Faith & Work: How Should We Think Biblically About End-of-Life Care?

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Bill Davis: My background in medicine is 27 years ago, I was told by the church chaired by department at a university in Ohio, the local hospital needs somebody to to be a community volunteer on their ethics committee, I think you should do that as community service. I was I was teaching ethics already. And I did. After doing that for a year, I added a bioethics course, to the curriculum at the college. And so I’ve been teaching undergraduate. And then I’ve done seminar level bioethics courses. But my medical training insofar as there’s any medical training is just being on ethics committees, and having friends who were doctors, usually friends that arose out of the work on the committee. So I’ve been a volunteer of continuously a volunteer and ethics committees for 27 years. And the the reason that my practical work has focused on end of life decisions is because that’s far more than 70% of what hospital ethics committees deal with hospital ethics committees usually are not in the weeds of experimental design. So if there’s going to be human subject research, so that in an undergraduate or graduate bioethics program, you would give pretty close attention to the history of mistreatment of subjects of medical research, the problems of expanding comfort. So how you do this safely, what what counts as exploiting people, all of that confidentiality, informed consent, all the things that go with medical research, so you do the theory about that. But ethics committees in hospitals, and large teaching hospitals might be doing research, the Ethics Committee, it used to be that the Ethics Committee decided whether the work was appropriate anymore, the legal part of it is complicated. And there needs to be a separate Institutional Review Board, where the members of the members of that board not only know the ethics, but they know the pharmacology, and they know the medical practice. And they know and they also know the literature well enough to know is this something worth risking exploiting people? Well, I don’t. I’ve been invited to serve as a volunteer on an institutional review board. But at the time, it was a long time ago. And at the time, I just, I didn’t think I knew enough about the the fact background, I can do the ethical theory. So ethics committees do that, that are not doing institutional review, board review board work, they really do two main things. They they advise families and the medical team when there’s confusion or a disagreement worst case, a disagreement between the family and the medical team about what comes next whether to whether there should be a do not resuscitate order on a patient, whether the ventilator that’s been the spin on it for 10 days, and the person is unconscious, and humanly speaking, not likely ever to regain consciousness, the medical team at that point, whether they’re Christians or not, and one of the some of the one thing I’ve learned, as I’ve served served on deeply dysfunctional, secular ethics committees deeply, profoundly, troublingly dysfunctional, and the Roman Catholic ethics committee that I’m, I’ve been serving on for the last 20 years. So I’ve I’ve kind of seen the range of what they might do and what I can’t the good news out of all of that, is that the most dysfunctional ethics committee, I think, possibly I was on the worst one in the country still thought that defending life is what doctors do. And so even in that setting, when the doctor said, isn’t the time to turn it off? What they were, what they meant was, medicine is everything that can be done, we’ve reached the end of so all the machine is doing now is flogging. They would sometimes say a corpse now, of course, it wasn’t a course. But to to the non Christian description of it, when you can smell rotting flesh and your your flesh can begin to decay before you’re dead. And you’re not responsive. You’re out. You’re probably not experiencing anything at all your your awareness. And yet, the machines still on your heart’s beating, possibly with electronic support, and you’re in the ventilators pushing air into your lungs and pulling it out. So as long as the autonomic system there is running the, you’re still alive? Well, so even non Christian doctors look at that and say, The medicine is not accomplishing anything productive. We’re not it’s not it’s not a comfort. It’s not restoration or cure, or whatever word the hospital uses for that goal of care. And so they’re just frustrated, and it isn’t. They’re not thinking about the money, they’re not thinking we need the bed. That’s one thing that COVID did is that it forced everybody to say, so at what point would we say we need your bed, we need that ventilator. Now that one, not like, we’re gonna run out the hospital where I volunteer, we never, we never tripped, we had to get to 75% of the ventilator available ventilators in use, before our triage, alternate standards of care policy would kick in, but we had right the whole policy. It never we never got there, we got to like 71% of available ventilators, but never went over the line. So we never had to say no to anybody or take somebody off. But we had to be ready to and we had to know how we would know which of the 36 people who were on ventilators were the one to give it up and go to a less successful mode of treatment for the sake of making it available to somebody who would who where the total benefit would be greater. But so that’s one of the things that hospitals had to do, because for the most part, you know, the American hospital system has capacity to absorb even that kind of surge. And so even though hospitals have on their books, policies about the allocation of scarce resources, they’ve the last time anybody had to worry about it was h one n one in 2009. So like 12 years of, and so people are taking out policies and like dusting them off?

