafted with the assistance of legal counsel to assure 100% conformity in Wisconsin and Michigan. It has since been drafted for all 50 states. We also review changes in state statutes to assure continued conformity.
With this document, we wanted to provide clear direction to the health care surrogate and medical professionals. At the same time, we wanted to use this opportunity to give a strong Christian witness.
We were concerned that the use of the document would simply become some legalistic formality in which those who used it would simply sign it and place it in a file without giving it much thought. For that reason, we wrote a supplement to it which provides the Biblical justification and logic behind the statements made in it. We continue to encourage pastors to review this complete document with their Bible classes. We encourage those who would use the document to review it with their families.
A free downloadable copy is available by clicking here.
If you prefer, you may purchase the expanded health care document packet which includes the state-specific Durable Power of Attorney for Healthcare – Christian Version document, the Explanatory Supplement, a wallet card, a Personal Record booklet, handy envelopes for holding your documents, and other helpful materials. Visit the CLR Store on this website to purchase the individual packet or the cost-saving couples packet.
The above article is part 9 of Rev. Fleischmann’s 10-part paper. Click here to view the complete outline.
April 3, 2018
May 4, 2018
September 9, 2018