Discernment and Hope in End-of-Life Dilemmas

Kathryn Butler: Thank you all for coming this afternoon. This is not an easy topic. After a very celebratory twenty-four hours with all of our sessions, this is a really hard one to dive into. I’ve just been so grateful for the messages over the past day, because I think when we’re dealing with something so heavy, the knowledge that heaven rules, that God is sovereign, and that no matter what happens—no matter what decisions we face, no matter our fear, no matter our grief—nothing can steal us away from God’s love for us in Christ. So thank you for joining me, and with that in mind I’d like to open us in prayer.

Heavenly Father, we thank You that You are ruler over all. We thank You and we praise Your name that You’ve stitched together the DNA within ourselves and yet also heaped the mountains skyward. That You know every hair that falls from our heads, and our times, Lord, are in Your hands. Lord, as we enter into some shadowy territory and talk about some questions that can be so anguishing for us and for those we love, we ask that You might always remind us that we are Yours, that You have swallowed up death in victory, that Your steadfast love and faithfulness endure forever, and that under Your sovereignty, heaven rules. In Jesus’ name we pray, amen.

As Nancy said, once upon a time I was a trauma surgeon. God’s since called me to a different phase of life, but during that period in my career I chose trauma surgery for the success stories, and had a particular interest in the intensive care unit. I loved and found it was a tremendous privilege to come alongside people when they were most scared, when they were dealing with things that were life-threatening, and to use the technology that God’s given as an ordinary means of His kindness through medicine to bring them back to their families, to restore them to the lives that they loved.

What I found over time, and what you might also have noticed if you’ve interfaced with the medical field in any way, is that the technologies that we use that can save life in the right circumstances and bring people back home can also prolong death and suffering when we use them without discernment at the end of life to people who are struggling with illnesses for which we have no cure. When that happens, we can pitch families into some agonizing situations of having to determine whether or not to continue life support for a loved one, whether or not to do CPR. For a believer, we wonder how our faith informs that decision-making process, and appropriately, we try to lean into our faith to say, “Okay, what would the Bible have me do?”

The problem is, the Bible tells us a lot about death and life and suffering and God’s hand in it all, but doesn’t explicitly mention ventilators. The landscape is so foreign to people and so out of the ordinary that they really can falter and their grief can be deepend even further as they struggle to know, “What is God-honoring?”

What I hope to do over the next hour is to shed some light a little bit on the kind of scenarios I’m talking about and give us some biblical principles to help. My encouragement would be, whatever your walk of life—whether you are considering these decisions yourself, whether you’re concerned for a loved one, a parent, a spouse, a sibling, a grandparent—to be okay with having these discussions and have them readily, knowing that because of our hope in Christ we need not fear this topic.

To give you an idea of the kinds of dilemmas I’m talking about, I’d like to tell you about a gentleman for whom I cared. I met him when I was working in the ICU, and he was in his 80s, and before he walked into my doors he was already suffering from the end stages of multiple chronic illnesses for which we’d run out of treatments, and was suffering from some degree of organ failure. So he had kidney disease and was on the verge of dialysis; he had end-stage emphysema and was requiring oxygen, then was refractory to our medications. And he had congestive heart failure on top of it. So he was in and out of the hospital constantly with respiratory distress.

Over the last six months he found that his conditions, which were progressing more and more each month, left him so debilitated that he couldn’t engage in the usual spiritual disciplines that brought him such comfort and reminded him of who he was in Christ. He wasn’t able to attend church anymore and felt cut off from his fellowship with other believers. He found it so difficult to concentrate, because his carbon dioxide levels were so high at baseline, that he couldn’t read the Bible anymore. So he relied upon the Scripture that he’d harbored in his own heart, but even just the normal things he relied upon to walk with Jesus in his daily life he felt were being stripped away from him.

In this setting, when he was already deteriorating, he then was found to have a quite aggressive cancer. He underwent a surgery at the behest of his family. He didn’t want to undergo it, but he did. Before he did, he had a discussion with his wife, and he knew that if he were to decline and needed to go onto a ventilator (a breathing machine), that he would never come off of it because his lung function was so poor. He’d been on one before and found it torturous, so he told her, “Please, if I decline after the surgery—I’ll do this—but if I decline afterwards, I’m at the end of my life. Let me go home to Jesus. Please don’t consent to put me on a ventilator.”

