by Between Life
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“If I face a critical, life-threatening illness, I will want an experienced clinician who is well versed in the most recent medical studies, who is kind and compassionate, and who respects my faith in Jesus. I will want someone who can coach me on the right questions to ask my medical team and help me make practical decisions. In short, I will want Dr. Butler. She will guide me to come to the end of life in a way that commends the gospel and brings glory to God. If she is not available, I will want to reread this book.”
John Dunlop, MD, Internal Medicine Doctor, Geriatrics, Yale School of Medicine; author, Finishing Well to the Glory of God
“Dr. Butler has done a masterful job in giving us a clear and comprehensive guide to navigating the difficult and complex waters of end-of-life care. Although Between Life and Death is written with patients and their families in mind, this book is a welcome and valuable resource for guiding Christian healthcare students through these challenging issues, in addition to providing the necessary biblical grounding and foundations.”
Bill Reichart, Vice President of Campus and Community Ministries, Christian Medical & Dental Associations
“It is inevitable that at some point, each one of us will face difficult or even heartbreaking medical decisions. We may have to make decisions related to our own care or, even tougher, the care of someone we love. To prepare to make such decisions in a distinctly Christian way, you won’t do better than to read Between Life and Death. It will inform, encourage, strengthen, and equip you to act in ways that honor our humanity while bringing glory to our God.”
Tim Challies, blogger, Challies.com
“Some of our weightiest decisions wait until the end. When death draws close, what medical treatments will we embrace or reject? Even Jesus-loving Christians struggle to know how to answer these questions, and we need a seasoned doctor to educate us on the options and their pros and cons. Dr. Butler educates the mind, answers the questions, and takes the imagination on an unforgettable ride, made vivid with the descriptive prose only a gifted writer and experienced trauma surgeon could offer us. This remarkable, Christ-centered book is loaded with reality checks and soul checks, and it will serve Christians and pastors for many years to come as they make these final decisions out of faith and not fear.”
Tony Reinke, journalist; author, 12 Ways Your Phone Is Changing You
“Dr. Butler has written a remarkable, unique, and timely book. Combining her medical expertise with biblical compassion and moral evaluation, she lucidly explains what we need to know about life-and-death medical situations. She does not offer vague advice, but grounds her counsel in medical facts, legal realities, spiritual principles, and real-life illustrations.”
Douglas Groothuis, Professor of Philosophy, Denver Seminary; author, Walking Through Twilight: A Wife’s Illness—A Philosopher’s Lament
“This is a marvelous book. Dr. Butler, a Christian intensive-care specialist, has woven together a clear explanation of detailed and complex medical issues with an intimate knowledge of Scripture to bring forth a book of immense value for patients, loved ones, and clergy as they face the seemingly insurmountable questions of ICU and end-of-life care. It is well written, illustrated with real-life dilemmas, and oozing with compassion, both her own and that of our Savior.”
Robert D. Orr, MD, CM, clinical ethicist; author, Medical Ethics and the Faith Factor
“As a pastor’s wife, a parent, a daughter, a granddaughter, a friend, a neighbor, and a member of the church, the issues in this book regularly loom over my life and the lives of those around me. How do we best love the sick and dying? How do we know when to pursue medical interventions and when to allow our loved ones to, as Dr. Butler puts it, ‘relax into the embrace of Jesus’? These are complex questions without easy answers. But Between Life and Death provides a helpful framework of biblical wisdom to illuminate otherwise murky scenarios. Dr. Butler explains the dense medical terminology that can baffle already-overwhelmed caregivers. And, with unflinching (but not unsympathetic) clarity, she brings us to the bedsides of the suffering and tells us what it is like to experience CPR, a ventilator, or artificially administered nutrition. The actual impact and likely outcome of such treatments is far from the glamorous glow of TV medical dramas, but we need to know the stark reality in order to make God-honoring and merciful choices for ourselves and our loved ones. Thankfully, this book also has an expiration date. One day, gathered in the near presence of Christ, we will no longer need to know how to make decisions about death. But in the meantime, I’m glad to have this book on my shelf.”
Megan Hill, author, Praying Together and Contentment; Editor, The Gospel Coalition
“For all the blessings of modern critical care, we have not sufficiently reckoned with its dark underside: what happens when medical technology and intervention do not preserve life but prolong death? With her keen medical training and experience on display, Dr. Kathryn Butler parts the curtain on an array of life-threatening situations that might befall us or those we love. In Between Life and Death, Dr. Butler points us to the hope of the gospel, showing what Christian discipleship might look like in some of the most agonizing moments in life. May this book serve as a useful guide and conversation starter as we prepare for death and gaze on Christ.”
Ivan Mesa, Books Editor, The Gospel Coalition
“Dr. Kathryn Butler has taken her Christ-centered life as well as her experiences as a trauma surgeon to give the reader ways to assess end-of-life decisions to the glory of God in Christ Jesus. Her book emphasizes that we live by the grace of God in Christ Jesus. Dr. Butler has included numerous Bible references that are extremely helpful within the context of living and dying in Jesus Christ. It is a must-read for all Christians, church leaders, and medical professionals who are living through end-of-life dilemmas.”
