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At Death's Door





A doctor's guide to counseling grieving families on end-of-life issues
A surgeon gives expert advice to pastors counseling families on the thorny issues of vegetative states, life support and blood transfusions. By Clark Gerhart, M.D.

Terri Schiavo's story became a touchstone for pro-life activists, bioethicists and a host of self-proclaimed experts on end-of-life issues. Technical terms such as “persistent vegetative state” and “life support” were bandied about with a vengeance. But what of the spiritual leaders that are placed in the uncomfortable position of providing counsel to families making life-and-death decisions at the hospital beds of family members?

Pastors cannot be expected to understand the latest advances in medical technology, but a working knowledge of some of the terminology and issues surrounding end-of-life care is in order. Physicians may provide medical counsel, but often it rests in the hands of church leaders to help families make bioethical decisions that they must live with for the rest of their lives. In the end, we must help families decide whether everything we could do is everything we should do.

Too often, the patient's wishes have to be pieced together from statements such as, “Well, Marcia said she never wanted to go through what old uncle Frank went through.” Or: “Charlie always said he never wanted life support. 'Just throw me in an old pine box,' he used to say.”

This is not good enough. Encourage families to sit down and talk specifically about what they want in various circumstances and get it written into an advance directive. As you work with families dealing with end-of-life issues, avoid getting hung up on buzzwords or lingo.

For instance, consider the phrase “artificial life support.” Many people prepare for end-of-life decisions by saying, “I don't want to be on artificial life support!” Some living wills and advanced directives even use the term.

The truth is that everything we do in modern medicine is “artificial.” Even the most basic treatments-hydration and feeding-involve formulas that rival any chemistry lab experiment, and mechanical tubes and pumps. And anything that you would die without is life support. The following are the most important terms with which families should become familiar.

Cardiac Resuscitation

Simply put, cardiac resuscitation occurs when hospital staff slap the paddles on a patient's chest, yell “clear” and then send a jolt of electricity through the patient to re-start their heart. It may also involve CPR-pushing the ribs down to compress the heart to pump blood through the body until it re-starts-and heart medications to alter heart rhythms or make the heart beat stronger.

The 45-year-old who falls over with chest pain playing softball with kids half his age will want cardiac resuscitation. For the 85-year-old with terminal cancer, this dramatic procedure will likely become a brutal way to exit this world. People who are weak and sick die shortly after a major cardiac resuscitation, and those whose hearts are strong enough to keep going will do just that after it is re-started.

With this in mind, at least one attempt at cardiac resuscitation makes a lot of sense in most cases. A second or third round, however, requires re-evaluation and recognition that this treatment may not be helping.

Mechanical Ventilation

When a person stops breathing or his or her lungs are not working properly, doctors place a tube through the mouth to fill the lungs with oxygen and take away carbon monoxide, mimicking the process of normal breathing. This is called mechanical ventilation. When a person stops breathing it must be done quickly since the brain can only survive a few minutes without oxygen. So, there is rarely time to debate the ethics of the situation.

Questions arise when a person does not recover the ability to breathe and needs to remain on a ventilator. If the person is otherwise awake and functioning they can use a portable ventilator and use mechanical ventilation indefinitely. (You might remember actor Christopher Reeve using this after a neck injury.)

This is very rare, however, and the more typical situation involves a severely ill patient who is stuck lying in an intensive care unit with little hope of leaving because of their lung failure. This situation requires a life-and-death decision. And it's only minutes after the ventilator is stopped that death occurs, so the consequences are immediate.

Because of the finality of the decision, family members often encounter guilt afterward. Since they give the order and their loved one dies, it is easy for them to feel like they “killed Grandpa.” It is important to counsel them that the disease killed their loved one, not them.

Older people with major chronic illness (heart or lung disease, diabetes, and so on) rarely survive after two weeks on a ventilator. (This is not true for younger people, head injuries, cold-water drowning and many other circumstances.)

One dilemma unique to this treatment is that it has to be started quickly and may be used without anyone ever asking if the patient wanted it. More than once a patient has been scooped up at home by paramedics, placed on a ventilator and dropped off at the emergency room.

Tube Feeding/Hydration

When a patient is unable to eat or drink, physicians insert a tube in the veins (i.e. an IV) or in the gastrointestinal tract. This might need to be done when a person is in a coma and not awake enough to eat. Or, the person could be wide awake but with a fractured jaw or paralyzed throat muscles and unable to swallow.

If the patient has a treatable illness and nutrition or hydration will be temporary, there is not much debate. The dilemma arises when there is serious, permanent brain injury such as in Terri Schiavo's case. This is when we must ask, “Are we prolonging life or just slowing the dying process?” And the answer is not always obvious.