How do we translate it to an entirely different, not an entirely, it’s a really different pathogen in terms of who it threatens, does he want anyone threatened 20 year olds, not 80 year olds. So that’s the sort of thing I’ve been doing. So you learn a lot of medicine passively, especially if you sit next to the head of Intensive Care Medicine at every meeting. And everybody’s talking about CR RT, and they all know what they’re talking about. It has something to do with kidneys, I can tell that. So I leaned over and asked, asked my friend, and he says that’s a continuous renal replacement there, anybody who wants it to go on for more than three days is evil. Not only when I get a little bit of medical education, I would get some, some nice evaluation to. That’s right. You know, so it’s much better than looking things up on your phone, because you’ve got a doctor, because the doctor is gonna tell you, here’s what everybody in the room thinks that brace means. So one of the things that when you teach undergraduates, so these are on their way to medical school, or nursing school or something, one of the things you have to put into the course is just a straightforward test on medical terminology, where they can, and they’re they’re great online tutorials, if you know Latin, and Greek, not to speak, but if you know the Latin and Greek words, or Greek roots, it’s really not terrible learning the medical terminology. So the students have to establish proficiency in the medical terminology, so that they can make sense of the doctors description of the case. But then they still we still practice asking, even when you’re embarrassed that you don’t know how, like you don’t know what that is, how would you ask in a way that won’t disrupt the conversation and make people laugh that you don’t know. So we practice all of those things, but it’s really fun to students get into it, they can see why this might matter. But the students who like they all quickly see that it’s going to matter. But the ones who have no trouble are the ones who had a loved one, if they were so if they were close to so my 20 year old college students, three of the five students that I had in this consultation class had had had been in the hospital in the waiting room when a grandparent had to listen to their parents got to listen to their parents talk to the doctors about the choices that had to be made. And they found it fascinating, but they also felt powerless. And their parents felt powerless, because there was so much that they didn’t understand. And one of the one of the hard facts about end of life care right now, and probably is going to stay this way is up until around 2000. If you were in the hospital, and you’re nearing death, the person who would be there to help you and your family understand what was going on and if you’re unconscious or the medicine is making it hard for you to tell what’s going on. So the family is going to have to make the decision, you’re going to be talking to the doctor who’s been doing physical exams on you your whole life, like for a very long time. So it’s going to be somebody you know, and when, when it just comes down to, you’re going to have to trust me, you can, that doesn’t happen nearly anywhere anymore other than in very small towns, where they probably don’t have an intensive care unit at all. So there’s a trade off here, but almost anywhere with large enough to have an intensive care unit, they have staff, physicians, intensivist. hospitalists, who are they are specialists in this sort of thing. And you want them to be the one who is responsible for your care, you want them to be the physician of record, because they know how hospital work, they can get it, if they think there’s a test that needs to be done, they can get the test done in minutes rather than days. Whereas your personal physician doesn’t know who to call, the hospital system is so complicated, doesn’t know which nurses are going to give a long and careful description of what’s going on, and which nurses are going to give an efficient description of what’s going on. Whereas the intensivist, this their staff, physicians, but it means that when you’re in the hospital, you’re dealing with a stranger. And so they’re never going to say trust me, but it’s going to be in every conversation, I’m giving you very hard, we’ve now reached a point where in my case, when my father was dying, a doctor that I’d never met, and at this point didn’t trust because his sense of whether my dad could speak for himself was I thought wrong.