Bob Weise, Professor Emeritus of Practical Theology, Concordia Seminary
Between Life and Death
Between Life and Death
A Gospel-Centered Guide to End-of-Life Medical Care
Kathryn Butler, MD
Between Life and Death: A Gospel-Centered Guide to End-of-Life Medical Care
Copyright © 2019 by Kathryn Butler
Published by Crossway
1300 Crescent Street
Wheaton, Illinois 60187
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means, electronic, mechanical, photocopy, recording, or otherwise, without the prior permission of the publisher, except as provided for by USA copyright law. Crossway® is a registered trademark in the United States of America.
Published in association with the literary agency of Wolgemuth & Associates, Inc.
Cover design: Tim Green, Faceout Studios
Cover image: Shutterstock
First printing 2019
Printed in the United States of America
Scripture quotations are from the ESV® Bible (The Holy Bible, English Standard Version®), copyright © 2001 by Crossway, a publishing ministry of Good News Publishers. Used by permission. All rights reserved.
Trade Paperback ISBN: 978-1-4335-6101-6
ePub ISBN: 978-1-4335-6104-7
PDF ISBN: 978-1-4335-6102-3
Mobipocket ISBN: 978-1-4335-6103-0
Library of Congress Cataloging-in-Publication Data
Names: Butler, Kathryn, 1980- author.
Title: Between life and death : a gospel-centered guide to end-of-life medical care / by Kathryn Butler.
Description: Wheaton, Illinois : Crossway, [2019] | Includes bibliographical references and index.
Identifiers: LCCN 2018033721 (print) | LCCN 2018047922 (ebook) | ISBN 9781433561023 (pdf) | ISBN 9781433561030 (mobi) | ISBN 9781433561047
(epub) | ISBN 9781433561016 | ISBN 9781433561047 (ePub) | ISBN 9781433561030 (mobipocket)
Subjects: LCSH: Death—Religious aspects—Christianity. | Medical care—Religious aspects—Christianity.
Classification: LCC BT825 (ebook) | LCC BT825 .B95 2019 (print) | DDC 362.17/5—dc23
LC record available at https://lccn.loc.gov/2018033721
Crossway is a publishing ministry of Good News Publishers.
2019-08-12 09:27:40 AM
To
My patients, whose courage inspired this book.
And to Scott, Jack, and Christie, who daily remind me of God’s love.
Contents
Introduction
Part 1: Dying, but Alive in Christ
1 Framing the Issue
2 Wisdom Begins with the Word
Part 2: A Detailed Look at Organ-Supporting Measures
3 Resuscitation for Cardiac Arrest
4 Introduction to Intensive Care
5 Mechanical Ventilation
6 Cardiovascular Support: Vasopressors, Inotropes, and Lines
7 Artificially Administered Nutrition
8 Dialysis
9 Brain Injury
Part 3: Discernment at Life’s End
10 Comfort Measures and Hospice
11 Physician-Assisted Suicide
12 Advance Care Planning
13 Being a Voice: Surrogate Decision Making
Conclusion
Acknowledgments
Appendix 1: Summary Chart of Organ-Supporting Measures
Appendix 2: Sample Advance Directive
Appendix 3: Scripture Passages for Comfort
Glossary
Notes
Further Reading
General Index
Scripture Index
I am sure that neither death nor life, nor angels nor rulers,
nor things present nor things to come, nor powers,
nor height nor depth, nor anything else in all creation,
will be able to separate us from the love of God
in Christ Jesus our Lord.
—Romans 8:38–39
Introduction
Their nightmare of blood transfusions and emergency surgeries receded into memory with a whisper.
As the respiratory therapist removed the tube tethering him to the ventilator, he sputtered, coughed, and squeezed his eyes shut. Then, with an oxygen mask misting his face, his eyes locked with his wife’s. For the first time in two weeks, he spoke, his hoarse voice barely audible: “Hi, Hun.”
“We’ve missed you,” she answered. Tears welled in her eyes, and her limbs relaxed, like taut petals unfurling. In that moment, the burden of the car accident, and the havoc that had seized them for so many days, seemed to slip like silk from her shoulders.
The nurses and I beamed. Stories like this had drawn us to critical care. After long nights standing vigil over him, turning dials, adjusting medications, and stilling our frantic hearts, his injuries—his shattered liver, his lungs foaming with blood—no longer threatened him. The laboratory results and the ventilator settings no longer dictated his days. God had reunited husband and wife with a draught of air.
While the nurses still reveled in his recovery, I walked into an adjacent room to check on another patient. My joy ebbed as I stepped through the doorway and laid eyes upon the elderly gentleman who withered into his mattress. He relied upon the same battery of machines that had rescued our car accident survivor, yet his illness had assumed a starkly different trajectory. A massive stroke had paralyzed him and obliterated his capacity for language. Jaundice yellowed his skin to the color of turmeric. Bruises mottled his arms as blood leeched into his tissues. Although a formidable array of lines and tubes pumped and churned, his organ function dwindled. He was dying.
As I stood at the doorway, his wife sat beside him with her gaze distant and her hands limp in her lap. We had already spent hours poring over numbers and statistics. We had discussed prognosis, outlook, disease processes, and research. Yet during those long hours, I had failed to address the anguish twisting in her heart.
“Do I have any right to make decisions about his living or dying?” she would ask, as my team and I inquired about whether to continue life support. “Isn’t that God’s place, not mine? I don’t think [my husband] would want any of this, but I don’t know what’s right.” She would search our faces for the reassurance she lacked, and when we offered none, she would place a hand over his to stroke the contours, once so familiar, that disease had bloated beyond recognition.
As I stood in the doorway this time, she did not raise her eyes to greet me. In the dim light, I barely discerned the silvery lines staining her cheeks. She had been crying for a while. “He’s the one who usually helps me with hard things like this,” she said, with her gaze still fixed on the past. “I miss being able to talk to him. I feel like I’m the one dying.” Finally she looked at me, her expression weary and pleading. “I wish God would just tell me what to do.”
In the right circumstances, modern critical care saves lives. The moments when I have lifted my most raw and heartfelt praise to the Lord have occurred within the walls of the intensive care unit, when I have witnessed his grace and mercy made manifest in the recovery of a child battling a widespread infection, a man fighting for his life after a motorcycle crash, or a woman whose heart strains in the throes of a heart attack.
Yet medical technology harbors a dark side. When an illness cannot be cured, aggressive interventions prolong dying, incur suffering, and rob us of our ability to speak with loved ones and with God in our final days. Ventilators steal both voice and consciousness. Resuscitation looks a lot like assault. In the ICU we often awake in panic and find ourselves physically strapped to a foreign bed, deprived of the familiarity and comfort of home. We clamber for air, only to find we have no freedom and no voice.
When our critically ill loved ones cannot speak to us, we wrestle with impossible decisions of whether to press on or to withhold treatment, all while we yearn to hear a beloved voice again. Like the wife holding my dying patient’s hand, such dilemmas thrust us into grief, doubt, fear, anger, and even guilt as we struggle to reconcile a web of hospital instruments with a mother’s voice, a father’s laughter, or a child’s smile. While we wrestle, concerns about faith also haunt us. Death is a profoundly spiritual event that rips from us the people we most cherish and pitches us into doubt about suffering, mercy, and the God whom we serve. What is God’s will? we ask. Why is God allowing my loved one to suffer? What does the Bible allow in this scenario? Such questions tap into our deepest anguish, a pain that echoes from our origins as image bearers torn from God. Death is the wages of our fallenness, and the final enemy (Rom. 6:23; 1 Cor. 15:26). Even Christ wept in the face of death (John 11:35).
Yet when they deliver devastating news, too often physicians—and I include myself among the culpable—ignore these concerns and suggest chaplaincy services as a conciliatory afterthought. We focus solely on monitors and machines, and, in so doing, we transform death from a process directed heavenward to one steeped in nomenclature and obscurity. Percentages soothe little when we pine for hope. Medical terms offer no solace when the soul thirsts for God (Ps. 42:1–2). When it so heaps decisions of life and death upon us without a grounding in faith and Scripture, medicine casts us adrift, rudderless. We stumble forward under duress, without understanding how the lines, tubes, and numbers equate with the truth that “death has been swallowed up in victory” through Christ (1 Cor. 15:54).
The idea for this book arose in my heart during my ten years caring for patients in the int
ensive care unit (ICU), first during my surgical and critical care training and then as a trauma surgeon who worked extensively in the surgical ICU. Over the course of that decade, I had the privilege of partnering with people during their most vulnerable moments, and I loathed the disconnect between the technical details that I laid out and the pain tearing them apart. As I would lean forward in my white coat to inquire about resuscitation and feeding tubes, the weight of unvoiced questions bore down upon us—questions of God’s authority, of his goodness, of sanctity of life, and of suffering. These questions sprang from concerns fundamental to our Christian faith, but they hid beneath the trappings and decorum of a secular medical system.
To honor God in the bleak setting of the ICU, we must clarify the expanse between life and death that our medical advances have blurred. The shift of dying from the home to the hospital challenges us to acknowledge the capabilities and limitations of the technology upon which we lean, and to embrace it in a fashion that keeps the gospel in focus. Compassionate, gospel-centered guidance in end-of-life care requires a consideration of medical technology through the lens of heaven. We must unravel the jargon and the statistics and appraise them against the clarifying light of the Word.
When I speak of “life-prolonging,” “life-sustaining,” or “organ-supporting” technology, I refer to the array of medical interventions that augment or replace failing organ systems, e.g., ventilators for failing lungs, and dialysis for failing kidneys. Doctors usually implement such measures in emergency or ICU settings, when organ failure is life threatening. The introductory chapters of this book provide a framework for understanding such treatment in broad brushstrokes, coupled with a discussion of the biblical principles that undergird Christian medical ethics. Thereafter, chapters focus on specific categories of life-sustaining technology. These discussions revolve around individual patient encounters and include in layman’s terms candid explanations of the interventions, their limitations, and their curative potential.