For those facing this heart-rending decision, there's a medical reality that I have frequently noted in my experience: When it is time to die the body doesn't want to eat. I believe God has built into us a “doomsday button” that shuts off our ability or desire to eat when the end is near. Of course, I am not referring to short-term or acute illness that also can give a loss of appetite. I'm talking about the times when a person has a chronic, debilitating illness that cannot be reversed by medicine.

Blood Products

Blood transfusions have saved the life of many a patient I have treated, but I have also encountered others for whom the procedure merely delayed an inevitable death. One patient of mine had inoperable colon cancer that had eaten through the lining of his large intestine. Unfortunately, he had been deemed a poor surgical risk, so there was nothing that could be accomplished through surgery to save his life. Instead, he faced the prospect of simply hemorrhaging to death unless a transfusion was given.

But the unfortunate outcome of the transfusion would be that the new blood would simply hemorrhage out also. So what do you do? Do you give him a transfusion every week for all of the months he may live, or do you not offer the life-sustaining treatment? Are you sustaining life or prolonging death? In instances such as this one, blood transfusions become life support and raise ethical questions.

Specific Medications/Procedures

Other medical treatments such as chemotherapy, antibiotics, kidney dialysis or even surgery can be considered life support if not having them will result in death. Chemotherapy keeping a tumor at bay can be the difference between life and death in some cases. Kidney dialysis removes the harmful chemicals from the blood stream before they reach deadly levels.

These treatments have clear advantages for the specific diseases they treat, so the ethical nature of their use is generally not questioned when they are started. It is when a patient desires that they be stopped that pastors are often called upon to help with the decision.

The specifics of these treatments vary from patient to patient and disease to disease, so it is difficult to discuss them in general. Each requires that the patient be fully aware of the risks and benefits before they decide to start on a course of therapy. The goal is deciding whether the treatments will prolong life or simply prolong the dying process.

Ultimately, we must be strong advocates for life. As we advocate life, however, we are called to help people come to grips with the biblical reality that it is appointed for each man once to die (see Heb. 9:27), and there is nothing medical science can do to change that.

Sometimes we can affect how it happens, however. And sometimes we must resist the pressure of science to cling to every last moment on earth with oftentimes extreme and excruciating medical procedures. After all, our hope is not here but in heaven, and we wait with bated breath on our arrival there.

A Time To Die

An ethicist offers biblical insights on making decisions about end-of-life issues.

Q: Have Westerners gone overboard in our desire to prolong life beyond when natural death would occur?
A: Since the Enlightenment, many in the West have forgotten that there is a life to come beyond the present life, and lost sight of the realism of the biblical outlook expressed in Eccles. 3:2: “There is a time to be born, and a time to die.”
Q: Should a person's spiritual condition affect how we make decisions about removing life support from a family member?
A: Any person nearing the end of life should be asked questions such as: “Is there anyone you still need to forgive? Have you said 'I love you' and 'thank you' to your family and friends? Have you made wise arrangements for your finances and property? Are you spiritually ready to die? Have you made peace with God?”
Q: What are some key principles we should keep in mind when applying the Bible to bioethics-especially considering that the biblical authors did not anticipate the medical technology we have today?
A: Key principles to consider include the value of all human life made in the image of God (see Gen. 1:26), the obligation to love our neighbors as ourselves (see Matt. 22:39) and the need to recognize the inevitability of death (see Eccles. 3:2).
Q: Is it ever right for a pastor to counsel families to deny their loved one's wishes when it comes to withholding care?
A: Pastors should do all they can to facilitate agreement and consensus among the family members on treatment decisions, but should leave the responsibility for the final decision to the family.
Q: Any final advice to pastors counseling people making end-of-life decisions? A: Teach and preach on end-of-life decisions, and encourage church members to discuss and plan for such situations before the crisis points arise.


John Jefferson Davis teaches systematic theology and ethics at Gordon-Conwell Theological Seminary. Davis is the author of Evangelical Ethics: Issues Facing the Church Today (P&R Publishing).

Vital Stats

50 percent of all medical expenses occur in the last 6 months of a person's life.
6 percent of Americans are over age 75. This figure is expected to double by 2050.
20 percent of Americans have prepared advance directives.
33 percent of Americans have drafted a living will.

Sources: American Family Physician, October 2000; CBS poll, March 2005 Clark Gerhart, M.D., is a general surgeon in Plains, Pennsylvania. He teaches and speaks regularly on Christian life and a variety of medical topics. He is the author (with Jefferson Scott) of Say Goodbye to Stubborn Sin (Siloam). For more information on your state's advance directive, visit the National Hospice and Palliative Care Organization at www.nhpco.org.

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