Between Life and Death

by Between Life

  The saving gospel of Jesus Christ transforms our view of dying. Even as we wrestle with decisions about ventilators and chest compressions, and even as we consider our final moments, we need not fear death! “For this light momentary affliction is preparing us for an eternal weight of glory beyond all comparison, as we look not to the things that are seen but to the things that are unseen” (2 Cor. 4:17–18). Christ has vanquished sin. Through the gospel, fear of our transient earthly death withers before the assurance of renewed life. As Christians, we share an immaculate hope unrivaled by any in human history. We rest assured of Christ’s promise by faith alone: “Whoever believes in me, though he die, yet shall he live, and everyone who lives and believes in me shall never die” (John 11:25–26). Christ’s resurrection transforms death from an event to be feared into an instrument of God’s grace as he calls us home to heaven. Although we die, we are alive in Christ.

  Preservation of Life versus Prolongation of Death

  To summarize, a gospel-centered approach to end-of-life care hinges upon the principles of sanctity of life, God’s authority over death, mercy, and hope in Christ. In concert, these tenets guide us to seek cure, but also to accept death when it arrives and to alleviate suffering when possible. Distinguishing between these elements—which appear stark on paper, but tangled and messy at the bedside—depends upon a key question: “Will life support in this scenario constitute preservation of life or prolongation of death and undue suffering?”

  Medical technology, while sophisticated, is imperfect. Life-sustaining measures are supportive, not curative. Doctors force air into the lungs, constrict blood vessels with potent drugs, filter the blood when kidneys fail, compel the heart to pump harder, and in experimental cases even bypass liver function, but none of these maneuvers cures disease. They only buy time.

  Life-sustaining treatment intends to buoy organ function long enough to correct the underlying illness. Physicians use such techniques to support us while they manage our widespread infection, occluded heart vessels, or stroke. If the inciting disease is treatable, then life support is indeed “life-saving,” because it maintains our body systems long enough for us to recover. However, if the core illness is irreversible, life support prolongs our dying without benefit.

  Why should we avoid prolongation of death? As previously outlined, God calls us to love our neighbors and to minister to the suffering. Life-sustaining technology inflicts suffering. Patients who survive critical illness report high rates of post-traumatic stress disorder (PTSD).3 Cardiopulmonary resuscitation (CPR), the chest compression technique that medical professionals perform with solemnity and television actors with bravado, breaks ribs.4 Patients undergoing mechanical ventilation report panic, anxiety, and fear of suffocation. Prolonged bed restriction breaks down skin, freezes joints, and induces pain with simple repositioning.

  Hope for recovery, with resultant preservation of life, warrants such extreme measures. Without expectation for improvement, however, these interventions constitute cruelty. Our challenge is to decipher when medical treatment has crossed the threshold from life saving, to death prolonging.

  Inviting Christ to the Bedside

  How does one weave these principles into the narrative of a loved one clinging to life? How do we deconstruct the lines and tubes and demystify the infusion pumps and the hum of continuous dialysis? How do we frame our own grief and desperation within the context of the gospel of Jesus Christ, our refuge and strength (Ps. 46:1)?

  Few physicians will volunteer for a spiritual dialogue. However, asking a medical care team specific, focused questions can illuminate where a condition falls along the spectrum between life and death. Armed with responses to these questions, as well as with biblical evidence of the sanctity of life, the value of mercy, and the inevitability of death, we can more clearly ascertain when the Lord urges us to press onward, or when he beckons us home:

  What is the condition that threatens my loved one’s life?

  Why is the condition life threatening?

  What is the likelihood for recovery?

  How do my loved one’s previous medical conditions influence his/her likelihood for recovery?

  Can the available treatments bring about cure?

  Will the available treatments worsen suffering, with little chance of benefit?

  What are the best and worst expected outcomes?

  Answers to these questions may unveil the truth with painful clarity. Some conditions so devastate the body that the certainty of death is obvious to all. More frequently, however, a clinical course fluctuates. Families and practitioners alike should return to this inquiry frequently, as recovery or decline evolves over time. Furthermore, all should feel empowered to seek second opinions, should we distrust the assessment of a treating physician.

  Paramount throughout end-of-life challenges is to couple contemplation with ardent prayer. Grief, anger, and anxiety flood both heart and mind during such ordeals and may obscure the path that God prepares for us. Compassion must galvanize our actions. When anguish and jargon disorient us, we must immerse ourselves in the Word of God, the Bible. Only then can we minister to one another and to those we love, when calamity ensnares us into an ICU.

  Take-Home Points

  A biblical approach to end-of-life care mandates consideration of four principles:

  1. Sanctity of mortal life

  2. God’s authority over life and death

  3. Mercy and compassion

  4. Hope in Christ

  Our life constitutes a gift from God, and our identity in Christ a call to glorify him in both our body and soul. We have a responsibility to preserve life when possible. We should consider accepting treatments that promise cure.

  Efforts to prolong life when there is limited hope of recovery threaten to prolong dying rather than save life, ignore God’s authority over death, and discount our great hope and faithfulness in Christ.