Sure enough, after his surgery he did develop respiratory failure in the setting of pneumonia. We tried oxygen, we tried bipap, which some might be familiar with, which is basically a ventilator without the tube down your throat, and he still continued to decline. So we had to make the decision.

His wife was absolutely sure. She didn’t even have to pause. She said, “He wants to go home to Jesus when he’s called. He’s ready. He would not accept this.” We talked with his primary doctor, who also said based on his discussions that would be his answer.

When I left that evening, we had transitioned to comfort measures, which is still care, but we change our focus from trying to cure to instead ameliorating symptoms. So we treat air hunger, we give medication to treat anxiety, we treat pain. He was peacefully asleep, with her holding his hand. Through tears she said to me, “I don’t want to lose him, but I know he’s going to be with the Lord. How can I grieve when I know that?”

A few hours later, in the middle of the night, their son, from whom they’d been estranged for several years, arrived in the intensive care unit furious with this decision. He stormed into the room, he demanded that we put his father on a ventilator, and he threatened to call the police if we didn’t. He also fell back on his father’s faith as his rationale. He said, “My dad went to church every Sunday for his entire adult life. He believed in the God of the Bible. Killing is wrong. As a Christian, I know that. You’re killing him. You need to put him back on a machine now.”

How do we reconcile these responses? I offer this because, unfortunately, this is very common. It’s very murky and so foreign and so out of our usual realm of experience, when we’re dealing with these sorts of dilemmas, that it’s very easy to cling to one tenet that we know from the Bible and ignore the overall narrative arc of who we are—that we are fallen but redeemed in Christ, and that God is sovereign even over our days.

You see that in this. Both of these individuals, out of love and fear, drew from biblical ideas in their rationale. The wife leaned into her confidence in her husband’s salvation through Christ. She also upheld his dignity as an image-bearer of God who had the authority and the free will to make decisions, and she was trying to determine what that decision would be if he had a voice of his own. She accepted God’s sovereignty over life and death, knowing that death will come to us all eventually. But her son was citing sanctity of mortal life, which is also a deeply-held Christian principle. Yet they reached diametrically opposed conclusions.

Unfortunately, this is more and more common as the landscape of death and dying has shifted over the last hundred years. A hundred years ago, 86 percent of people died at home. We all knew what death looked like; it occurred in the spaces that shaped our lives among families, with our pastors beside us, in a community. It was something we all knew was a reality, and it was something that we could see and understand. Today, 70 percent of Americans still wish to spend their last days this way. We still cleave to the truth that we are more than just the mechanization of our bodies, that we have lives, and how we end those lives and our last days matter. But only 30 percent of us actually do. The majority of us spend our last days in an institution. More and more, thankfully, we are seeing hospice centers be the place where we end life, but the vast majority is hospital rooms and nursing homes. Twenty-five percent of people over the age of sixty-five spend their last hours in an intensive care unit, far removed from the spaces and the people that helped to shape their lives.

What this does, this shift in the landscape, is it removes the process of death and dying from our daily understanding, and it also screens it behind a wall of technology and vocabulary that we just don’t understand. Additionally, what it does is it heaves the burden of decision-making on our loved ones. Most of us don’t want to talk about death. There is no faster way to stop conversation at dinner than to bring up death! Trust me, I can’t talk with my husband about certain things at certain times of the day.

But the truth of the matter is, when we don’t discuss it, because it’s so foreign, because the toll is so heavy, we wind up crippling our loved ones and stranding them with some horrible situations of making decisions for us when they feel ill-equipped to do so. We don’t want to discuss it, we want to wait until the time comes—I’ve heard that. “I’ll deal with it when I need to.” But the truth is that 75 percent of us won’t be able to communicate at the end of life, either because our illness will actually take away our ability to think and reason, or our lungs will fail and we’ll have an endotracheal tube down our throats, or we’ll need to be sedated. But the vast majority of us won’t be able to say and offer guidance to our loved ones.