So he said, but he gave me the news, your father’s never going to leave the house. I didn’t trust him. But I was also pretty sure that there is no doctor that would say that unless they had a really good medical reason for it. It wasn’t that he was tired of taking care of him, or that he thought that my dad’s life was worthless, or that because his health had deteriorated to this point that he should just go and die somewhere. I didn’t think I trusted the medical judgment even when I didn’t really like him. But that’s a hard without a lot of experience, talking with doctors about end of life cases. I think my trust in this person that I didn’t know at all. And like in another city, it was in Washington state it wasn’t in wasn’t around here. I think the experience meant that I had seen enough of these cases to know, you know, that’s actually a pretty reasonable thing for a doctor to say. But if if I didn’t have that experience, I would want to talk to somebody who I knew who I could trust. Who could say that sounded important. Do I believe because it’s going to it like an awful lot is going to depend on whether that’s true? Do I Do I trust him? So I think that’s part of one of the things that the book hopes to do. And one of the things I hope to communicate to my students is that there are ways that you can help people that you don’t know terribly well, it’s that you’re going to either give them or ask the questions yourself, were pretty quickly, you’ll be able to tell Okay, the doctor does care about about my father, even though I that was too quick. He does care. He is a professional, the judgment that he just gave, I can base other decisions on the judgment that he just gave. And that’s you want to get there. Because until if you’re advising someone who’s making a lot of life decisions, they they need to they need to know two things. They need to know what is the medical condition, and then they need someone else to help them remember what the person who can’t speak for themselves anymore valued. Now, ideally, you know, what they valued? You and you put if you’ve got siblings or they have siblings, there are other people who know them. Well, people from church, if you’re not from there, you can get other people into the conversation. And not just go ahead, the more you can depend on other people to confirm your sense of what they would have valued. So here’s let’s go difficult and possibly gracefully. Someone’s never gonna regain consciousness, and you’re talking with them about so what do we do then the doctors are saying let’s let’s go to the hardest of all, the doctors are saying we think that now’s the time to attempt to wean them from the respirator. And one of the things that we think is likely to happen is that they won’t be able to breathe on their own, and they will then die. We don’t think they’re ever going to regain consciousness. We think that all that the all of the ventilator is doing is pushing air in another body to keep the autonomic system running. And here’s here’s the money question. Would he your dad, would he want that or not? Do you want that? Not do you think that would be best? They want to know would he want that? And in a, you know, a humane that most hospitals would say, why don’t you take a time as a family to talk about this? And and then spiritual care people might say, Would you like to pray about this, which is great. And together, you’ll try to remember, what What did dad say. And if there wasn’t anything together, you’re gonna have to try to agree what he want. And then everything is in play, what he wants to spend the 10s of 1000s of dollars a day that it will cost to keep this machine on with no humanly speaking, reason to think that he will regain consciousness. And I’ve talked with people who said, Yes, that’s what he would want, he would want everything done until the money was gone. But he wouldn’t want us to spend our money to keep it on. And what I have to say to people like that is I think that’s something he can choose. I’m not sure that he can choose to spend other people’s money. No, that’s actually very, very difficult, because there are Christians for, I think, sincere reasons, I don’t think I don’t think it’s right. I mean, I don’t think that I don’t end up in the same place. But there are Christians who think that life is of infinite value. And therefore as long as it’s possible to secure either through taking on debt or for expecting the hospital to forgive the what you owe them or expecting the government to pay for it. Or something like that. No, but But seriously, because if you can secure the care, you’re obligated to secure it, because life is that sort of thing. So I don’t end up there. I think that we can we say, how would Jesus have me use the resources that I currently have? Well, money’s one part of it. But time and energy and talent and opportunity. Those are all things that are part of it, but money’s a part of it. And that turns out to be one of the hardest things for Christians to talk about. Because it immediately feels selfish and achy, as long as we can keep money out of it, it’ll be a matter of principle. No, I think the principle is that Jesus is asking you to use faithfully everything you have. And money is part of it. And especially so my advanced directive says that if I’m not going to regain consciousness, so I’m irreversibly unconscious, permanently unconscious, or permanently confused.

