One of the most challenging areas where medicine, ethics, morality, and social policy collide is that of end-of life decisions. A reader posed a question regarding sustaining life vs. terminating care in those who are not terminal per se, but no longer have intact cognitive function, e.g. severe dementia and persistent vegetative state: I was wondering if you’d answer a question. … I have a real problem with the idea of removing someone’s feeding tube unless their systems are shutting down and they can no longer absorb nutrients … I just heard a Medical Director of a nursing home on the radio talking about Alzheimer’s patients losing their appetite and having feeding tubes inserted. The MD thinks removing the tube in such circumstances is justified. Perhaps it is if their systems are shutting down and they no longer want to eat… I saw your post about extraordinary measures and agreed with it. But, as a Christian doctor, do you see acceptable parameters in all this? The challenge of end-of-life decisions is a byproduct of our successes and breakthroughs in preserving and sustaining life. They are the unintended consequence of technological advancement. 50 years ago, it is likely that a young woman with cardiac arrest would have died before she received emergency care, or if not, would likely have passed away shortly thereafter from complications, such as sepsis, embolus, or pneumonia. The advancements in acute emergency medical care and resuscitation have saved many lives, but some of these lives end up so severely impaired that the success proves a Pyrrhic victory. The moral and ethical dilemmas which have arisen from our dramatic improvements in emergency care go straight to the heart of what it means to be human, to be alive, to have meaning and quality in life. If one must use a pigeonhole, I would certainly be classified as a pro-life proponent. Life is perhaps the most precious gift given by our Creator, and cannot simply be measured by a superficial standard such as health, mobility, or even lucid mentation. Yet life is a gift, and not a god. As I have written in Dancing with Death, dying itself is also an integral part of life, and irrational and misguided attempts to prolong it can be very destructive, demeaning, and degrading to its dignity. It seems to me that there is considerable confusion in our contemporary discussion of end-of-life decisions, engendered by such unfortunate and inexact terms as “pulling the plug.” And each situation must be judged by its own merits, taking into account the overall prognosis for life, patient and family wishes, and the potential for the patient to return to some measure of meaningful relationship with family and others. Here are the core principles I fall back on when considering these difficult decisions. They are by nature generalizations, and exceptions will arise (especially in the very elderly), but they are useful guideposts nevertheless: Life is more than any of its components. We are more than our health, more than our bodies or mind. We are a composite of these things, and more: comprised of soul and spirit, defined as much by our relationships as by our physical or mental capabilities. Our lives do not become meaningless because of physical illness or disability, nor because of mental incapacitation — hereditary or acquired. Our relationships with other humans and with God define us — and not only our ability to relate to others (lost in persistent vegetative state and severe retardation or dementia), but also the relationship of others to us. This why, even though severely mentally impaired and unable to relate to others, an individual still has great value: they are of great value to God, and to others who love and care for them. When we narrow the meaning of life down to physical health or mental capacity, and deem it unworthy based on such factors alone, we are destroying that which is precious to others. When the individual’s outlook from a life-threatening acute or chronic illness is optimistic, or uncertain, we should choose to preserve life. Consider two scenarios: a previously healthy man arrives at the emergency department with cardiac arrest of undetermined length. He is resuscitated, requiring placement on a ventilator. His cerebral function is impaired, perhaps comatose, but it is early in the illness, and his expectancy of return to a normal life is potentially optimistic. Ventilatory or other artificial life support in this situation, where the prognosis of the underlying condition and the chances for optimistic recovery are good, or uncertain, should be aggressively pursued. This is an entirely different situation from stopping ventilatory support for patient who requires it to live, and for whom clinical evidence, such as length of time in a coma, or absence of brain activity on EEG, indicate little or no chance for functional recovery. In the first case, the cessation of life support will terminate the patient who may well have a very good outcome and lead a normal or nearly normal life; in the second, the patient’s chances of recovering spontaneous breathing and cerebral function are nil, and therefore cessation of ventilatory support allows the underlying disease process to take its natural course. A similar scenario might be found in the patient who is dying of cancer and requiring ventilatory support, where the life support has no hope of changing the outcome — death — but only of changing its timing and prolonging its suffering. The outlook spoken of here involves both mental, relational, and physical, although mental and relation have a much higher priority. Few would argue that Christopher Reeves should have had his life support terminated, despite the fact that he required a ventilator to live, as his mental facilities and ability to have relationships was intact. Those incapable of functioning mental, social, and relational abilities, but whose underlying condition is not a threat to life (e.g., persistent vegetative state), should be sustained with basic care and life support. The persistent vegetative state is…
Category: Death & the Afterlife
Death and the afterlife viewed from a Christian perspective
Dancing With Death
The war rages on. It is a battle with ancient roots, deeply embedded in religion, culture, and the tensions between rich and poor. It is a war of contrasts: high technology and primitive cultural weapons; knowledge versus ignorance; speed and urgency against the methodical slowness of an enemy who knows time is on his side. It is a war in which enormous strides have been made, with countless victories large and small. The enemy is death. The avenger is medicine. And the war is going very poorly indeed. In many ways, the gains of modern medicine against death and disease are truly impressive: longer life expectancy; progress and cures against heart disease, cancer, and diabetes; surgical and procedural marvels hard to imagine even 15 or 20 years ago. Yet, it is these very advances which seem to lie at the heart of a growing problem. We are so engaged in the battle, so empowered by our growing capabilities, that we have lost sight of the bigger picture. While pushing back the adversary of death, we are ever so steadily being destroyed by the very battle itself. Several experiences have driven this dichotomy home for me. Recently I was asked to evaluate a man who had been hospitalized for a over a week. A nursing home resident in his late 80’s, his overall health was fair to poor at best, and he suffered from severe dementia. He was unable to communicate in any way, and could recognize no one — not even his wife of many years, who remained in possession of her full facilities. He was admitted to the hospital with a severe urinary tract infection with a highly resistant bacteria, and septic shock. When he arrived at the ER, the full extent of his dementia was not apparent to the physicians there, and his wife insisted that all measures be engaged to save him. Aggressive medical care was therefore initiated — intensive care unit, one-on-one nursing care, hemodynamic monitoring, drugs to support blood pressure, intravenous nutrition, and costly antibiotics. After nearly two weeks of such intensive therapy, the patient largely recovered from his life-threatening infection — returning to his baseline of profound dementia. Yet the underlying risk factors which led to it — his age, a chronic bladder catheter and bacteria-harboring stones, diabetes, — remained in place, lying in wait for another, inevitable opportunity, in a matter of weeks or months. The cost of his hospitalization was easily in 6 figures. In another situation, an elderly women presented to the hospital with signs of a serious, life-threatening infection in her abdomen. A healthy widower, she lived independently with her sister prior to her illness. Emergency surgery was performed, and an abscessed kidney removed. Her medical condition deteriorated after surgery, with coma due to stroke and failure of her remaining kidney brought on by the infection. The patient’s sister and living companion communicated the clear final wishes of the widower: a women of strong faith, she wished no extraordinary measures, such as ventilators or dialysis, to extend her life needlessly. She was comfortable with death, and not afraid. The staff prepared to allow her to die gracefully, comfortably, and in peace. But such was not to be. There was no living will, and the sister did not have legal authority to make such decisions. But the widower’s daughter, a nurse living out-of-state with little recent contact with her mother, arrived in town demanding that aggressive measures be taken to save her. A nephrologist (kidney specialist) was called in. A superb physician, compassionate and dedicated, he had been successfully sued in a similar case after recommending that dialysis be withheld in a patient with a grim prognosis. This was a mistake he would not make twice: the widower was transferred to another hospital, placed on dialysis, and died 3 weeks — and a quarter of a million dollars — later, in an ICU. She never woke up. The issues which these two cases bring up are numerous, complex, and defy easy answers. They touch upon the subjective measure of quality-of-life and what it is worth; the finite limit of economic health care resources; the relative responsibilities of physicians, patients, and their families in end-of-life decisions; the pressures placed on the health care system and its practitioners by after-the-fact second-guessing in an aggressive tort environment; and a host of others greater or lesser in weight and substance, up to and including the meaning of life itself. All the players bear responsibility in this passion play. Physicians excel at grasping what they can accomplish, but are woefully inadequate for the task of deciding whether such things should be done. In the urgency of acute care, delay to consider the ramifications of a decision to treat may cost an opportunity to save a patient for whom such treatment is desirable; better always to err on the side of salvage. Pressured by family, potential litigation, or instinct, the path of least resistance is to follow your training and use your skills. And physicians themselves are uncomfortable with death, though inundated in its ubiquity. Family members naturally resist the agonal separation of their loved ones, often harboring unrealistic hopes and expectations of recovery in the face of inevitable death. A curious dance of denial often ensues between physician and family, as each, unwilling to face the unpleasantness of the inevitable, avoids the topic at all costs. The physician hides behind intellect, speaking of blood counts, medications, and ventilators, or at best tiptoeing around the core issue with sterile terms like “prognosis.” Family members hesitate to ask questions whose answers they already know. Too rarely are the physician and family willing to place the subject squarely on the table, in all its ugliness and fearfulness. Decisions which need to be made are put off, unspoken and deferred. The clock ticks on, the meter is running, and only the outcome is not in doubt. The tort system provides a ready outlet for the anguish and anger of…