In addition, there’s the option of advance directives, which is indicating your wishes ahead of time and discussing with your family, but only one third of people in America actually have one filled out. What this translates into is a huge number of people—maybe some in this room—who are making decisions for loved ones in dire circumstances when they are afraid and they’re grieving and they don’t know what to do.

The toll is very heavy. We actually have studies showing that when loved ones make decisions for patients who then die in the intensive care unit, they suffer from depression, from complicated grief, which is stuck grief that doesn’t get better, anxiety, and post-traumatic stress disorder for up to a year afterwards.

You can understand why, because in addition to just the fear and the grief and the heartache of potentially losing a loved one, you’re trying to make decisions for which you feel completely ill-prepared. From the doorway, a patient in the ICU will look identical if they’re recovering and on the verge of going home or if they’re at death’s door. They will all have a similar arma materium of a monitor, they’ll have infusion pumps, they’ll have potentially a ventilator, they could have a dialysis machine, and it’s up to a doctor to be able to look at the trends in the lab work and in the vital signs to be able to offer guidance about whether someone has a hope for recovery or not.

We try to lean into our faith, but like I said, we struggle, and we can stumble. We have questions that are tied up in our beliefs. We might ask, “If I withdraw a ventilator, am I killing my loved one? Does being a Christian mean that I have to do everything at all costs, all the time? Will God perform a miracle if I keep things going? What does the Bible say about this scenario?”

These questions about faith at the end of life matter, both practically and also for our walk in Christ—it matters that we love our neighbors, which includes those for whom we’re making decisions, that we honor God. But what we’ve actually seen is that our faith influences the choices that we make. Studies have shown that those with high religious coping—those who attend church and who fall back onto their spiritual beliefs to help them make decisions—are more likely to pursue aggressive measures at the end of life, less likely to receive hospice services, and more likely to die in an intensive care unit.

Additionally, when we seek guidance, we often don’t find it in the hospital, okay? Doctors are notoriously very poor—and I’ll be the first to say this, I am one—at offering guidance for people from a spiritual standpoint. In one study of end-of-life care family meetings where a physician was meeting with family members to discuss care and make decisions for a loved one who was in the ICU, 80 percent of them voiced during the meeting that faith was important to them, but the doctors actually followed up in only one fifth of cases. The most common response was silence.

Additionally, we’ve seen that you could say, “Okay, you know what? Doctors aren’t spiritual leaders; they shouldn’t have to be.” But the problem is that they are so uncomfortable with the idea of spiritual dialogue, they don’t even refer to chaplaincy. Chaplains are the ones who are specialized, who have the training, who could interface and offer spiritual guidance and support. But in another study of terminally ill cancer patients from Boston (my city) they found that 85 percent of those patients had spiritual concerns, but only 1 percent that their doctor had mentioned chaplaincy to them.

This corroborates other data we have showing that we doctors are most likely to consult a chaplain in the last day or two of life, usually to patients who are incapacitated and noncommunicative and so can’t dialogue with that chaplain.

All this is to say that there is a heavy burden on loved ones. There’s a disconnect between what we know in Christ and what we have to decide at the bedside, and there’s not very much support in the hospital.

My goal now is to unpack: what does the Bible actually say? Sure, it doesn’t talk about ventilators. Sure, it doesn’t talk about advance directives. But it says a lot about life and death and suffering and our hope in Christ. My goal is to unpack some of these principles, so that when you’re dealing with these issues yourself, you can have some peace and some discernment about what’s in front of you.

When we’re talking about end-of-life care, the four principles that I like to discuss are: sanctity of mortal life, God’s authority over life and death, mercy and compassion, and our hope in Christ, which supersedes all of them. I’d like to emphasize that these four principles really should all be considered together. As I hope I illustrated in the beginning, I think we falter when we cleave to one and ignore the overall arc of the Bible and what the Bible teaches us as a whole about who we are.

So, sanctity of mortal life; here we go. As beings created in God’s image, we each possess irrevocable value, right? This is taking us right back to Genesis 1. We are made to steward God’s creation, and part of that stewardship means we have concern for mortal life. We are not our own, but we’re bought with a price, and so we’re to honor God with our bodies, because our bodies are temples of the Holy Spirit. The Lord entrusts us with life, and He commands us to cherish it. This is the most obvious, from Mount Sinai: “You shall not murder.”

