Between Life and Death

by Between Life

  Even with the comprehensive support of hospice, death can scare us as it approaches. In a tragic scenario all too familiar to emergency medicine clinicians, a hospice patient who has lovingly and peacefully lived out her last weeks at home suddenly arrives in the emergency department intubated and with CPR in progress. Even with education and hospice support, we can panic when death looms. Hospice staff encourage us to call them in the event of a worsening medical condition; however, fear can compel us to call 911 instead. In such scenarios, even when we elect to focus on meaningful time in our final days, we can suffer painful medical treatments in vain and ultimately die in the hospital.

  What to Expect in the ICU

  As we consider our advance directives (chapter 12), we need to remember that intensive-care technology, although it can preserve life in the right circumstances, can rob us of speech and mental clarity at the end of life. When patients transition to comfort measures in the ICU, they rarely have opportunities to communicate. Final conversations with loved ones or time spent in prayer to reconcile ourselves to God seldom occur. This lack of closure can strip all involved of their resolve and hope. It can steal from us the opportunity to examine the trajectory of our lives, settle unfinished issues, heal fractured relationships, and set our eyes upon the new heavens and the new earth (Isa. 65:17; 2 Pet. 3:13).

  In comfort measures, nurses stop all blood draws and other maneuvers that cause pain. Pressors and other cardiovascular medications are discontinued, as is dialysis. For those of us on minimal ventilator support, the endotracheal tube is often removed to maximize comfort and permit communication. When we require high levels of ventilator support, however, approaches vary. Death can occur rapidly after tube removal if we depend upon the ventilator for survival, and in some cases continuing the ventilator but reducing its settings to improve comfort may avoid traumatic air hunger at the end of life. In other cases, physicians prescribe sufficient doses of medications to alleviate distress after tube removal, enabling discontinuation of the ventilator even in severe respiratory failure.

  Oftentimes ICU staff lift certain visiting restrictions for those receiving comfort measures, allowing family members to remain in the room for as long as they choose. Nurses turn off all monitors and alarms in the room, although such screens continue to project at the nursing stations so that clinicians may respond to any changes indicative of pain, fear, or agitation.

  Key symptoms that surface as death nears are pain, anxiety, and shortness of breath. Difficulty breathing occurs as levels of acid rise in the bloodstream, compelling us to breathe faster to clear carbon dioxide and restore a normal acid-base balance. To guard against such distress, physicians often prescribe a morphine infusion. Morphine not only treats pain but also slows breathing and relieves the sensation of breathlessness. Nurses carefully monitor not only any signs of pain but also quickened breathing and will fine-tune the infusion accordingly.

  In the ICU, people near death often suffer from delirium and somnolence, and families may fear that narcotic infusions will lethally sedate their loved ones. Although morphine does sedate, rarely does an infusion quicken death.13 Unlike cases of physician-assisted suicide, in comfort measures the aim of narcotics is to palliate symptoms, not to speed demise.

  In the final hours and minutes before the end, patients adopt unusual breathing patterns that can unsettle us. They lapse into cycles of deep, sometimes rapid breathing followed by a period of shallow breaths, and then up to two minutes without taking a breath. Patients may gasp as these cycles recur, and secretions in the upper airway can create an alarming rattling sound.

  Reading about such symptoms is disturbing, but it might be comforting to know that they occur when death draws very close and the patient is already unconscious. While to onlookers we may appear to gasp for air, in fact we are drawing close to our Savior.

  Out of the Depths I Cry to You

  As our bodies fail, we need to lean ever more fervently upon God—our rock, our salvation, the edifice upon which we rest our hopes (Ps. 18:2). Lord willing, we recognize our own mortality before it seizes us and enjoy days still rich with God’s workmanship, seek him prayerfully, and continue to serve him with our remaining breath (Phil. 1:22–26). Open and frequent dialogue with clergy and with primary doctors about our goals can aid us in living well while we can and in seeking hospice if eligible.

