How Should Christians View the End of Life?

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Dr. Katie Butler: Hi, you’re listening to TGC Q&A, a podcast from The Gospel Coalition, and this is the Christians and Healthcare series during which we seek to answer your questions about issues that arise at the intersection of faith and medicine.

My name is Katie Butler. I am a trauma and critical care surgeon turned writer and homeschooling mom. I’m the author of Between Life and Death: A Gospel Centered Guide to End-of-Life Medical Care. Today, I’ll be answering some challenging and thoughtful questions that you posed about how we can approach end-of-life care through a Christian lens and also how we can minister within the healthcare setting.

Before we get started today, I’d just like to preface our discussion with the acknowledgement that the topics we’re going to be going through today are really sensitive. They are at times heart wrenching. Given the fact that we are in the grips of a pandemic that pitches people into the ICU, some of these issues might hit close to home.

I’m going to try to go through the questions that were raised as thoroughly as I can, but given the limited time and given my lack of knowledge about what individual people are going through in your specific situation, I would encourage you to please, if you still have questions after this session, seek out a pastor, a chaplain, a doctor whom you trust who also is a believer. You can even reach me actually if you’d like to contact me through my blog privately. The link will be in the TGC bio on the site.

But please, do seek out support, because these are really hard, challenging questions that can create a lot of heartbreak, and we as the body of Christ don’t need to suffer that alone. I will do what I can, but please do seek out support.

The first question that was raised was, should Christians always choose to extend life? This is a very heavy question, and it is one with pretty far reaching implications.

When I hear this, I’m presuming that the questioner is asking if we as Christians are always obligated to either accept or offer technology that supports organs in critical illness, so ventilators to support the lungs, dialysis to support the kidneys, feeding tubes for those of us who can’t feed ourselves due to brain injury or other severe illness. Are we always mandated to accept these interventions?

It’s really a crucial question because we are going to be encountering this issue through many avenues of life. Perhaps you are filling out an advanced directive and trying to determine your living will, and you’re looking at all these options and saying, “Do I have to accept all these all the time? Is it okay for me to say no?” You might be a healthcare who’s seen the harm that we can do with some of these technologies in people who are actively dying and at the end of life and saying, “Is this really loving? Is this really how we love our neighbor?”

Or what is probably most common unfortunately, because 75% of people at the end of life can’t vouch for themselves, and so hard decisions about end-of-life care then falls to loved ones, they might be in a position of making some really hard choices for our loved ones who are sick. Do we take them off the ventilator? Do we say yes or no to CPR?

When we have these situations that we’re in, the technology and the terminology is so foreign and so far removed from our daily experience that it’s overwhelming. On top of this, it’s just so tumultuous because we’re afraid, we’re grieving, we’re scared for our loved one. With tend to appropriately fall back to our faith for guidance and say, “What would the Bible direct me to do?”

That’s appropriate, but the problem that arises is in this tumultuous setting, this hotbed of suffering, we tend to cling to one principle of the Bible and ignore the overall narrative arc that tells us who God is, who we are, and what it means to be within the body of Christ, to be saved by Christ. When that happens, it can create some really difficult conflicts.

To give you an example, a few years ago I cared for a gentleman who was very advanced in age. He had multiple chronic illnesses that were in their end stages without further options for treatment. He was very debilitated. This was a gentleman who was a churchgoer all his life, read his Bible every night, and he was so enfeebled by all of these medical conditions that just got ahead of him that we didn’t have a cure for that he couldn’t even read his Bible anymore.

He underwent a surgery at the prodding of his family. He didn’t want to do it, but his family said, “No, you have to keep going. You have to do this.” He had a bad outcome afterwards, and his lungs began to fail, and he needed to be put on a ventilator.

His wife held his hand and through tears pleaded with us, “Please, don’t put him on a ventilator. He made me promise him this time that if something happened after this surgery, it was his time to go home to the Lord. That’s been on a ventilator before. He can’t endure that suffering again, and he’s asked us to just let him go and be with Jesus.”

Her son, when he learned about this discussion, came in enraged saying, “How can you do this? Dad believes in the God of the Bible. He wouldn’t be okay with killing. You’re killing him.”

This kind of dilemma, which is so heartbreaking, happens frequently. Both responses are coming from a place of love. Both responses also can be cited to Christian faith. How do you reconcile that? What do you do? What’s the right answer? These questions are really, really murky, and the answer is not to just cling to one principle, but to look at everything that the Bible tells us about life and death, about compassion, and about who we are.

I’m going to give you today four principles that I hope will help you so that when you’re dealing with any kind of situation with these technologies that are so scary with end-of-life and you’re wondering what is okay, that you can at least have some guidance knowing what does scripture actually say. Okay.

The first principle that I’d like you to keep in mind is that, yes, mortal life is sacred. Okay? First breathed into Adam, God has given life to us all so that we can glorify him and steward his creation. We are all infused with dignity and inherent value as his image bearers. We are mandated from the top of Mount Sinai when Moses received the Ten Commandments not to murder. Life is a gift that we’re to cherish.

It’s this principle of the sanctity of mortal life that prompts us to protect the unborn and also prods us to actually protest against physician assisted suicide. I could talk for a whole hour about that. We’re not going to today. It’s a different topic than what we’re talking now. Physician assisted suicide is the active taking of life. We’re talking about is it okay to refuse aggressive treatments at the end of life. Different discussions, okay? But because we are called to protect life, if we are in a situation where we are ill and there are treatments that do have the potential to cure, we should consider accepting them.

Okay. The second principle, which sometimes people will hold in opposition to the first but it’s not, is that God ultimately has authority over our life and death. While we are called to protect life, throughout the Bible God makes it very clear that our times are in his hands and that our lives are fleeting. Death is the wages of our sin. Until Christ returns, it’s the consequence of the fall, and all of us are walking that road. Death will come to us all. It is inevitable at some point.

The thing not to forget too is that God actually can work through our death for good. From Romans 8:28, “He works all things for the good of those who love him.” That includes the timing and the manner of our death. Which we might look and say, “That’s horrible. How could he work good?” Look at what the Bible shows us. Jesus delays rushing to Lazarus’s side when he’s dying because allowing Lazarus to die and then reanimating him demonstrated to all the disciples and all the onlookers that Jesus was the Son of God. There was a greater good that came at that moment for allowing that death to occur. The Father himself gave his Son over to death to save us. God can work through our death for good that we can’t perceive.

While we are to protect and honor life, we also have to accept that death is inevitable and will come to us all. If we fight against it at all costs when that moment comes, we’re denying the grace and the beauty of the resurrection, that Christ has defeated death and we need not fight against it.

The third point is that as Christians, we are all called to mercy and compassion for one another. That we are called to love our neighbors as ourselves. That we’re called to love one another as Christ loved us. Thinking about that, that is a sacrificial and deep and abiding love. That means that we need to have concern for the suffering of others.

In the ICU, this matters, because the interventions that we use in the ICU can cause profound suffering. Patients who survive a stay in the intensive care unit report rates of post traumatic stress disorder with the same frequency as that given by soldiers returning from the Iraq War. Ventilators give patients a feeling of panic and like they’re suffocating. CPR, which is essential to restore life after cardiac arrest, breaks ribs and induces other chest trauma in 90% of cases. Which means if you survive CPR, afterwards every breath you take hurts. Okay.

All these things are worth it if we can cure you, if doing these things means we get you home. But if someone is actively dying and we have no options to reverse the underlying process causing death, then enforcing such measures on people actually constitutes cruelty and doesn’t show compassion and love for neighbor.

Then the fourth thing, which really overrides all the others, is that we have our hope in Christ. Death is not what it once was. Christ has defeated death. Death has been swallowed up in victory. From 2 Corinthians, “This light and momentary affliction,” that we are experiencing at any point in our lives, “Is preparing us for an eternal weight of glory beyond any comparison.”

It’s crucial to realize this, that death is the enemy, but Christ has overcome it, and so we don’t need to fear it with everything in us. The cross has transformed death into something to be abhorred and resisted at all costs to an instrument of grace, because through death God calls us home to him. The hope of the cross is something to which we can cling, because we have the truth from Romans 8 that, “Neither life nor death, nor angels, nor rulers, nor anything in creation can wrench us from God’s love through Christ Jesus.” He has won us, and not even death, not even a ventilator, nothing can wrench us from that love.

Putting all these things together, because I know that’s a lot. Get a drink of water if you need it. I’m sorry. Okay, to boil all that down, does that mean that we must always extend life? What I would like you to remember instead of that kind of an approach is that the Bible teaches us to seek cure if it is possible, but also to accept death when it is inevitable, and to ameliorate suffering when possible. Okay, I’m going to say that again. Seek cure when possible, recovery, full recovery when possible. avoid death … I mean accept death when it’s inevitable and when it’s imminent and unavoidable. Then alleviate suffering when possible.

Okay, so what does that look like? Whenever you are considering whether or not to accept or decline any kind of aggressive treatment, the answer to this question is going to depend upon your medical background and what is making you sick, okay? Any time you’re considering, “Should I take a ventilator? Should I not? Should I use a ventilator for my grandmother? Should we not?” the question to ask is, will this measure preserve life, will it have a chance of bringing about recovery, or will it prolong death and suffering?

If it does have a reasonable chance of preserving life, then yes, that measure may be the right thing. If it’s going to prolong death in someone who’s not going to be able to get home or if it’s going to incur such suffering that is undo, meaning that the burden far exceeds any particular benefit, then no, as Christians we’re not mandated to accept those interventions.

This question is going to highly depend upon the individual, because I think it’s important to realize, which I think many lay people don’t because they’re used to seeing things only in the media and it’s not explained, is that these measures we’re talking about, these organ supporting measures are supportive, not curative. What I mean by that is that the ventilator will support your breathing until doctors can figure out what is causing the underlying problem and reverse it. Whether or not a ventilator is going to be helpful depends not so much on the ventilator itself. The ventilator can’t cure you. It depends on whether or not we can fix the problem making you sick in the first place.

To give you an example of this, if someone comes in who is otherwise healthy, has no medical problems, and she develops a bacterial pneumonia, we will put that person on a ventilator. We’ll give an antibiotic that we know can treat the type of bacteria she has. If all goes well, the bacteria will be eradicated and the pneumonia gets better. In five days, she’s off the ventilator and she will go home. Okay.

That is a very different story than someone who is quite advanced in age who has end stage emphysema, who has metastatic cancer clogging her lungs who then comes in with a viral or a fungal pneumonia, which is much harder to treat. In that kind of situation, that ventilator will likely be a permanent fixture and may not make a difference, because while it may extend her life, we ultimately can’t treat the underlying causes of her respiratory failure.

Okay, so when we’re asking these kinds of questions, it’s critical to have discussions with your doctor about what is your baseline level of functioning, okay? If you’ve got very few medical problems, it makes sense to accept everything in the moment. If you are very debilitated, you might not have the reserve to handle many more insults, and aggressive things at the end of life might not actually restore you to the status you want, being able to pray, being able to commune with loved ones, being able to live out your life as a child of God.

It’s really important to have discussions with your pastors, to have discussions with your doctors, and especially as we’re talking about this, your family. Because as I mentioned, in about 75% of cases, we cannot speak for ourselves at the end of life, so waiting to see what happens is not a good option. It’s imperative, even though these conversations are so hard, to speak with your next of kin, tell them of your values, tell them what’s important to you, tell them about your ideas of suffering and what is too much, and fill out an advanced directive so that they have some guidelines. Because we’ve seen actually that families who are walking alongside of a loved one who dies in the ICU suffer high rates of depression and complicated grief.

And so as you’re thinking about these things, no, you’re not mandated to accept everything, okay? It depends upon your own situation, your medical problems, and also your concept of suffering, which is very, very personal. When we’re talking about suffering, it’s important that those of us who are making decisions for others recognize others as unique individuals who are image bearers of God. When I say that, what I mean is that suffering for one person is going to be very different for another.

I had one patient who was content and wanted to continue with everything as long as she could watch TV with her family next to her, even if she couldn’t communicate. Others are imperative saying, “I don’t want to be dependent. It would drive me insane.” Others will say, “I want to make sure I can read. If I can’t read, I can’t commune with the Lord because I can’t read the Bible.” It’s talking with loved ones and really getting a sense for who they are, what they are willing to go through to be able to still do the activities they cherish, and what is too much suffering.

That was a very long answer, I know, to the question, but it’s a very complicated issue. I would encourage you please to continue to read on it, talk to a pastor, talk to a chaplain, remain prayerful about it, and just keep coming back to this question too as things evolve, because those of us in 20 years will have a different medical situation than we do now. Just know overall in these hard questions that Christ has overcome and that he risen and he has gone ahead of us. Even while we suffer so much anguish about these questions, that we have hope in him.

Your second question is, health workers are told not to evangelize to patients. How do you manage this with ICU and palliative care patients? Has there ever been a time when you were able to minister to someone or to a family at the end of life?

This is a wonderful question, because many of us who go into healthcare are motivated by our love for the Lord and want to share with others what we … the well that we draw from for such peace. Especially when patients are going through such dark moments where they’re scared, and afraid, and struggling with a bad diagnosis, what a joy to be able to share what we know of the gospel, that Christ has risen and that we are saved and we’re forgiven.

However, what this question I understand is reflecting is that the medical environment is actually quite hostile to any kind of talk of spirituality. Part of this is to remain objective and to respect patients’ wishes, and autonomy, and own backgrounds, which is appropriate. But there is a point at which we go too far and where we actually neglect the spiritual needs of those who are will and who are questioning.

There is a fantastic book, and we’ll include the link to it, called From Hostility to Hospitality. It’s by a husband and wife pair, Doctors Balboni. It looks at research done over the past few years about support for spiritual concerns at the end of life. What it shows is that in general, medical staff really fail at this where we don’t refer to chaplaincy, and if we do, it’s usually in the last moment when a patient is too near death to actually converse with a chaplain. It shows that when patients will raise spiritual concerns, the most common response from doctors is not even referral to a chaplaincy. It’s usually silence.

We really leave patients stranded with some very, very hard questions. The questions are there, because you’re thinking about in the hospital, people are dealing with life and death situations. Even if it’s not threat to life, oftentimes whatever illness they’re undergoing has wrenched them away from their daily lives. Their sense of independence and autonomy is stripped down. They’re away from their families. They are no longer able to engage in the things that make them whole. In addition to that, they often are not able to continue the usual spiritual disciplines that help to uplift them.

In this kind of setting, there are so many questions that come up. What is God doing? Why hasn’t he healed me? I’ve prayed so much. Why hasn’t God healed me? Why is he punishing me? If there was really a God, this wouldn’t be happening.

Okay, so these questions are there, and patients are struggling with them. Then how do we as physicians support them through it, knowing that we are interfacing with them on a daily basis through the struggles? While I think it’s appropriate that the medical establishment tries to make sure we’re being objective and not enforcing beliefs on them, it’s still appropriate to support.

I want to make a distinction in this question between evangelism and ministry. I have not actually evangelized with my patients. For more information on evangelism, the Christian Medical and Dental Association has a fantastic program called Grace Prescriptions that you can purchase from their website, and it’s actually going to be revamped in the next year so there’ll be whole new modules put together. But it talks about this, about how to share the gospel with those you encounter in the workplace as a healthcare provider.

I will say that I have ministered to patients, and ministering meaning that when they are expressing questions of doubt or concern or just struggling with their faith, I have tried to walk with them through that. I think the most important thing is invitation, meaning that patients will ask these question and will voice them. It’s been found that in family meetings in the intensive care unit, surrogate decision makers have actually said that, in up to 80% of cases, spiritual concerns are at play in the decisions they’re making for loved ones, but we only talk about them in the family meeting about one-fifth of cases, and usually it’s the family raising the question and the physician nodding. That’s the extent of it.

I think as healthcare providers who also know Christ, it’s important that when these questions come up, we don’t let them drop. Even if you want to do it privately, but don’t just let it land. If they voice a concern about how their faith drives all this, rather than silence, ask a followup question. It’s appropriate to refer to chaplaincy too and get them involved, but just ask a followup question. Why do you think that? Tell me more. What’s your understanding?

I think especially if you’ve develop a relationship with patients and their families, those kinds of conversations become much more natural. If they offer any kind of invitation to discuss it, you can take them away separate, privately away from a meeting if you want to, and just walk with them, and support them, and love them. Then avenues will open for you to share your own knowledge of the gospel.

I had one case that I remember in the ICU when I was a fellow, so this was some years ago. There was a young lady who had been through just an awful, tragic situation where she was in multi organ failure after a car accident and had a young baby at home and was just not recovering. Her mother was beside herself, appropriately. She was shattered.

The day before her daughter died, she was in tears saying, “God’s punishing me. I feel like this is all my fault.” What a burden to have, to feel that you’re abandoned by God and that he’s taken away your daughter because of something that you did. I was just so grateful for the Spirit’s work in that moment, because she was forgiven. Like, “Do you know that through Christ you’re forgiven? God’s not punishing you for this.”

There are moments that will arise, and I would just say that when ministering to patients, it’s not about going out and passing out flyers. It’s just being present with them, acknowledging that they’re going through some really hard times, and that when those questions come up, don’t let them drop, but be there with them and support them through it. Windows will open where you can show them Christ’s love and talk about the gospel.

Whenever families would also tell me that their loved one was a Christian, I would make sure I would pray over him or her. I would ask families, “May I pray with you,” if they had already said, yes, I’m of the Christian faith. I think it’s seeing the windows and then just walking with people as brothers and sisters has been just a gift, a gift. It’s not always easy to do, but there will be windows there where you see that families are struggling with these issues, and I would say just walk with them and not be afraid to engage in those moments, because they need the support.

The last question that you submitted was, how would you encourage a healthcare worker to show compassion and empathy without becoming spiritual exhausted? This is a great question. It is a question that I’ve actually discussed with a lot of medical students over the years, because for reasons that I alluded to in the last discussion, medicine does not provide a lot of spiritual support.

It’s this strange situation, because we go into medicine as a way to serve, as a way to serve the Lord and love neighbor, but from the training system to the way medicine is run, it seems bent on stamping out our faith. From starting with the training, the fact that we go into it to love neighbor, but the training itself is so incredibly cutthroat where we have a one minded focus on getting through the next exam, and am I at the top of my class or not? Am I going to be able to get a high enough score on my board exams? Am I better than this person next to me who’s going into the same specialty I am? It is a nightmare in terms of the competitiveness and not at all a spirit of love and collaborating that seems like medicine should be.

Then when you get into the field, you witness such suffering, and heartache, and despair, and people going through a horrific illness and then they’re discharged and you celebrate, and then they’re back the next day for more. Seeing loved ones cry when their loved one has died unexpectedly. This is just the normal fodder of the day. You do these long hours where you’ll work 14 hour shifts enduring all of this, and it is physically trying. You lose your stamina. You’re exhausted. Then the emotional toil is so heavy with very little support, very little discussion of grief, very little opportunity within the workplace to talk about what is God doing in this. Then you go home, and you shower, and you pass out, and you get up the next day, and you do it all over again.

I can’t think of anyone who has gone through this crucible of medical training and work and not had some challenge to their faith. The usual things that we would cling to, the spiritual disciplines, going to church, taking communion, being involved in a small group become so hard because your schedule is occupied entirely with the work. Even when you’re home, you feel tied to the work, and you’re thinking about your patients, and you’re worried about them, and you’re checking on them remotely from home. It just consumes so much of your head space and your actual physical time.

It is really easy to burn out in this kind of scenario and feel adrift from who we are. You might know, yes, Christ died for me, but day to day it’s really hard for me to see what good is happening here.

What do we do in these moments? How do we prevent his? I wish I could give some kind of flashy program or formula. I think truly the most fundamental thing is that we need to stay in the Word, because no program or philosophy of the world is going to take away what you see and is going to paper over it, or bandage it, or make it okay. It is only the truth that Jesus has died for our sins and has gone ahead of us and is preparing a place for us, only that truth that can really be life giving.

It can be hard to stay in the Word because of all the things I’ve mentioned. You’re just so depleted. You’re so exhausted. But I would say really try to prioritize it and cling to it as if it was a darling, your time with the Word. Whether it’s that you keep an audio Bible playing as you’re on your way into work and make sure that you’re hearing the Word on your way in. Whether it’s that you have a devotional sent to your email. Whether an alarm goes off, whatever’s going on during the day, and you make sure you read. Just get up and out half an hour early. Whatever it is, but really cling to that, those moments with the Lord where you’re reading his Word and drinking in the truth of who we are.

Praying throughout, praying without ceasing. Because there will be times when he does not seem near, but that’s when we need prayer and reminders of his love in the Word all the more. Because you go to the Psalms and you see that David felt stranded, and David did not see God’s work in what was horrific around him, and David felt cut off. Guess what? So did Christ in Gethsemane, falling to his knees, crying out, “Lord, please take this cup from me. But not as I will. As you will.” On the cross, “Why have you forsaken me?” Declaring that he was the Son of God, back to Psalm 22. But anyway.

But it’s these moments that the Word itself is really, I think, what it crucial and life giving. As much as so much gets in the way, I really think it’s crucial that we jealously guard that time in the Word to guard our hearts against all that is going to be assailing us in the hospital.

The other thing that I would say is that when we constantly remind ourselves of who we are in Christ, it gives our work new meaning because it really transforms medicine into a mission of mercy. You can see the suffering and realize that you are there with that woman who is alone and scared because she’s got the Coronavirus and there’s nobody from her family who can come see her, but you are there with her. For the time that you are there with her, you can be the hands of feet of Christ and you can show her Christ’s face when no one else is there to remind her.

It’s a privileged position to be able to walk with people through suffering and to also carry the hope that their suffering is not without meaning, because Christ suffered. Christ knows what it is to go through the pain, and the abandonment, and everything else that we do endure, he’s endured it for us. We know the ending.

I would just say that, yes, the struggle is very real, that burnout is very real, but God. Stay within the Word, pray, and try every morning when you get up, say a prayer to the Lord, “Please use me as your hands and feet today.” Realize that even in the midst of all the suffering, Christ gives meaning to that suffering and you are there on his behalf as one of his disciples, there to minister to God’s people and to those who are downtrodden. That is a gift and a privilege, and I just pray that the knowledge of that propels you onward.