A Life Not Long
Recently, I’ve been ruminating on a subject which is a frequently heard online and elsewhere: the endless pursuit of a longer — or eternal — life. Here’s the question I’ve been pondering: is it an absolute good to be continually striving for a longer life span? Such a question may seem a bit odd coming from a physician, whose mission it is to restore and maintain health and prolong life. But a recent article describing the striking changes in health and longevity of our present age, seemingly presents this achievement as an absolute good, and thereby left me a tad uneasy — perhaps because I find myself increasingly ambivalent about this unceasing pursuit of longer life. Of course, long life and good health have always been considered blessings, as indeed they are. But long life in particular seems to have become a goal unto itself — and from where I stand is most decidedly a mixed blessing. Many of the most difficult health problems with which we battle, which drain our limited resources, are largely a function of our longer life spans. Pick a problem: cancer, heart disease, dementia, crippling arthritis, stroke — all of these increase significantly with age, and can result in profound physical and mental disability. In many cases, we are living longer, but doing so restricted by physical or mental limitations which make such a longer life burdensome, both to ourselves and to others. Is it a positive good to live to age 90, spending the last 10 or more years with dementia, not knowing who you are nor recognizing your own friends or family? Is it a positive good to be kept alive by aggressive medical therapy for heart failure or emphysema, yet barely able to function physically? Is it worthwhile undergoing highly toxic chemotherapy or disfiguring surgery to cure cancer, thereby sparing a life then severely impaired by the treatment which saved that life? These questions, in some way, cut to the very heart of what it means to be human. Is our humanity enriched simply by living longer? Does longer life automatically imply more happiness — or are we simply adding years of pain, disability, unhappiness, and burden? The breathlessness with which authors often speak of greater longevity, or the cure or solution to these intractable health problems, seems to imply a naive optimism, both from the standpoint of likely outcomes, and from the assumption that a vastly longer life will be a vastly better life. Ignored in such rosy projections are key elements of the human condition — those of moral fiber and spiritual health, those of character and spirit. For we who live longer in such an idyllic world may not live better: we may indeed live far worse. Should we somehow master these illnesses which cripple us in our old age, and thereby live beyond our years, will we then encounter new, even more frightening illnesses and disabilities? And what of the spirit? Will a man who lives longer thereby have a longer opportunity to do good, or rather to do evil? Will longevity increase our wisdom, or augment our depravity? Will we, like Dorian Gray, awake to find our ageless beauty but a shell for our monstrous souls? Such ruminations bring to mind a friend, a good man who died young. Matt was a physician, a tall, lanky lad with sharp bony features and deep, intense eyes. He was possessed of a brilliant mind, a superb physician, but left his mark on life not solely through medicine nor merely by intellect. A convert to Christianity as a young adult, Matt embraced his new faith with a passion and province rarely seen. His medical practice became a mission field. His flame burned so brightly it was uncomfortable to draw near: he was as likely to diagnose your festering spiritual condition as your daunting medical illness — and had no compunction about drilling to the core of what he perceived to be the root of the problem. Such men make you uneasy, for they sweep away the veneer of polite correction and diplomatic encouragement which we physicians are trained to deliver. Like some gifted surgeon of the soul, he cast sharp shadows rather than soft blurs, brandishing his brilliant insight on your now-naked condition. The polished conventions of medicine were never his strength — a characteristic which endeared him not at all to many in his profession. But his patients — those who could endure his honesty and strength of character — were passionate in their devotion to him, personally and professionally. For he was a man of extraordinary compassion and generosity, seeing countless patients at no charge, giving generously of his time and finances far beyond the modest means earned from his always-struggling practice. The call I received from another friend, a general surgeon, requesting an assist at his surgery, was an unsettling one: Matt had developed a growth in his left adrenal gland. His surgery went deftly, with much confidence that the lesion had been fully excised. The pathology proved otherwise: Matt had an extremely rare, highly aggressive form of adrenal cancer. Fewer than 100 cases had been reported worldwide, and there was no known successful treatment. Nevertheless, as much for his wife and two boys as for himself, he underwent highly toxic chemotherapy, which sapped his strength and left him enfeebled. In spite of this, the tumor grew rapidly, causing extreme pain and rapid deterioration, bulging like some loathsome demon seeking to burst forth from his frail body. I saw him regularly, although in retrospect not nearly often enough, and never heard him complain; his waning energies were spent with his family, and he never lost the intense flame of faith. Indeed, as his weakened body increasingly became no more than life support for his cancer, wasting him physically and leaving him pale and sallow, there grew in him a spirit so remarkable that one was drawn to him despite the natural repulsion of watching death’s demonic…