  For those of us who spend our last days surrounded by the unfamiliar, and for the loved ones whom we leave behind, hope in Christ Jesus is all the more precious. However terrible the toils of this world, and however gravely death’s shadow unsettles us, the Lord remains steadfast in his love for us (Ps. 136:1). While our time in this world crumbles away, we rest assured of the promise of a new heavens and a new earth, when the calamity of disease no longer reigns (Rev. 21:4). Death does not signal the end. Not even its sting can separate us from the love of God through Christ (Rom. 8:38–39).

  Take-Home Points

  When medical interventions at the end of life threaten to harm rather than help, goals of treatment shift from cure to comfort.

  Those who are terminally ill may be eligible for hospice. In hospice care, an interdisciplinary team assists patients with the goal of maximizing quality of life as death nears.

  Hospice care often allows patients to spend their last days at home and is associated with better quality of life, less caregiver grief, and improved survival in some cases.

  Critically ill patients near death usually cannot survive an ambulance ride home to initiate hospice care. In these situations, ICU physicians, in collaboration with loved ones, transition care goals from cure to comfort measures only.

  In comfort measures, all treatments that inflict pain or discomfort are discontinued, and medications are given to treat pain and anxiety.

  The decision to shift to comfort measures only can strike caregivers with regret, guilt, and grief, with long-lasting impact. Patients often cannot participate in decision making themselves and rarely communicate with loved ones when they die in the ICU.

  11

  Physician-Assisted Suicide

  With its recent sweep in legalization, physician-assisted suicide (PAS) promises to confront us with increasing frequency in the coming years. As medical technology wrenches dying from the home and commits so many to a long, debilitating end, the permissibility of assisting in death as an act of mercy has become woven into the public consciousness. Just as prayerful consideration of organ-supporting measures can better equip us to tackle end-of-life dilemmas, so also can an examination of PAS from both medical and biblical standpoints prepare us to respond to the issue in the light of the gospel.

  Defining Terms

  Controversy over assisted death broils over two practices: voluntary active euthanasia (VAE) and physician-assisted suicide (PAS). In VAE, at a patient’s request a medical practitioner administers a lethal dose of medication, usually via IV injection, to speed dying. In PAS, physicians prescribe a lethal dose of pills, usually a powerful anti-seizure medication that deeply sedates, for a patient to ingest in his own timing.

  Although some countries in Europe have embraced VAE, it remains illegal throughout the US. Debate about PAS, however, currently rages. As of September 2018, PAS is legal in California, Colorado, the District of Columbia, Montana, Oregon, Vermont, and Washington State. One in 5.5 people in the United States has access to PAS practices.1

  Most states limit consideration of PAS to terminally ill people with a life expectancy of less than six months—the same eligibility criteria for hospice care. In Oregon, the state with the longest history of legal PAS, since 1997 1,127 people have died after ingesting lethal doses of medications prescribed by physicians.2

  Nebulous Ethics

  Before I knew Christ, I had compelling reasons to advocate for physician-assisted suicide. When I was a child, one of my relatives developed a debilitating disease that attacked the nerves controlling his muscles. The condition traps its victims within a paralyzed body, even
while they remain aware and mentally sharp. Over time, he lost his ability to speak and relied upon a handheld keyboard to communicate in a robotic voice. He could no longer smile or dress himself, and fits of choking seized him when he attempted to eat. As a fiercely brilliant and aloof man who prized his self-sufficiency, over time his loss of independence fractured his spirit. His wife recounted with tears how they would embrace at random in the hallway or after she helped him to eat or dress. Such embraces occur regularly in many families, but for this couple, it was a new phenomenon, a green shoot of tenderness breaking through as witness to their grief.

  One morning, while his wife was out, he laid a black plastic tarpaulin out upon the lawn of their backyard. He lay down among the birds and the trees he had so admired over the years. Then he raised a gun and took his own life.