The sanctity of mortal life mandates that we advocate for the unborn and that we safeguard against physician-assisted suicide. I have to pause here and emphasize that last point. When I talk about withdrawal of care or comfort measures, I’m not saying that as a Christian we should advocate physician-assisted suicide or euthanasia. I know that’s a movement that is in Canada right now that is going to be infiltrating into the United States. They are two different things. In physician-assisted suicide or euthanasia you are actively taking a medication with the express purpose of ending your life. That’s different than acknowledging that you are at the end of life, that what is threatening your life is not recoverable, and saying, “I don’t want treatments that are going to cause suffering but not get me home.” Those are two very different ideas. When I’m talking about this, physician-assisted suicide is not consistent with the Bible, but withdrawal of care or declining measure may be, okay?

When struggling with an array of decisions about life-supporting measures, out of concern for life, we should consider treatments that offer the potential for cure that can offer to have us recover and come back home.

Over and again, this is the fact and the truth—that God has authority over our life and death. I think sometimes people at first glance think that these two principles are in tension with one another. They’re not, but it’s important to recognize that we just need to be thoughtful and careful about how we consider them. They’re not in opposition.

Although God directs us to honor the life He’s created, He also reminds us of its fleeting nature. We read in Isaiah 40 that we are like the grass of the field; we are here today, we wither tomorrow. We are dependent on the Word of the Lord throughout. 

From Paul’s letter to the Romans, death persists in this earthly kingdom as the wages of our sin, and until Christ returns it will take all of us. Because of the first man who sinned, Adam, so sin came to all and death came to all.

Sanctity of mortal life doesn’t refute the inevitability of death and God’s work through and authority over it. We aim to protect life, but death will come to all of us until Jesus returns.

Additionally, when we blind ourselves to our own mortality, when we don’t acknowledge this, we actually deny the resurrection and deny its power and the grace that it can have over our lives. Through the resurrection, death has been swallowed up in victory. Jesus says, “I am the resurrection and the life; all who believe in me, though they die, yet they will live” (John 11:25 paraphrased). That is tremendously powerful in guiding our lives. When we buck against the reality that death will come to us, we ignore that God can actually work through our death for His glory. Heaven rules even over our last days. We read from Romans 8:28 that He works through all things, even death, for the good of those who love Him (paraphrased).

The third, which is Christianity 101, is mercy and compassion. The second greatest commandment, according to Jesus, is to love our neighbors as ourselves (Matt. 22:39). As Christians, reflecting upon God’s tremendous grace toward us through Christ, we’re to extend mercy toward the downtrodden and afflicted. First John 4:19: because He loved us so we’re to love one another (paraphrased). As our Father is merciful, so we are to be merciful (Luke 6:36 paraphrased). From Micah 6, we are to act justly and love mercy and walk humbly with our God.

Mercy doesn’t justify euthanasia, physician-assisted suicide, but it does guide us away from measures that are aggressive and painful if they are futile, if they are not going to help. This matters, because ICU measures do cause suffering. CPR, which is chest compressions needed to continue blood flow to the heart and the brain when the heart stops, causes chest trauma, most notably rib fractures, in 90 percent of cases, which means that if you survive CPR it hurts every time you breathe. 

People who survive a long ICU stay report rates of post-traumatic stress disorder comparable to that suffered by soldiers who fought in the Gulf War. People wonder, “How can it cause that much suffering?” I like to give a bit of a scenario of what’s actually very typical. 

Let’s say you come into the emergency room and you’re in respiratory distress. You can’t breathe; it feels like you’re choking or you’re drowning. You’re panicking. People are swarming around you; you can’t understand what they’re saying. Then the lights go out because they give you a sedative and put you on a ventilator.

You then wake up, and the first thing you notice is that you have something in your throat and it’s making you cough. You’re coughing and you’re coughing, and your eyes start to tear. There’s something in your mouth, and you don’t know what it is, so you try to remove it. Then you realize that all of your limbs are tied down to a bed. You look around, you try to call for help; you can’t. You don’t know where you are, you don’t know who’s around you. You look around and you realize that there are tubes in places that are for you only. Then, as you start to panic, the lights go out again as your nurse gives you a sedative.

