Departing in Peace

Biblical Decision-Making at the End of Life

Bill Davis

• Publisher: P Publishing
• Year: 2017
• Print ISBN: 9781629952598
• eBook ISBN: 9781629952604
• Topic: Theology & Religion
• Subtopic: Christian Theology

Providing case studies and biblical, ethical insight, Davis guides readers in making difficult end-of-life decisions for themselves and others, preparing advance directives, and facing new realities in American hospitals.

1

INTRODUCTION

MY FATHER’S DEATH

During the first week of June 2014, my earthly father died in a hospital bed in Wenatchee, Washington. My twin brother and I were in the room when he died, and we had participated in his decision to stop using the mask that was forcing air in and out of his lungs. Rather than staying on the mask and struggling to breathe, he decided to focus instead on being comfortable. He knew that it would mean that he would die before long, but he had been fighting a gang of physical challenges for a week. Together we agreed that his fight to get better had been faithful, and that he was never going to leave the hospital. While it was very sad to lose him and difficult to accept that his time had come, it was not difficult to decide to stop doing everything that medicine could do to extend his life. The decision was not difficult in part because my father had decided long before his final illness that he did not want to be kept alive on a ventilator and did not want to be resuscitated if his heart stopped. He had put these wishes in a legally sound form and explained them to me. I did not have to wonder whether he would want to have either of these means used to keep him alive.

A summary of my dad’s final hours that I wrote for my family shows another reason that the decisions involved were not difficult:

Friends,
Last night at 9:45 my dad went home to be with the Lord. The end came much more quickly than I thought possible, but it was peaceful and may have happened exactly as he would have scripted it.
At 11:00 A.M. yesterday, my dad spoke his last clear word. He had fallen asleep earlier in the morning during the family conference with the doctors, his wife, Carolyn, two of my siblings, and me. At that conference we came to the conclusion that (a) he would never be strong enough to leave the hospital and (b) all of the ways forward involved fatal risks. Even the BiPap mask pushing his oxygen involved the risk of making him nauseated to the point of vomiting. And vomiting into the oxygen mask would bring a rapid and painful death by aspiration. Discontinuing the mask would be much more comfortable, but without it his carbon dioxide level would rise, eventually to a fatal degree. But the slow buildup of CO2 would not be uncomfortable provided he had morphine to manage the air hunger drive. In light of all this, the family decided that he would want to have the mask removed and to be made comfortable.
Before changing his treatment level, we asked the doctors to let us discuss it, this time including Dad in the conversation. (The only unsatisfying part of the medical care Dad received was the last hospitalist’s unwillingness to take the time to try to explain Dad’s situation to Dad. The hospitalist had decided that Dad was too out of it to direct his own care. Neither Carolyn, nor Russ, nor I agreed with the hospitalist’s judgment about Dad’s ability to follow and participate. The hospitalist had been on the case only a couple of hours, and he did not make a serious attempt to wake Dad up to talk to him.) So with the doctors out of the room, we slowly explained to Dad what we had learned about his condition (that the attempts to restore his breathing capacity were not working), his prognosis (that he would never be strong enough to leave the hospital and that continuing to use the mask involved risks), and his options (to stay on the mask and accept the discomfort and the risks involved or to change the goal of his care from curing his many illnesses to maximizing his comfort). When we were convinced that he understood enough of this, we said we thought he would want to focus on being comfortable and to take off the mask. He visibly summoned his strength, looked each of us (Carolyn, Russ, and me) in the eye, and said “Okay” through the mask. It was a great blessing to have him confirm the decision.
At 1:30 p.m. the equipment and specialists were assembled. They turned off the monitors. They started an IV morphine drip to make sure he would not have unmanageable pain. After 10 minutes on the morphine, they took out all the other IVs, took off the oxygen mask, and put on the nasal cannula (high-flow oxygen). He did not struggle to breathe, but it did take 15 minutes to find a comfortable position in the bed.
When my dad was settled on the initial dose of morphine, the palliative-care specialist, Dr. W, started to leave the room, insisting that the nurse, Greg, was fully able to supervise the process of finding the appropriate level of morphine. I did not doubt Greg’s competence at all, but I did not want Dr. W to leave the room. So I stood in the doorway and asked if he could stay. As he had been throughout his time caring for my dad, he was willing to meet my needs as well as my dad’s: he stayed to oversee the process. Morphine is a powerful pain suppressor, and it is wonderful for controlling the air hunger drive. The morphine would enable my dad to sleep easily for the first time in days. But morphine also suppresses breathing, and I did not want the morphine to be the cause of my dad’s death. I wanted him to be comfortable, but not to be terminally sedated. With patience and careful monitoring, the specialist would be able to find a dosage high enough to end the pain and anxious struggling but low enough for him to continue to breathe.
Over the next 45 minutes the morphine drip rate was slowly increased under the supervision of the palliative-care specialist. We watched for signs of struggle or restlessness, confident that if he could go 15 minutes without jerking, grimacing, or crying, his pain and anxiety were under control. Three times the specialist directed Greg to give Dad a shot of morphine and to increase the drip rate on the IV slightly. After each increase, we watched for signs of discomfort. After the third increase, he went 15 minutes breathing steadily and showing no signs of distress.
After switching from curative care to comfort care, my dad rested as Russ, Sarah, and I talked about our children. He would open his eyes from time to time and smile. It is likely that he was listening almost all the time. His breathing was not regular like he was asleep, and sometimes he would shake his head and smile at a funny turn in a story. He never opened his eyes, but we could tell he was with us.
Between 3:30 and 8:00 p.m. I went to the hotel and slept. Russ and Sarah stayed with Dad and continued to talk. His breathing was consistent and on the few occasions when he furrowed his brow or squirmed, the nurse would give him a 1 mg shot of morphine on top of the drip.
At 9:00 p.m. they moved him out of the ICU to a comfort-only room on another floor. He did not open his eyes during the rather complicated move, but his breathing remained steady and strong at 16 respirations per minute. Russ was about to go back to the hotel and get some sleep. I was settling in for a night of watching and reading the Psalms to Dad. But with Dad breathing steadily, Russ and I started talking about Richard Feynman’s lectures on quantum physics. We lost track of time. At 9:43 Russ noticed that Dad’s breathing pattern had changed. We went to the bedside (all of four feet away) for a closer look. His breathing was very shallow, and now about 2 breaths per minute. I went to find a nurse to see if something needed to be done, although Dad was not struggling and looked like he was sleeping peacefully.
The nurse came a couple of minutes later. She examined him and said, “He has passed. I’ll get another nurse to confirm it.” We were shocked at how quickly it had happened, and a little unhappy that we hadn’t noticed that his breathing was decreasing as we talked. But on reflection I believe that Dad would have wanted to drift out of this life listening to his children enjoying each other’s company. When Russ and I were seven years old, Dad would help us get to sleep by playing recordings of Dr. Edward Teller explaining Einstein’s theory of relativity. I’m sure Dad did not mind being helped in his final sleep by our talking about physics. He was a nuclear engineermost of his life. He may have thought that the loop was closing in an appropriate way.
My dad made arrangements to be buried at sea. We found a card in his wallet with a number to call, and they (the Neptune Society) took care of everything concerning the disposition of his body. I’ll see him again when the sea gives up its dead.¹
Thanks for all your prayers and friendship.