Crossing That Dark River
Often in the sturm und drang of a world gone mad, there comes, through the chaos and insanity, some brief moment of clarity. Such times pass by quickly, and are quickly forgotten — as this brief instance might have been, courtesy of my neighboring bell weather state of Oregon: Last month her lung cancer, in remission for about two years, was back. After her oncologist prescribed a cancer drug that could slow the cancer growth and extend her life, [Barbara] Wagner was notified that the Oregon Health Plan wouldn’t cover it. It would cover comfort and care, including, if she chose, doctor-assisted suicide. … ‘Treatment of advanced cancer meant to prolong life, or change the course of this disease, is not covered by the Oregon Health Plan’, said the unsigned letter Wagner received from company that administers the plan. Officials of the plan and the state policy-making Health Services Commission say they’ve not changed how they cover treatment of recurrent cancer. But local oncologists say that … patients with advanced cancer no longer get coverage for chemotherapy if it is considered ‘comfort care’… Studies have found that chemotherapy can decrease pain and time spent in the hospital and increases quality of life… We have, at last, arrived. The destination was never much in doubt — once the threshold of medical manslaughter had been breached, wrapped as always in comforting words of compassion and dignity, it was only a matter of time before our pragmatism trumped our principles. Once the principle that physicians should be healers, not hangmen, was heaved overboard, it was inevitable that the relentless march of relativism would reach its logical port of call. Death, after all, is expensive — the most expensive thing in life. It was not always so. In remote pasts, it was the very currency of life, short and brutal, with man’s primitive intellect sufficient solely to deal out death, not to defer it. There followed upon this time some glimmer of light and hope, wherein death’s timetable remained unfettered, but its stranglehold and certainty were tempered by a new hope and vision of humanity. We became in that time something more than mortal creatures, something extraordinary, an unspeakable treasure entombed within a fragile and decomposing frame. We became something more than our mortal bodies; we became something greater than our pain; we became a thing whose beauty shown through even the ghastly horrors of the hour of our demise. Our prophets — then heeded — triumphantly thrust their swords through the dark heart of death: “Death, where is your victory? Death, where is your sting?” We became, in that moment, something more than the physical, something greater than our short and brutish mortality. We became, indeed, truly human, for the very first time. That humanity transcended and transformed all that we were and were to become, making us unique among creation not only in the foreknowledge of our death, but our transcendence of death itself. Life had meaning beyond the grave — and therefore had far more weight at the threshold of the tomb. Suffering became more than mere fate, but rather sacrifice and purification, preparation and salvation. The wholeness of the soul trumped the health of the body; death was transformed from hopeless certainty to triumphant transition. But we knew better. We pursued the good, only to destroy the best. We set our minds to conquer death, to destroy disease, to end all pain, to become pure and perfect and permanent. We succeeded beyond our wildest dreams. The diseases which slaughtered us were themselves slayed; the illnesses which tortured and tormented us fell before us. Our lives grew long, and healthier, more comfortable, and more productive. Our newfound longevity and greater health gave rise to ever more miracles, allowing us to pour out our intemperate and prodigious riches with drunken abandon upon dreams of death defeated. Yet on the flanks of our salient there lay waiting the forces which would strangle and surround our triumphant advance. Our supply lines grew thin; the very lifeblood of our armies of science and medicine, that which made our soldiers not machines but men, grew emaciated and hoary, flaccid and frail. We neglected the soul which sustained our science; the spirit which brought healing to medicine grew cachectic and cold. So here we stand. We have squandered great wealth to defeat death — only to find ourselves impoverished, and turning to death itself for our answers. The succubus we sought to defeat now dominates us, for she is a lusty and insatiable whore. We have sacrificed our humanity, our compassion, our empathy, our humility in the face of a force far greater than ourselves, while forgetting the power and grace and the vision which first led us and empowered us on this grand crusade. Our weapons are now turned upon us; let the slaughter begin. We will, no doubt, congratulate ourselves on the wealth we save. We will no doubt develop ever more ingenious and efficient means to facilitate our self-immolation while comforting ourselves with our vast knowledge and perceived compassion. Those who treasure life at its end, who find in and through its suffering and debilitation the joy of relationships, and meaning, and mercy, and grace, will become our enemies, for they will siphon off mammon much needed to mitigate the consequences of our madness. It has been said, once, that where our treasure is, there will our heart be also. We have poured our treasure in untold measure into conquering death — finding succor in our victories, while forgetting how to die. The boatman now awaits us to carry us across that dark river — and we have insufficient moral currency to ignore his call.