  While his death sent us reeling, a stack of letters on the kitchen table revealed the detail with which he’d calculated his end. The first note alerted his wife to call 911. In the remaining sheaves he recounted his fondest memories of bringing new babies home from the hospital. At the close of one of the letters, in a shaky scrawl that remained emblazoned upon my mind as I donned my white coat and recited the Hippocratic oath years later, he wrote the words, “Support Kevorkian.”3

  Over the ensuing years, as I witnessed the suffering that welled up from every corner of the hospital, I would remember that letter and sympathize with proponents of PAS. I would recognize the same stifling despondency in my own patients that compelled my relative to end his life. Like PAS proponents I would wonder, Isn’t there a better way? Are we really demonstrating beneficence and justice and mercy as doctors when we so thrust people into suffering that suicide seems their best option?

  Compassion for Choices, the oldest nonprofit organization in America that advocates for PAS, writes in their introductory materials, “Our vision is a society where people receive state-of-the art care and a full range of choices for dying in comfort, dignity, and control.”4 Who wouldn’t agree with comfort, dignity, and control? Who would argue against compassion and choice at the end of life? Advocates of PAS assert that we all have a right to self-determination, including control over the circumstances of our death. When terminal illness strips people of the capacity to pursue life meaningfully, they argue, compassion and respect dictate that physicians honor requests to facilitate a peaceful death.

  Despite my sympathies with such arguments, as I hustled through the hospital before dawn each morning during my training to change dressings, listen to lungs, and field questions among those in my charge, I could never envision myself prescribing my patients pills with the intent of ending their lives. The abstract theory of PAS seemed appealing; the practical execution did not. As it happens, others share my hesitancy. Multiple surveys over the previous decades show that only half of US physicians support PAS.5 The American Medical Association condemns the practice in its code of medical ethics, stating, “Physician-assisted suicide is fundamentally incompatible with the physician’s role as a healer, would be difficult or impossible to control, and would pose serious societal risks.”6 Skeptics warn that the imbalance of power between physician and patient exposes the dying to abuse and coercion.7

  Even in the public sector, PAS generates confusion and uneasiness. In a 2012 Gallup survey, 64 percent of respondents agreed that doctors should be permitted to painlessly end a terminally ill patient’s life upon request.8 However, when the phrasing of the question was changed to include the term suicide, support dropped by 10 to 15 percent.9 This jarring change of opinion with substitution of a single word captures both the confusion PAS engenders and the ethical dubiousness fundamental to its debate.

  Compassionate, but Unbiblical

  When a tweak in semantics drastically shifts support for a life-and-death issue, we need to pay attention. Even the adversary disguises himself as an angel of light (2 Cor. 11:14). The scaffolding of any argument for PAS disintegrates when silhouetted against the Bible. “Your word is a lamp to my feet and a light to my path” (Ps. 119:105). God’s Word illuminates the way for us, even through the dismal and echoing confines of the hospital corridor.

  When comfort measures are employed, as we noted in the previous chapter, death may occur immediately, over the course of days and weeks, or not for months, depending upon the severity of illness. If someone survives, we never take further actions to facilitate death because the aim is not to end life but to palliate suffering.

  PAS, in contrast, drags us back to Mount Sinai. Among the ten commandments Moses received on that mountaintop, with “the thunder and the flashes of lightning and the sound of the trumpet and the mountain smoking” (Ex. 20:18), was the clear directive, “You shall not murder” (Ex. 20:13). Even when we soften words and disguise the issue with jargon, euthanasia violates this commandment. Although mercy and a respect for autonomy may motivate us, the active taking of another life, with the explicit goal to end it, violates God’s Word. In VAE, physicians commit murder directly; in PAS, they act as accomplices.

  Consider, for example, a frail women for whom I cared during my fellowship training in the ICU. She arrived in the emergency room in distress, her breathing rapid, her abdomen taut as a calfskin drum and excruciatingly painful to the touch. A surgeon rushed her to the operating room, where he found her viscera encased in tumor. The muddy yellow tint of intestinal contents stained her organs, betraying a bowel perforation, but disseminated cancer had frozen all her organs into place. The surgeon could not even manipulate her intestines to find the rupture.