In many ways, it is clear to me that God was merciful to my dad, my brother, and me. My dad may have continued breathing for days, or even weeks, probably never waking up and possibly in some pain. If he had continued to breathe, we would have had to figure out whether to set up a schedule to keep watch over him. It may have been necessary to find a facility that could care for him in a minimally conscious state. Every day would have given us the opportunity to second-guess our decision. As it happened, we could see that he was comfortable, and we were there when he breathed his last. We have not had to wonder whether he died for lack of close attention or someone’s mistake. It was a more peaceful passing than I could have invented with a blank sheet of paper.

The final decision was not difficult because Dad had left crucial instructions. Its difficulty was also diminished by my own preparation for making biblically appropriate end-of-life decisions. I am a philosophy professor with no formal medical training. While I teach bioethics at Covenant College and Reformed Theological Seminary, what I know about morphine, palliative care, oxygen-delivery options, and the difference between hospitalists and nurses comes from serving for seventeen years as a volunteer community member on the ethics committee at Memorial Hospital and with the PACE program in Chattanooga, Tennessee. I have an MA from Westminster Seminary California and a PhD in philosophy from the University of Notre Dame.² That training prepared me to think through the biblical principles that informed the final decision for my dad. Without the years of experience on the ethics committee, including serving as an ethics consultant on cases at the hospital (always with at least one doctor and one nurse), I would not have known how to connect the biblical principles to the practical demands of decision-making in a hospital context.

Since 2013, I have served as a ruling elder at Lookout Mountain Presbyterian Church (PCA), pastored by Joe Novenson. In that role, I have had the difficult privilege of advising families faced with end-of-life decisions about their parents and their children. One of the more recent cases involved the decision not to resuscitate a 2-year-old who had suffered a global brain injury but still had a functioning brain stem. Between the ethics committee work and cases referred to me by PCA churches, I have talked, walked, and prayed with people through more than thirty end-of-life situations. Every one of these cases has been emotionally taxing, but it has been an honor to be a part of each one.