That happens in the ICU over and over and over again. We’ve seen that people who survive an ICU stay struggle with nightmares, PTSD, and delirium afterwards.

If we can bring people home, it’s worth it! It’s absolutely worth it. But if not, if we’re dealing with somebody in their last days, it can start to look a lot like cruelty. So it’s very important to be aware of the toll that these measures can have.

Additionally, showing mercy and compassion and loving our neighbors through this kind of an ordeal means viewing them as the unique image-bearers of God they are and acknowledging that suffering is subjective. I’ve had patients who would never consent to being in a nursing home. I’ve had others who want everything done as long as they can watch TV with their family nearby. What is torturesome to one person might be perfectly acceptable to another if it enables them to continue to live according to what they value. So it’s really key, as we’re thinking through these hard questions, to think about the person in the bed and who they are. To try to put aside what my own wishes might be, but instead to think about, as a unique image-bearer of God, with his own story and values and fears and experiences and temperament, what would he or she say? That can be a very loving act during these hard situations.

The fourth, which is the most important, is our hope in Christ. So vast is God’s love for us that nothing, not even death, can pry us from Him. From 1 Corinthians 15, Christ has relinquished us from the permanence of death; He has swallowed it up in victory. “O death, where is your sting?” we read (verse 55).

We savor the promise of the resurrection of the body and the hope of eternal union with God. The gospel transforms our view of dying. It chases away our fear, because although we die, we live in Christ. If there’s any verse that I think of the most when I’m dealing with this topic, this is the one. Of all the promises that Joni so beautifully articulated yesterday, this would be the one I’d be yelling over and over in these kinds of scenarios. “Nothing, neither life nor death, nor angels, nor rulers, neither present nor future; nor any powers, nor height, nor depth, nor anything else in all creation, can separate us from the love of God through Christ Jesus our Lord” (Rom. 8:38–39 paraphrased). The gospel transforms our view of death.

So, where does that bring us—putting these four principles together in end-of-life situations? The sanctity of mortal life directs us to consider treatments that cure. God’s authority over life and death prompts us to also, however, accept that death will come and its reality in our lives. Out of mercy and compassion, we’re to have concern for the suffering, and for the suffering that we might inflict through treatments. And our hope in Christ is what helps us endure every minute through prayer.

How do I apply that? Putting all these things together, there are a couple questions that you can ask yourself if you’re in one of these situations of having to make decisions for loved ones and you don’t have a lot of guidance. It should be in general, but especially if you don’t have a lot of guidance. 

If the doctor is talking to you about your loved one and saying, “This is the situation; what would you like to do? What would your loved one do?” Ask, “Will life support in this scenario constitute preservation of life or prolongation of death and undue suffering?” Differentiate between those two. To figure that out, the key question is not actually about the technology, it’s, “Is the underlying illness treatable?” This is really key, and it’s difficult to grasp if you’ve not worked in a hospital, but these life support measures that we use are supportive, they’re not curative. A ventilator cannot cure your pneumonia. What it does is it supports your lungs to give us time to give you antibiotics that will eradicate the pneumonia. Dialysis doesn’t fix your kidney failure, it supports your kidneys and takes their place. So it’s really important. If you’re dealing with a situation where it’s a potentially recoverable illness that’s causing organ failure, life support makes total sense. But if it’s not—if it’s the result of a very long, drawn-out, and arduous ordeal with a condition that we can’t treat, then that ventilator is going to be a permanent fixture; it’s not going to help.

To give you an idea, I can tell you a hypothetical scenario. Let’s say a gentleman in his forties develops community-acquired pneumonia. That’s something that’s easy to treat; we can use antibiotics. He comes into the hospital, he worsens, he needs ventilator support. Once we start the antibiotics, that ventilator will probably be on for 48 hours, and then he’s expected to come off of it as the antibiotics clear the infection from his lungs. Because he was healthy beforehand, he’s likely to recover his lung function really quickly and go home.

It’s going to be a very different situation when you have a patient who’s in their nineties who has end stage emphysema, who has metastatic lung cancer, who comes in with a fungal pneumonia, which is much harder to treat. In that kind of a scenario, that ventilator is not likely to ever come off or prevent death in that situation.

I hope that that gives some kind of help with what I’m talking about the difference; one is life-preserving, the other is prolonging death and suffering. That’s really the key question to ask: “Is the underlying process reversible?”

Questions to ask a doctor as you’re trying to tease this out: What is the condition threatening life? Why is the condition life-threatening? Can the available treatments bring about a cure? What is the likelihood for recovery? Answers to these questions should offer some guidance to that overwhelming answer of, “Is this recoverable or not?”

How do my loved one’s previous medical conditions influence his or her likelihood for recovery? That’s an important one that I think we often miss. You might have something that’s recoverable, but if you’re at the baseline dealing with a lot of medical problems and you’re very tenuous, it can take one severe insult to knock all of your other organ systems into failure. So that’s a really important thing to ask. Say, “Okay, what about the baseline lung function of my dad? What about my mom’s heart failure? How is that going to affect what’s happening here?”

Will the available treatments worsen suffering with little chance of benefit? There might be a marginal chance of recovery, but it might come at a very heavy cost. What are the best and worst expected outcomes?

Now, if we factor all that questioning and the answer is not clear, it’s always fine to err on the side of life. We oftentimes will do a time trial in the intensive care unit. When someone comes in very sick and we’re very concerned but we’re not sure, and there is a chance, we’ll say, “You know what? Let’s reconvene in 48 hours. Let’s just keep going, and we’ll see.” Eventually it will become clear. Remain prayerful throughout so that you can be at peace and be connected with God throughout the process.

Oftentimes, what happens is it’s not full recovery that we’re looking at, but partial recovery with disability. That’s when we need to ask questions about suffering. What would my loved one say? Would my loved one be okay with the ramifications of this? This is what surrogate decision-making really is about; it’s discerning their voice. It’s thinking about who they are, what makes them tick, and saying, “If he could speak for himself, what would he say?” Not, “What would I have him say?” but, as I gave in the scenario at the beginning of this, his wife didn’t want to leave him, didn’t want to say goodbye to him, but said, “I know what he would say in this scenario.”

If you’re not sure—by God’s kindness we have discussed this with our loved ones, and we know, and we have that peace, or maybe we have an advance directive we can refer to, and that makes this process so much easier, even as we’re still grieving. But if you’re not sure, if you haven’t had those discussions, ask about what matters to your loved ones and what drove him in life. What comments has he made in the past regarding end-of-life care, if any? What are his goals, both in the short-term and for his life in general? What is he willing to endure to achieve those, and would he be unwilling to face?

I find it helpful, if you’re really not sure and you feel like you’re blind, to even think about your loved one’s hospitalizations in the past. How did they respond to them? Was it something they were able to go through without getting terribly upset, or was it very strenuous for them?

The best thing to do, though, is to have these conversations before disaster strikes. I hope I can impress that upon you. The process is called advance care planning. More important than any individual document is the conversation. I still encourage you to seek the documents out, but even more so, I would encourage you to sit down with your loved ones and talk about it and make sure they understand what you would advocate. This process protects against treatment that contradicts our values, it guides physicians and caregivers when death nears. 

Sometimes people worry and say, “I don’t want to do an advance directive, because then the doctor’s going to have to do what’s on there, and what if my loved one doesn’t think that’s the right thing?” Our goal is to do what the patient would want. So all the time we would have discussions with a caregiver or next-of-kin who was a healthcare proxy, who could say, “You know what? That document said this, but in this situation this is what I think my loved one would say, and here’s why.” Our goal is to try to honor the patient’s wishes. So it will never be, “Oh, sixteen years ago you said you didn’t want a ventilator for anything, so we’re just not going to do it.” No. Our goal is to say, “What would you say if you could speak?” There is no downside to this documentation.

It prevents futile and aggressive treatment that prolongs dying, and it lessens—this is huge, actually—it lessens depression, anxiety, and stress among loved ones. I’ve had loved ones explicitly say to me after a really, really hard decision, “Yes, I’m grieving, but at least I know that I made the decision that he or she would have wanted,” and there’s tremendous peace that comes from that.

The types of advance directives—there are three main ones. The first is a healthcare proxy or healthcare power of attorney. This is the document by which you appoint someone to make decisions on your behalf. You can find them on your state’s website. An excellent resource is the National Hospice and Palliative Care organization website. It has links to all of these types of forms. Usually you appoint a surrogate decision-maker and a backup in case that person’s not available, and it usually requires that someone witness the signing of it. It doesn’t necessarily need to be done by a lawyer, or notarized, or anything like that. It usually just requires a witness.

The most important thing, though, if you do this, is make sure you have a discussion with the person you’re appointing. It helps to have it in place, especially if there are multiple people who might be involved in decision-making and they could disagree; it really helps. But it helps even more if you equip them with what to do.

The second is a MOLST or POLST form. That stands for Medical Orders for Life-Sustaining Treatment. This, I will be honest with you, I think is really only appropriate for people who are terminally ill, on hospice care, or absolutely sure they don’t want resuscitation. The reason is because it doesn’t allow you to elaborate on your values. It’s a checkbox form; it’s called a DNR/DNI form, Do Not Resuscitate form. It’s most helpful to tell paramedics if they come to your home after you’ve had an arrest, “Don’t resuscitate me.” It’s helpful in that setting. 

But for the majority of us it’s much more helpful to have more of an elaboration of, under what circumstances would I be okay being resuscitated? A DNR/DNI form does not allow you to do that. I would only recommend this in cases where you’re on hospice care or you’re terminally ill and you know for sure you don’t want to be resuscitated under any circumstances because it would not be recoverable.

A living will is what I think we should all do as well. You can find these on that site that I mentioned. Another great site is FiveWishes.org, which takes you through the process of forming a living will. A living will has prompts. It allows you space to write and to narrate when you would be okay with these things. Instead of saying yes or no to a ventilator, under what circumstances would I consent to a ventilator? As Christians, the language might say something like, “Because I am a follower of Christ and believe that life is sacred, if I’m suffering from something that’s potentially reversible I would consent to a ventilator. However, if I’m at the end of life and I’m struggling with multi-organ function, it’s not anticipated I’ll recover, I would not want to be on a ventilator long term.” Language like that you can include in a living will, which is a beautiful way to witness to your loved ones who are reading it, and also the hospital staff. You can actually include your faith and how it’s guiding you and the hope that you have and the assurance you have in that language.

As a clinician, the most helpful living will I ever saw was actually not a form. I got seven pages stapled together that a family member gave me, with the patient’s name signed at the bottom. He had basically told me his life story, and what drove him and what mattered to him and his faith. By the time I got to the end of it, I looked at the family member and I said, “I think it’s obvious. I think he’s told us what to do.” So, anything that you can elaborate most on your values will be helpful compared to a checkbox form.

I should say, always complete this in consultation with a physician. Make sure they’re aware of it. They should have a copy of it. If you have any questions about your baseline history and what would be your chances of recovering, those are questions to ask a doctor. It can change over time. What your advance directive looks like now might not be what it looks like in a few years, as your health conditions change. But just know that that’s okay. You can always go back and revisit it.

For some concluding thoughts, and then I’ll take questions, I know this was a lot to take in, so thank you for sticking with me. I think it’s key throughout, because these are such heavy situations, to pray without ceasing, knowing that our Lord is sovereign even over our lung functions and what goes on at the bedside. Don’t go through this alone. Ask questions of the doctors. If you don’t trust the doctor you’re talking to, get a second opinion. Talk to a primary doctor you trust. Don’t feel like you have to go forward with limited information or the opinion of one person. Involve your pastor or a chaplain throughout the process as well, so that you can feel peace and discernment and have some guidance.

In the midst of the sorrow, cleave to our hope that comes only from Christ, because death is the end of our earthly lives, but thanks be to God, through Christ it is not the end! We cleave with all our hearts to the promise that when He returns He will wipe away every tear from our eyes and death will be no more. We’ll be in His presence forever. Thank you so much.

All Scripture is taken from the ESV unless otherwise noted.