  When aggressive measures inflict suffering upon patients, either in excess of anticipated medical benefits or in the case of clear futility, we fail in our mandate to love one another.

  Asking a treating medical team key questions about disease and recovery can guide us to determine if aggressive treatments offer hope of life, or prolonged suffering and death.

  Part 2

  A Detailed Look at Organ-Supporting Measures

  3

  Resuscitation for Cardiac Arrest

  As we consider life-sustaining measures, it helps to categorize them into two classes:

  1. Resuscitation. When death is imminent, physicians intervene to salvage life (e.g., with CPR).

  2. Organ support. After initial resuscitation, organ support is continued in the ICU (e.g., with a mechanical ventilator).

  Untangling Definitions

  Overlap exists between these two categories, but this framework helps guide our thoughts as we consider end-of-life care. In this chapter, we will review the resuscitation phase, i.e., treatments offered acutely to save a life when death is imminent. The next chapter will provide an overview of organ support provided in the ICU.

  Paramedics, physicians, or other first responders responding to 911 calls perform resuscitative maneuvers when we go into cardiac arrest or when we stop breathing. Doctors may also resuscitate us in the hospital. Here we will focus on cardiac arrest, specifically CPR (cardiopulmonary resuscitation) and defibrillation. Physicians often place a tube into the airway during CPR, but we will defer discussion about that until our review of mechanical ventilation in chapter 5. Additionally, we will examine do-not-resuscitate orders in chapter 12.

  To begin, let us direct our attention past jargon and theory to the heart of the matter: the impact of cardiac arrest upon those who love, breathe, and yearn.

  At the Bedside

  He worked as an arborist until disseminated cancer snatched him from the treeline. When he retired his harness, dementia soon followed, and afternoons found him far from home, wandering in unfamiliar places and
conversing with strangers.

  During one such amble, he toppled down a flight of concrete stairs and lay bleeding on the pavement for half a day. A store clerk discovered him and called for help. When paramedics arrived, they could barely detect a pulse.

  Upon arrival at the emergency department (ED), his faint pulse disappeared. A dozen doctors and nurses scrambled to revive him. They pushed on his chest, pumped him full of powerful medications, and guided a tube into his windpipe.

  After half an hour, he regained a pulse but then lost it again. Several more rounds of CPR resumed. When his pulse finally returned, his blood pressure hovered precipitously low, and his heart rhythm convulsed in erratic beats. Laboratory tests revealed high levels of acid in his bloodstream, and failing kidneys. A computed tomography (CT) scan of his head showed a fractured skull and a large blood clot compressing his tumor-studded brain.

  When I entered his room to examine him, his daughter watched me through a sheen of tears. She huddled in her chair with her arms wrapped around herself and caressed a gold cross between two fingers.

  I rubbed his sternum, examined his head wound, and flashed a light in his eyes. His extremities were dusky and cool to the touch. Bruises blackened his skin. A high dose of medication dripped into his veins to constrict his blood vessels and shunt blood to his organs. As I watched the monitor, his heart tracing periodically spasmed into an ominous rhythm.

  I sat down with her and searched her face. Love, conflict, and despair deepened in her eyes. “I’m so sorry for what’s happened,” I ventured. The words seemed shallow, a string of platitudes.

  “I know it’s bad,” she replied. “He didn’t want any this. None of it. The other doctors . . .” she motioned to the door of the room. “They did what they had to. They didn’t know he was DNR.”

  “Wait—he had a do-not-resuscitate order?” Dread swept over me as I realized he had signed an order prohibiting the battery of invasive treatments he had just received.

  “Yes.”

  “How clear was he about his wishes?”

  “Before his mind started to go? He had a body full of cancer, and he knew it. He didn’t want any of this. But now they’ve done everything, and they want me to be the one to say, ‘stop.’ How can I do that? How can I say, ‘Don’t save my father’? He’s my dad. I love him.”

  When she spoke these last words, an alarm sounded, and his heart tracing flattened. We leapt in yet again with compressions and shouts and medications. As we performed CPR, his shoulders sprang off the stretcher with each thrust, with each grisly attempt to squeeze blood from his heart.

  After ten minutes of CPR had still not achieved a pulse, she asked us to stop. Agony darkened her face. As the crowd of clinicians thinned from the room, and as I too exited with eyes downcast, I glimpsed her holding her head in her hands and weeping.

  It’s Not Like on TV

  The emergency bay in which my treetop-seeking patient clung to life harbored no hint of excitement. As is so common when death looms, the air hung heavy with sorrow and yearning (Ps. 42:2). The loss of a life has a way of hollowing us out, of expunging all traces of hope.

  Unfortunately, such realities defy the expectations promoted by popular media. Sitcoms portray cardiac arrest in moments thick with hyperbole, with nurses hollering for help and heroic doctors rushing in with paddles raised high. While such depictions capture the adrenaline of medical crises, they ignore the desperation and dread that seize all involved. They dismiss the brutality inherent to resuscitation and the remorse that troubles doctors and nurses who, as adherents to a profession built upon altruism, are paradoxically tasked with administering treatments that seem barbaric and futile. They disregard the turmoil thrust upon families as their loved ones linger between life and death, suspended in a place where God’s will appears elusive.

  In addition to trivializing the emotional upheaval that resuscitation stirs, television can wrongly skew confidence in CPR. Outcomes in the hospital differ starkly from the grand portrayals on TV.1 Sitcoms depict a CPR survival rate double that which occurs in the real world.2 Additionally, rarely do TV programs illustrate treatment limitations, and they ignore the effects of preexisting health conditions that significantly worsen CPR outcomes.3

  Such inaccuracies mislead us. In one survey of patients over the age of seventy, the majority of whom cited television as their source of information, 81 percent estimated their chances of surviving CPR at 50 percent or better.4 Twenty-three percent thought their chances of survival was as high as 90 percent. In reality, the survival rate after CPR is dismal. On average, less than 10 percent of patients who receive CPR leave the hospital alive.5 Fallacious depictions of CPR in popular media are not only dishonest, but dangerous, because they lull us into false hope. They convince us to chase after brutal treatments even in futility.

  To navigate issues of resuscitation with discernment, we must put down our smartphones. With faith in Christ motivating our quest, we must disregard hyperbole and examine the realities of cardiac arrest and resuscitation with clear vision. We must cast aside drama and consider reality with our minds and hearts fixed on the cross (Col. 3:17).

  Introduction to Cardiac Arrest

  The job of the heart is to pump blood throughout the body. Blood collects oxygen from small blood vessels in your lungs, and then the heart pumps this blood to your organs, to supply your cells with the oxygen they need to produce energy. Cardiac arrest occurs when this delivery system fails. Physicians commonly refer to cardiac arrest as the heart “stopping”; however, in most cases the heart actually continues to beat but does so ineffectively. When the heart cannot pump blood with enough strength to produce a pulse in the neck, oxygen deprivation damages cells within minutes. Without an adequate supply of oxygen, cells eventually deplete their energy reserves and die.

  The speed and extent of cell injury in cardiac arrest depends on the organ in question. For example, skeletal muscle, like that in your arms and legs, can sustain lack of oxygen for as long as thirty minutes. In contrast, the needs of the brain are so high, and its energy reserves so limited, that without oxygen its cells suffer irreversible damage in just four to six minutes.6 So vulnerable is the brain to low oxygen levels that cardiac arrest is associated with a high risk of brain damage, especially with any delay in CPR. If blood flow is not restored quickly after cardiac arrest, you suffer severe brain damage at best. If cardiac arrest cannot be reversed, death is inevitable.

  Causes of Cardiac Arrest

  The heart contains a network of electrical fibers, with a bundle between the upper (atrial) chambers coursing like a power cable toward the lower (ventricular) chambers. This bundle ensures the normal flow of blood to and from the heart.

  In two-thirds of cardiac arrest cases, this electrical system in the heart misfires.7 Electrical cells elsewhere in the heart can override command of the main bundle in severe disease, and when this happens the heart takes on a chaotic rhythm. In some cases, the heart muscle quivers, without coordination between chambers (ventricular fibrillation, or V-fib). In others, the ventricles pump too quickly to fill with blood (ventricular tachycardia, or V-tach). In the worst cases, electrical activity of the heart stops altogether (asystole). Any of these scenarios can produce cardiac arrest, i.e., loss of a pulse due to diminished blood flow throughout the body.

  In the remaining cases of cardiac arrest, the heart beats with a normal rhythm, but disease or injury impedes delivery of blood to the organs. Trauma, massive bleeding, myocardial infarction (“heart attack”), and clot within the arteries of the lungs are common culprits.

  Cardiopulmonary Resuscitation (CPR)

  CPR refers to manual compression of the heart between the backbone and the breastbone. Clinicians place their hands on your chest and press down with their upper-body weight to squeeze your heart between your sternum and your spine. This maneuver mimics circulation and aims to maintain blood flow to the brain and heart until cardiac arrest can be reversed.

  Contrary t
o popular perception, CPR does not fix cardiac arrest. Rather, it aims to provide oxygen to brain cells until doctors can correct the cause of cardiac arrest. In other words, CPR buys time.

  In the event of a quickly reversible problem, CPR saves lives. Even outside the hospital, with only nonprofessional bystanders available to help, CPR increases the likelihood of survival from cardiac arrest threefold.8 As a striking example, a young patient of mine fell unconscious in the ICU when his heart lapsed into a fatal rhythm (arrhythmia). After a minute of CPR and one shock with the defibrillator, he sat bolt upright in bed. With his face screwed into a befuddled expression, he scanned the hoard of clinicians staring at him and asked why his room was so crowded.

  Such dramatic outcomes with CPR occur most commonly among healthy patients with a quickly fixable issue. More complicated circumstances, in contrast, should temper our enthusiasm. While essential for survival, CPR can inflict serious harm when employed indiscriminately.

  After fifteen years, the memory of my first experience with CPR continues to haunt me. In a middle-of-the-night emergency as a medical student, I performed my first-ever round of compressions on an elderly woman whom I had never met. She appeared haggard, her muscles wasted away, her sunken temples betraying years of debilitating disease and malnutrition. Her lifeless eyes were fixed on the ceiling.