This book is driven by the most common source of anxiety expressed by Christians as they have faced end-of-life decisions. Desiring to honor God’s Word and obey his commandments, they have often thought that they were obligated to do everything medically possible to extend earthly life as long as possible. It is common for sincere believers to say something like this: “Because life is precious to God, I must be called to do everything possible to keep my loved one (or myself) alive.” Medical technology is now able to extend earthly life in ways that would have seemed miraculous even fifty years ago. Very often it is possible to extend life for a long time even though there is no human reason to think that the person will ever regain consciousness. Sometimes the medical means are available but come only with greatpain, confusion, isolation, and radically diminished spiritual opportunities. Even when the gains from medicine are meager, sincere believers find it hard to resist the conclusion that they must seize every medical treatment because God requires it.

GOD’S LAW: A GIFT TO GOD’S PEOPLE

If I believed that God’s Word required us to use every means available to extend life as long as possible, I would not have agreed to removing the BiPap mask from my dad. And I would have urged him not to accept a do-not-resuscitate order when asked by his doctors. It would be foolish to trust my own understanding more than God’s law. God’s law is perfect and the only inerrant source of guidance. God’s revealed will is for our good at the beginning of life, at the end of life, and at every moment in between. God’s Word speaks to every area of life as well. While we can ask questions that God’s Word does not answer in detail—such as “Should I ask my boss for a raise?”—it shines light on the path ahead of us with warnings, principles, and direction. Even when I do not understand how God’s law is for my good, I know that it is. As the world around us grows less and less curious about God’s design for our good, followers of Christ should continue to look to God’s Word as our rule of faith and life.

Because the culture around us is increasingly comfortable treating life as cheap, Christians are right to be suspicious about trends away from fighting for every life. In 1985 I moderated a panel discussion on end-of-life care at Mercy Hospital in San Diego. I was a seminary student at the time, and I was eager to speak boldly for the protection of life. One of the physicians on the panel was not a believer, and he was openly frustrated by my resistance to discontinuing treatment that was not showing any benefit. When I asked him whether he was “playing God” when he turned the machines off, he said, “Of course I’m playing God. That is what doctors are paid to do.” It was not a helpful response. I assumed (wrongly) that he was saying what any doctor would say, and it led me to think that Christians must double their resolve to extend life regardless of the obstacles. Without studying what the Scriptures have to say about life and death, I set out to defend what I thought the Bible must be saying.

My confident presumption that I knew best led me next to disagree forcefully with a Christian doctor in my home church. In casual conversation about a friend who was in the hospital but in decline, he said that the decision to turn a life-support machine off is ethically the same as the decision not to turn it on in the first place. This seemed dangerously incorrect to me. Turning a machine off would mean killing someone. Not turning it on would be merely letting the person die. I argued (proud of my insight and holiness) that turning on a machine to keep someone alive implied a promise to keep it on as long as it was doing its job. His response was simple, and I now know that it is decisive: if turning a machine on brings with it a promise to keep it on, then first responders (paramedics, ER personnel, etc.) will be forced to make long-term promises without vital information. Often, no one knows what effect a course of treatment will have. It might be just what the person needs, but it might also do very little good and even cause great pain, isolation, and spiritual deprivation. If ineffective or greatly burdensome care cannot be withdrawn when the true impact of the treatment is finally known, then emergency workers will have to see the future or make promises that everyone will regret. As I will show in chapters 2 and 3, I am now sure that this Christian doctor’s reasoning was both biblical and sound. At the time, however, I insisted that he was rebelling against God’s Word, duped by the world’s indifference to the sanctity of life.

In the thirty years since loudly taking these positions, I have served on three different ethics committees. Most hospitals now have ethics committees because it is expected by the Joint Commission that accredits hospitals to receive government funds. Some hospitals don’t make much use of these committees, but I have had the pleasure of volunteering for three that were active. All three did “consults,” working with caregivers to sort through contentious decisions. Two of them made and reviewed hospital policies about informed consent, privacy, and how to limit medical treatment that was excessively burdensome. The one on which I currently serve does all that and also works hard at educating everyone about ethical challenges—sick people and their families, doctors, hospital staff, and the local community. Each of these committees on which I have served spent well over 75 percent of its time on end-of-life decisions. The decisions involved are momentous, urgent, medically complex, and typically plagued by communication breakdowns. As a philosophy professor, I find t...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Analytical Outline
• Foreword by Joel Belz
• Preface
• 1. Introduction
• 2. Foundational Considerations
• 3. End-of-Life Treatment Decisions: Challenges
• 4. Putting Biblical Principles into Practice: True Stories
• 5. Advance Directives
• 6. Money and End-of-Life Decisions
• 7. Hospital Realities: Making the Most of Them
• 8. Things to Do Now
• Appendix A: Principles Identified, Defended, and Applied
• Appendix B: Sketch of the Lesson Plans for “Ask the Doctors”
• Appendix C: Sketch of the Lesson Plans for “Leaving Instructions”
• Glossary
• Bibliography
• Index of Scripture
• Index of Subjects and Names