  She arrived in the ICU intubated and sedated. “She’s going to die,” her surgeon said. “It was awful. What I would do is give her a big dose of paralytic and take the tube out.”

  At first, I thought he was making a macabre and tasteless joke. The medication he referenced paralyzes the muscles to help ventilation, but administering “a big dose” immobilizes the diaphragm. She would be unable to breathe on her own.

  Yet the surgeon’s expression remained severe. “I’m serious,” he said. “She shouldn’t have to know she’s about to die. I think the humane thing is to paralyze her and take out the tube.”

  Shocked, I tried to explain how this approach was out of the question. We would allow her to wake up and breathe, take the tube out, and do our best to support her in her last hours. We would treat her pain and encourage her family to remain with her.

  Unconvinced, the surgeon continued to insist. This time, a colleague of mine stepped in and was far more blunt:

  “Sorry, but that’s murder. We’re not in that business.”

  Discussions such as these occur rarely in medicine. I had never before debated such a request and have not since. Yet this encounter demonstrates how, when we loosen our grip upon the truth of God’s Word, we can commit immoral acts with kind intentions.

  On Autonomy

  Modern medicine prizes self-determination as a fundamental principle guiding medical care, and arguments for PAS uphold individual autonomy as the greatest good. The human right to pursue what we deem best for our lives, proponents of PAS reason, includes control over how we die.

  The Bible teaches that each of us has inherent value as an image bearer of God. Additionally, the Lord gifts us with free will and authorizes us to hold dominion over his creation (Gen. 1:26; 2:15–19). Christian principles, however, diverge from secular medical ethics on the issue of autonomy. In modern Western society, rugged individualism, and the freedoms it assumes, is a sacred virtue, the bedrock principle upon which the United States was founded. In the Bible, however, true freedom comes not from individualism but from using all we have and are to glorify God. From Colossians 3:17: “Whatever you do, in word or deed, do everything in the name of the Lord Jesus, giving thanks to God the Father through him.”

  In his first letter to the Corinthians Paul reminds us that while we remain free in Christ, the cross must temper our conduct: “You are not your own, for you were bought with a price. So glorify God in your body” (1
Cor. 6:19–20). Although God has granted us free will to steward his creation, we are to wield our freedom in service to him. Using it to serve ourselves leads us to break his commandments. Like Adam, we covet the premise that we can govern ourselves without limit and deny the authority of the one who blessed us with freedom in the first place.

  Our God-given ability to make individual choices does not justify the active taking of life through PAS. While God endows all of us with free will, our identity in Christ compels us to exercise our autonomy in faith, as an instrument of service. “‘All things are lawful,’ but not all things are helpful. ‘All things are lawful,’ but not all things build up” (1 Cor. 10:23).

  Options in Suffering

  The emergence of PAS in courtrooms and clinics signals our failure as a society to support the dying, particularly as illness disables us. The most common reason that people cite for pursuing PAS is not intractable pain, but rather loss of independence. A review of data in Oregon from 1998 to 2016 revealed that 79 to 92 percent of people who committed suicide with physician assistance cited loss of autonomy, inability to engage in activities that make life enjoyable, and loss of dignity as their motivations for ending life.10 The intractable pain we might assume at the end of life was a factor in only 25 percent of cases.11 These alarming statistics suggest not a solution in PAS but rather a gross failure on the part of American society to uplift people with progressive and debilitating illness.

  Sadly, the transfer of dying from the home to the hospital mirrors a nationwide institutionalization of the debilitated. As disease and age erode independence, the solution has been to admit our elderly to nursing homes to ensure their safety. While such facilities aim to provide compassionate care for the infirm, their performance benchmarks focus on medical details rather than on the richer nuances of living life well. Dr. Atul Gawande, endocrine surgeon and author of the book Being Mortal, eloquently stated the rift between medical and personal care when he testified before the Senate Special Committee on Aging in 2016: