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A Time to Die

A deep tragedy is that congregations seldom offer opportunities for people to declare the values they intend to guide their end-of-life choices. Classes that help people understand the difficult decisions they may make for themselves and their loved ones are seldom offered.

Betty is 83 years old. She has lived a generally healthy life, although for 25 years she has dealt with the growing debilitating effects of diabetes. Now she is sustained on a regimen of medications for diabetes and poor blood circulation. Her difficulty in any physical exertion, as well as a clear genetic predisposition, has resulted in obesity.

None of these conditions is life threatening, but together they increasingly call for medical interventions. She resides in an assisted-living facility. Any significant degradation in any one of these conditions will result in a need for skilled nursing care. Should major organs begin to fail, she will need intensive medical care. Her daughter lives 40 miles away; between work and family responsibilities, she makes the drive to see her mother only once per week.

“Why do I have to go through all this?” Betty asks her pastor. “Why can’t I just die?”

So, pastor, can she simply die? At some point in her slow decline, does she have a “right” to declare that she wants no more physical and mental anguish? The streets of gold that she has been promised are much more inviting than the approaching respirator, bladder catheter and dialysis. When, how, where can she “just say no”?

There are two ways to say “no” within the medical world. One way stops interventions that sustain life. The other route is physician-assisted suicide, or a physician’s assistance in dying, depending on one’s ethical and political understanding. That route is overtly illegal in all states except Oregon and will be the subject of a future essay.

A classic example of declining an intervention is the “do-not-resuscitate order.” Should Betty be admitted to a hospital, professionals assume that she has given permission for resuscitation efforts to proceed, if needed. These efforts include advanced cardiac interventions (chest pumping, powerful medications) and respiratory support (external breathing pressure, insertion of a mechanical breathing tube). If Betty does not want these procedures, she must tell her physician.

What most laypeople do not recognize is that a very small percentage of people who experience cardiac or respiratory arrest while hospitalized return to their former baseline health status. That is, when sick people attempt to die and are retrieved from that situation, their health status will almost certainly be reduced, if they survive to discharge.

Actually, the competent patient may decline any medical intervention. Patients who are critically ill are seldom informed as to their full range of choices until the situation is “hopeless.” At this point they have frequently exhausted their physical, emotional, spiritual and financial resources on a futile effort (and sometimes predictably so) to stop a terminal or progressive chronic disease process.

Betty can say “no” simply by telling her physician that she does not want to increase the level of medical interventions she is already receiving.

American medicine is very aggressive in seeking to rescue dying people from the brink of death. A huge percent of the Medicare budget is spent on people during their final three months of life. Terminally ill patients are not referred to hospice organizations for supportive care until their very last days.

The conscious and rational person can always say “no.” What if Betty should become unconscious or irrational? Her “no” can then be offered in two ways.

First, the legal next of kin is given the authority in most states to make medical decisions on behalf of the loved one. Although there are several caveats, these decisions are widely respected by medical personnel, especially when someone like Betty’s daughter can say, “I talked with Betty about this type of situation, and this is what she said. I want this situation handled the way she wanted.”

A “no” can also be expressed through legal instruments such as a “directive to physicians” (a living will) and a “durable power of attorney for health care.” Every adult should consider executing these important tools. Since each functions slightly differently from state to state, it is important to consult a person knowledgeable about these documents before signing.

Unfortunately, medical experience has proven that these documents play a very small role in end-of-life decisions, even when they have been executed and filed.

A deep tragedy is that congregations seldom offer opportunities for people to declare the values they intend to guide their end-of-life choices. Classes that help people understand the difficult decisions they may make for themselves and their loved ones are seldom offered. Too often, Betty must initiate the conversation with her pastor and her physician.

There is a time to die. What better community in which to consider this reality than the Christian community which declares that death does not have the final word?

Steve Ivy is vice president for values, ethics, social responsibility, and pastoral services of Clarian Health Partners in Indianapolis, Ind.