And my reasons for, for the reasons for treating permanent confusion, like permanent of unconsciousness is that if I’m permanently confused, as far as I can tell, I’m deprived of all of the spiritual joys that go with corporate worship, the reading, and hearing the Word of God preached and the participation in the sacraments. Those are the best things in the world. And as long as you’re keeping my keeping me alive, I don’t want to say my body, because that’s me. As long as I’m being kept alive, in that condition, I’m deprived of those things. So and that’s a great burden, I think being deprived of those things is a great burden. And so and having resources that might be spent on other gospel purposes, is also depriving me something. It’s depriving me of using those resources in a way that because if I were conscious, and could make decisions, I could say, Please kind of take me to the hospital, let me die peacefully in my sleep, and go spend the $200,000 that you would have sent to the hospital and the doctors, I’d like that sent to the gospel coalition. For that matter, I could do that. And I would, it would be biblically permissible for me to do that. If I were conscious. So what my advanced directive says is, I give you the power to make that choice. I have that I have that authority from Jesus, and I’m giving it to you, my wife, or my brother, the lawyer, or my brother, the pastor. I give it to them to make that choice for me, which is all the hospital wants anyway, what they want is for someone to say what I would choose, and so and the hospital, if, if my wife says he wouldn’t want the money spent on this hospital is going to be stunned because nobody ever says that. But they would still say that’s what we need to know. It would be legal, and it’s, it’s always been pretty unproblematic that it would be legal, but it’s been much more difficult matter for Bible believing Christians. And they’re good, I think good and important reasons and ones that I hope I take seriously. We’re not allowed to be the cause of our own death. So we’re not allowed to have either to cause our own death or to give someone else the permission and means to cause our own death. So assisted death with dignity. Ha, those, even though it’s legal, it’s still not appropriate because my life is not mine to start or stop. But, and the phrase, so I’m pretty sure I don’t give credit in the book to kill my lender. For the formula that I ended up recommending. In the book, I had to read the fourth edition to find out how it was different from the first three, all of which I had read utterly fantastic. I don’t agree with him about absolutely everything. But when I grew up, I’d like to be on my lander. But so I ran across the formula that I had been using having forgotten that I’d gotten it from reading him, which is pretty embarrassing when you’re an academic, you really ought to remember and give credit. But but the formula is that we are biblically permitted to choose a shorter life over a long over a longer one in order to accomplish. And here I changed his wording slightly gospel purposes in order to accomplish great goods, I think is the way he puts it. But what it means in in the way he talks about it is to accomplish what Jesus would have you accomplish with your resources. And so we’re not talking about the difference between living and living for 20 years, rather than 80 years, we’re talking about living seven months longer. And like suppose I suppose I could live nine, I have a condition, that means I’m going to die either in two months or nine months. And in order to live nine months longer, I’m going to have to be nauseated and probably confused, for all nine of those months, that if I don’t use, if I don’t pursue that treatment, probably chemotherapy is what I have in mind here. If I don’t pursue that treatment, I’m going to get, it’s going to be like somebody turning down the dimmer switch on the light, I’m going to get very slowly, there’s going to be this, there’s going to be a buildup of toxins, I’m going to get a little more confused every day. And I’ll have a little less energy every day, and it but I’ll be able to meet with my family and go to church, and everybody will know you need to come see me because you’ve only got about a month to get here for me to be able to recognize you and carry on a conversation. But please come see, I’d like to, I would like to see you again, as if I’ve been reconciled to all of you already. And I can imagine someone saying easily imagine someone saying there are people that it will take too much more than two months to find and to seek their forgiveness. I want to live the unpleasant life in order to pursue reconciliation with those people. That’s what I would advise someone to do, I would say it’s worth feeling sick and confused, if it’s going to take that long for you to track them down and get together with them. But all of those end up being the result of the same question. How would Jesus have me use all that I have right now to pursue what Jesus values? Not. I mean, like Deeley, I’ve value what Jesus values but not perfectly. And often very helpful to get other people to say, what do you suppose Jesus wants me to do with my remaining energy, talent and wealth? So that’s, that’s the decision procedure that my wife is going to be considering. So she’s supposed to ask a doctor that she trusts, humanly speaking, what are the medical likelihoods? How much time does he have? Is he going to regain consciousness? Is he going to regain the ability to make decisions for himself? And if the answer is no, then it’s okay. Definitely keep him comfortable. Don’t do anything to cause him to die. But don’t be aggressive in your use of medical technology. Keep him comfortable, that is a very clear part. I want to be comfortable and there aren’t any doctors who are going to say, Yeah, we’re okay with watching him rise on the bed. So the like believing or not, the doctors are going to want to, and nurses are going to want to keep you comfortable. But they’re also going to be really happy with permission not to be aggressive. If the goal of care is comfort, say well, so we become aware of a cancer. And it’s not a cancer that’s in he’s gonna die before the cancer causes discomfort. And he might die a little sooner, because the because of what the cancer is doing to his overall ability to fight the other dysfunctions and then my yet don’t don’t do surgery for the cancer don’t do chemotherapy for the cancer. Yeah, he’ll die a little sooner, but if it doesn’t affect his comfort, now, if I get a urinary tract infection, please give me antibiotics. That’s a new condition, but it will affect my comfort. Unless I’m conscious, but even then I think I want the antibiotic, not a big cost and who knows what your interior life is like when you’re unconscious? We don’t know. And I think I want even if I’m unconscious I I know that if I’m confused, I want the antibiotic. But these are really hard conversations to have. They’re hard for two reasons. One is, it’s really no fun to think through what it will be like to die. Christians, I think should find it actually kind of fun to think about what it will be like to be dead.

