Preparing To Cross the Finish Line:
By Christina M.H. Powell
The recent death of my husband’s grandfather after living a full and fruitful Christian life for 88 years brought the words of the apostle Paul to mind, “I have fought the good fight, I have finished the race, I have kept the faith” (2 Timothy 4:7). In our current world with ever-increasing medical technology, the last weeks and days before one crosses the finish line in the race of life can be filled with complex medical decisions that must be made. The Christian’s desire is to cross the finish line in the same manner he has run the race — giving glory and honor to God.
Ministers often find themselves called on to provide guidance at this crucial time to both patients and their families who are seeking the will of God in the particular end-of-life situation that is facing them. The principles that must guide our responses to challenging end-of-life questions flow from a biblical view of life and a biblical view of death. Let us turn our attention to a biblical view of life.
A Biblical View Of Life
The apostle Paul told the men of Athens, “The God who made the world and everything in it is the Lord of heaven and earth and does not live in temples built by hands. And he is not served by human hands, as if he needed anything, because he himself gives all men life and breath and everything else” (Acts 17:24,25). Paul’s words echo the account of creation: “The Lord God formed the man from the dust of the ground and breathed into his nostrils the breath of life, and the man became a living being” (Genesis 2:7). God is the Creator of life. Our life is a gift from God.
The prophet Jeremiah realized that since our life is a gift from God, our life belongs to God. He expressed this thought eloquently: “I know, O Lord, that a man’s life is not his own; it is not for man to direct his steps” (Jeremiah 10:23). Our purpose is not self-fulfillment, but rather glorifying our Creator (Isaiah 43:7). Furthermore, a biblical view of life includes the promise of eternal life at the end of our earthly existence (Titus 1:2; 1 John 2:25).
A Biblical View Of Death
While death appears to be a natural conclusion to life, we must remember that death came as a result of the fall of man and not a natural part of the creation of man (Genesis 2:17; 3:3; 1 Corinthians 15:21; Romans 6:23). The Bible teaches that death is an enemy that ultimately will be destroyed (1 Corinthians 15:26; 2 Timothy 1:10; Revelation 20:14). Yet, death is indeed an experience that all will face. As the Psalmist asks, “What man can live and not see death, or save himself from the power of the grave?” (Psalm 89:48).
There is One, however, who did overcome the power of the grave. God raised His Son, Jesus Christ, from the dead, “freeing him from the agony of death, because it was impossible for death to keep its hold on him” (Acts 2:24). For those who trust in Jesus Christ as their Savior, the day will come when “He will wipe every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away” (Revelation 21:4).
A Biblical Basis For End-Of-Life Decisions
With a biblical view of life and death firmly in place, we are ready to establish a biblical basis for end-of-life decisions. For the Christian preparing to cross the finish line, death marks the end of the earthly race and the beginning of eternal life. The hope of eternal life offsets the fear of the dying process. While the Christian might long to be with Christ and out of the suffering body, the Christian recognizes that God’s will and purpose for life can still be accomplished until the moment of death. As long as a person is conscious, he is capable of actively influencing others for Christ and interceding in prayer. The runner should not seek to shorten the racecourse, but trust the Lord for strength to complete the race.
Furthermore, the Christian recognizes that his life is not his own, for he was bought with the price of Christ’s redemptive sacrifice on the cross (1 Corinthians 6:19,20). Patient autonomy exists within the limits of God’s sovereignty. In addition, the Christian is sensitive to the needs of loved ones, choosing to strengthen relationships as life draws to a close.
A Christian who is responsible for making end-of-life decisions for another will seek to honor the wishes of the one for whom he is making decisions. The caregiver’s desire not to see his loved one suffer should be channeled into advocating for effective palliative care measures for the patient. Sometimes the employment of appropriate pain-killing measures will shorten the patient’s life, but the goal should be the alleviation of pain, not the hastening of death.
Prolonging Life By Extraordinary Means
A Christian’s respect for the sanctity of human life does not mean that life must be prolonged by every technological means possible. A Christian should seek to be cured of a disease if a cure is available. In the case of an incurable condition, however, where the course of the disease cannot be reversed, sometimes it may be appropriate to discontinue a particular treatment. There are times when the burden of the treatment outweighs any potential benefits of the treatment to a particular patient. For example, a cancer patient whose condition cannot be cured may prefer to choose home or hospice care where he can face death surrounded by loved ones in a familiar setting. A person making such a decision has not given up on life, but has chosen to live life to the fullest in the time remaining on this earth.
Experimental treatments, such as a phase I clinical trial for a new cancer drug, may be viewed as an extraordinary means of treatment. A phase I clinical trial is concerned with determining the correct dosage and overall safety of a new drug. These trials are a crucial part of the four-phase system of clinical testing of experimental drugs. However, since the main concern of the phase I trial is how the drug is metabolized in humans as opposed to the effectiveness of the drug for the particular disease affecting the patient, the benefit to the individual patient may be small or nonexistent. Patients who participate in phase I trials usually have exhausted all other treatment options. While patients who chose to participate in such trials are assisting the advance of medical science and the development of new treatments that may someday benefit other patients, it is not morally wrong for a Christian to decide not to participate in such a trial.
Certain treatments, such as cardiopulmonary resuscitation, that are lifesaving and appropriate in most circumstances, may be futile for a terminally ill patient whose death is imminent. Examples of conditions for which CPR is futile include metastatic cancer, septic shock, and acute stroke. CPR is a supportive therapy designed to establish circulation and breathing in a patient who has suffered an arrest of both with the goal of restoring spontaneous breathing and cardiac rhythm. The standard of care in the hospital setting is to perform CPR in the absence of a valid physician’s order to withhold it. In cases where CPR would be futile, a Do-Not-Resuscitate order may enable a patient to experience a more peaceful death, without employing technology that is intrusive, but ineffective.
Another example of a technology that is helpful in many circumstances but may not be beneficial in a patient whose death is imminent is artificial hydration and nutrition. Artificial hydration and nutrition are used when a patient is no longer able to take food or fluids by mouth. Two means of providing artificial hydration and nutrition are an intravenous line, and a feeding tube. Artificial hydration can also be provided by injecting fluids directly into tissues beneath the skin, a procedure known as hypodermoclysis. If an IV line is used, fluids, liquid nutritional supplements, and medications can be introduced through a patient’s vein. A feeding tube can be inserted into a patient’s stomach either through the nose (nasogastric tube) or through the abdomen by surgical means (gastrostomy or PEG tube, or g-tube). As with an IV line, liquid nutritional supplements, fluids, and medications can be given to a patient through a feeding tube.
One risk associated with the use of IV lines is the possibility of infection occurring at the IV insertion site. To reduce the risk of infection, the IV site may need to be changed every few days, creating discomfort for patients who find IV insertion painful. A risk of IV line usage for a patient near the end of life is that the patient’s body may not be able to handle the IV fluids well. As death nears, a person does not need as much food or fluids and dehydration normally occurs. The addition of IV fluids at this time can cause swelling in the patient’s arms and legs as well as fluid accumulating in the patient’s lungs, making breathing more difficult. Swelling and the accumulation of fluid in the lungs is also a risk with hypodermoclysis for a patient nearing death.
Risks associated with the use of feeding tubes include the development of pneumonia if fluid from the stomach is aspirated into the lungs, infection at the point of insertion for a tube surgically inserted through the abdomen, and irritation of the stomach lining sometimes resulting in stomach ulcers. As a patient nears the end of life, it is normal for the patient’s metabolism to slow. As a result, nutritional supplements given through a feeding tube can cause digestive problems such as bloating, heartburn, or indigestion.
In many cases, artificial hydration or nutrition can improve the quality of a patient’s life by increasing his energy and decreasing symptoms, such as nausea or weakness. The important principle to follow in making decisions regarding artificial nutrition and hydration is that one must balance the risks and benefits with knowledge of a patient’s condition and particular needs. It would be a mistake to decide that a technology, such as artificial nutrition and hydration, should always be employed or, conversely, always be avoided.
Pain, depression, and fear of becoming dependent on others may cause a person with a terminal illness to consider ending his life. Often a dying person does not realize that loved ones want to provide care as an expression of love and do not view this opportunity as a burden. A terminally ill patient may look to his physician to provide the means for the patient to voluntarily cause his own death, a practice known as physician-assisted suicide.
Physician-assisted suicide usually involves the physician prescribing lethal doses of medication for the patient. Currently, the only state in the United States to legalize physician-assisted suicide is Oregon, which permits the practice for the terminally ill under limited conditions. Since the Death With Dignity law went into effect in Oregon in 1997, one-seventh of one percent of all deaths in the state are classified as physician-assisted suicide.
Frequently, the reason a patient seeks information about physician-assisted suicide is that the symptoms associated with the dying process (such as pain, depression, or nausea) are not being managed effectively. It is important for family members and caregivers to be sensitive to the pain-management needs of a terminally ill patient. In addition, the emotional and spiritual needs of patients must be addressed. Chaplains and others who provide pastoral care can support and guide family members in finding effective ways to address the patient’s needs as death nears.
Historically, physician-assisted suicide has been prohibited in the practice of medicine for more than 2,000 years. The Hippocratic Oath, taken by many new doctors as part of their graduation ceremonies, includes the pledge, “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.” Many Christian doctors feel that physician-assisted suicide undermines the trust relationship between a patient and a doctor. Another concern of physicians is that the availability of physician-assisted suicide would decrease the impetus for improving good palliative care for dying patients. In other words, if prematurely ending one’s life is an option, there is less reason to improve pain management and comfort measures for the dying.
Euthanasia goes one step further than physician-assisted suicide and permits the physician to directly end the life of a suffering patient at the patient’s own request. For example, giving a patient a lethal injection would be considered euthanasia, while prescribing a lethal dose of medicine that a patient then intentionally consumes by himself would be considered physician-assisted suicide.
Euthanasia can be further subdivided into three categories: voluntary euthanasia, nonvoluntary euthanasia, and involuntary euthanasia. Giving a patient a lethal injection at the patient’s request would be classified as voluntary euthanasia. Nonvoluntary euthanasia occurs in circumstances where the patient is unable to make a voluntary request (an unconscious or mentally incapacitated adult; an infant or child). Involuntary euthanasia is ending the life of a patient who is perceived to be suffering and who is capable of making a voluntary request, but has not done so.
People have a natural fear of suffering and dying. Those who promote euthanasia and assisted suicide capitalize on this fear. Under the guise of compassion, they seek to reduce medical costs by classifying euthanasia as a medical treatment option. Pastors and chaplains are in a unique position to counteract the forces in our society that promote euthanasia by addressing the spiritual needs of patients and their family members. The fear of suffering and dying can be replaced with hope and trust in a sovereign God who is capable of bringing healing in spite of even the most dire circumstances, and who is capable of gathering us home at our appointed time. May ministers help others join the race of living for Christ, help them run that race with purpose and meaning, and help them complete the race by crossing the finish line victoriously.