To be on the other side of the process of the dissolution of your physical frame, but it’s not any fun to to think through. How exactly do I expect this to go? Both of my grandfather’s died of heart slash stroke events, yeah, that makes it likely that I’m that there’s going to be something so I’m more. I’m 61 years old, I’m more vigilant about the blood pressure management and the medicine and low sodium diet, things like that. Because well, because of the family history. Well, so when you start thinking about so how is it likely to end and you start game planning, and you start talking to your spouse and your siblings about if I can’t make choices? How do I want, I want these to go? Well, all of my siblings are believers, which helps, I know that when the whole family gets together, so when my wife gets everybody together, and says, Okay, I’m pretty sure he wants this, let’s talk through, does that seem right? It’ll be all believers in the room, all of all of my siblings and all of their children. So even if it’s the superset of 40, something people, it’ll still be all believers talking about it. So I have a high degree of confidence that even though my wife will be leading that discussion, that there won’t be a lot of disagreement. Even, even, even though I do this for a living, and teach it to other people, it was hard to have that first conversation with my family. It’s, they don’t want to think about it. I didn’t want to think about it. I asked other people to think about it, didn’t want to think about it. And so and so you push, you have to push yourself to think about it, because they need to hear it from you, in order for them to make in order for them to say what you would say, and not for it to be something that they keep going back to and asking themselves, did I do the wrong thing? They probably would get it right. Even if I never, they never heard me say if I’m permanently confused, please do not start chemotherapy. No matter how aggressive that cancer looks. I’m ready to be with Jesus. Go ahead, say no, but they probably would have ended up there after a conversation. But they still would have thought did we miss something he’s dead maybe a week earlier than likely than he would have been if we’d started chemo, and then they start second guessing themselves. And then it adds to the challenge of grieving. And so it’s better that they hear it from you. So you really people should push themselves. There are relatively Fun, fun, not fun. There are less painful ways to do it. One way is to one, one of the purposes of the book is for people to read through the stories, the chapter that has stories of choices that I help people make real people, I help these real people make these choices, and to read through those as a family and say, so what do you think? What do you think the loved one would say right here.

So because for that chapter, I stuck to real people. It’s not a perfect set of covering the most likely that was one of the trade offs in the book was I thought it was important to describe things that had actually happened. And I think if I had a medical background, if I have medical practice in my background, I would be able to just pick I’ve seen everything. So let’s pick a representative sample of the most likely outcomes. But I mentioned Okay, one and the doctors who reviewed the book and said, that’s a pretty good set of likelihoods. But so that would be one way to do it. Another is to watch movies about people who are dying. These aren’t happy movies, typically. But you can get comedies about just a bit at one level sort of death humor, you can get movies, where the comedy is, in part connected to having to make make hard cases about somebody who’s in the hospital and dying and watching those together with family members and saying like, right, don’t want that, like that thing. Don’t do that to me. And then you heard it out of their mouth. And then when you have to make the decision, I do remember them saying we were watching this movie, and they said don’t do that. And then you don’t do that. Because you remember what they said. Or reading books reading books together about so you might read something like me before you or see the movie made before you which is dreadful, both of them. Yeah. And like even more dreadful because it was written and acted well. For what it’s worth. It’s like good you have to like really? So the book is the book which I read first is frustrating because From a non Christian point of view, it’s really hard to see what was wrong with the reasoning. If you don’t know the value that God places on your life and that your life is not your own, that it’s not yours to do with and to manage to control the time and manner of your death as your last act of defiant autonomy, if you don’t know that the movies could be kind of beautiful. The willingness to help him realize the only ambition that he has left nevermind that the ambition is self destructive, and literally, in this case, self destructive. So you might watch a movie like that and talk about so why wouldn’t that make? You know, why wouldn’t you want that? Well, because my life isn’t my own. So that’s a way to make progress. Because it it does really help the people who have to make the decisions that they can remember you saying things about it, rather than you having to stitch together and infer from things they said conclusions about how they want their care to go. So it’s very hard to do it from a workbook. So do you want to be resuscitated if you have massive kidney failure and your heart stops? What else is great and I need to know more than that? Am I reconciled? Like maybe I want to be resuscitated. Because tomorrow, the guy that I, the guy whose reputation I maligned is coming into town. And I wanted I need to seek his forgiveness. And yeah, please resuscitate me, keep me on the the renal replacement therapy and keep the ventilator letter letter going. And then you can pull it out for me to guess about my repentance. So yeah, I just need to know more. So it’s probably following any conversation is better than no conversation, though. So something I haven’t said yet. And that is that the Scriptures are clear, death is an enemy, but it’s been defeated. So it’s dangerous. It’s kind of like a live wire hanging from a telephone pole. If you’d, if it doesn’t, you know, it can’t hurt you. If you don’t touch it. Death is gone, unless Jesus returns. So just this afternoon, somebody asked me to sign a copy of the book. And I wrote, here’s hoping that Jesus returns before you need the book, because he could, I think Jesus could come this afternoon or right now, that’d be fine.

But because of that, even though death is almost certainly going to be unpleasant, it’s not something to fear as the undoing of you. It’s, it’s the undoing of the connection between your bodily parts, but we are immediately with Jesus. And we want to be faithful to the end, which means that even when you are down to a handful of breaths, and let’s, let’s say you’re down to a handful of breaths, and you’re conscious, like my dad was, he was conscious. What he wanted was he wanted the people around him talking about the things of the Lord, he wanted to be, he wanted to be part of singing praise to Jesus talking about what Jesus was doing in our lives, talking about what it meant to be part of what Jesus has them doing in the world. So he was participating. So he was still in it all the way to the end. And so when you’re down to only enough energy, but it also one of the last things he said is when I’ve been paying the Neptune society, to take my body and bury me at sea, for years, I’ve been paying them a few dollars a month, there’s a card in my wallet, when I’m when I’ve died, call the number and they will take care of every so he’s still thinking of us. But it was part of what it meant to him to be our dad. But it was part of being a faithful father was that he had gone ahead of us so that we wouldn’t have to find 12 death certificates to send to the insurance company as a whole bunch of stuff that comes. So you want to take you want to be a faithful father, in my case, so that your children so that you limit the burden that you put on your family members. But that’s all part of right now. I’ve got the energy and the time and the money and information I need in order to serve my family in that way. And when I get close to the end, they’re going to have to carry out those wishes. But they’ll also that will be an extension of what it meant for me to serve Jesus, they will be doing it for me, I think if you but this is just true about all the choices we make the choice about whether to join you for this conversation today was a choice about so what’s the best use I can make of the opportunity that the gospel coalition has given to me to talk about it? Yeah, definitely say yes. Yeah. And do a little preparing. So I got through the list of things that I knew that you know, based off of your prompt, I did end up talking Oh, now there’s one other Yeah, here’s the last one. Take the legal steps to specify your agent. Every state has a form. It’s either called a durable power of attorney for health care, or it’s called an Advanced Directive. don’t think any state still calls it a living? Well, they’ve got a form and it works super well. And it’s really simple. But if you take the step of specifying the person you want speaking for you, it will dramatically simplify things for your family and for the medical team, almost sure I can’t rent Well, no, that’s not true. Here’s the only way that it won’t work if you’ve got a family member who is obnoxious and willing to go to court. And if you’ve named someone else’s, your agent, and the obnoxious person who’s willing to go to court shows up and says, I know better than the person named on that document what they want, and I’m willing to sue to make it happen. Okay, yeah, that happens once a decade for me, but when So, but you can, if if it’s been done, if we’ve got the document that says this is the person that we look to, then it simplifies and for you are far more likely to get good the care that you would want quickly, and with minimum hassle for your family if you’ve identified an agent. So if you only do one thing, identify an agent and if you only do two things, identify an agent and talk to the agent about what you want, so that when the family says we don’t know they can be your the person who you chose to speak for, you can say, I do remember talking to her about it, and that almost always the family says, Oh, that does sound like what you would have said so that help.

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